phase 4 - research
Running head: HOW TO REDUCE ERRORS WHEN ADMINISTERING HEPARIN DRIP? 1
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HOW TO REDUCE ERRORS WHEN ADMINISTERING HEPARIN DRIP?
Sample Paper
Abstract
This phase of the project is presenting the results of the project in numerical forms, using statistical tools to illustrate the final outcomes of the research project. It will be focusing in demonstrating the correlation between the Incidents Reports and the most common type of errors within the nursing staff, and the specific amount of nurses involved in the incidents.
The first table will give the information subdivided into four principal groups, so this time the analysis will be in base to the principal administration reason according to the principal diagnosis, from this table was created a representative graph that specify the attention in the relative frequency percent by administration reason.
The second table focuses the attention in the correlation between the Incident Reports, the numbers of nurses involved and the most common errors involving the medication administration. As part derivate was two different graphs to demonstrate the different aspects involving the incident that lead to the error. The first analysis that I can do from this table is from the most common errors involved in the incidents. The second analysis will be focus in the number of nurses involved by incident that makes a total of 17.
Introduction to the Results
This phase will have as goal to demonstrate the results of the research project, demonstrating the correlation between the Incidents Reports and the most common type of errors within the nursing staff, and the specific amount of nurses involved in the incidents. I will also be given the information in numerical forms to help responds the research question. It is crucial to take into the consideration when you give the results of the study do not prove the final answer. The findings help to illustrate the hypothesis supporting your study.
Table 1
Diagnosis for administration, numbers of incidents and relative frequency.
|
Diagnosis |
No. of Incident Reports |
Relative Frequency |
|
Strokes and TIAs |
5 |
46% |
|
Deep Vein Thrombosis (DVT) |
3 |
27% |
|
NSTEMI |
2 |
18% |
|
Pulmonary Embolism (PE) |
1 |
9% |
|
Total |
11 |
100% |
Note: The first table shows the results taken from the data collection from the Incident Reports, which was a total of 11 Incident Report in the past six months. The table illustrates the numbers of Incident Reports and the amount of incidents per administration reason; also the relative frequency in percent. The table gives us the information subdividing the information into four principal groups, so this time the analysis will be in base to the administration reason.
Relative Frequency by Diagnosis Reason
Figure 1: Graphic for relative frequency by administration reason. With these numbers we can see the relative frequency. In Figure 1 demonstrates the highest 46 percent was from the reports that involved the patients receiving the Heparin Drip for Strokes and TIAs.
It was a possible expected result since the majority of the patients admitted in this floor the diagnosis is for Strokes and TIAs. So the vulnerability will be higher in this type of population when the first line of medication management is the Heparin Drip. . The commonly use is because has a short biologic half-life in the body system about one to two hour, so it must to be order frequently or as continuous infusion. Safe and effective mechanisms need to be use in order to reduce the increasing medical-error of this high-risk medication.
Table 2
Most common errors, No. of incident and nurses involved.
|
Most Common Errors |
No. of Incident Reports |
No. of Nurses Involved |
|
Wrong weight |
3 |
6 |
|
Aptt out of time |
2 |
4 |
|
Administration line |
2 |
2 |
|
Transfer patient |
1 |
2 |
|
Bag Replacement |
3 |
3 |
|
Total |
11 |
17 |
Note: This second table will subdivide the results based on the Incident Reports, the numbers of nurses involved and the most common errors involving the medication administration.
From this table we can create two different graphs to demonstrate the different aspects involving the incident that lead to the error. The first analysis that I can do from this table is from the most common errors involved in the incidents. The second analysis will be focus in the number of nurses involved by incident that makes a total of 17 nurses that were interview with specifics questions to help support the research study. These questions can help us to identify the contributor's factors that lead to the problem.
Most Common Errors
Figure 2: The graph demonstrates that between the most common errors Bag Replacement and Wrong weight have the highest incidents so we need to focus our attention in those to found out a solution and give one answer to our research question.
No. of Nurses involved related to the most common errors.
Figure 3: The pie graph was also created from the previous table 2 information shows the No. of nurses related to the most common errors. The highest incident of 6 nurses is related to the Wrong weight, so next step to correct will be pay attention in the first phase of the Protocol Initiation when the nurses are starting the Drip; analyze how the nurses are weighting the patients and the frequency to recheck it. When we talk about weight control special attention needs the patient with history of Congestive Heart Failure and End stage of Renal Diseases requiring Dialysis, the weight of patient change more often than the normal person.
Conclusions
Quantifying the amount of incident reports on the road to the most common errors in the floor involves the integration of the staff. For this investigation, one quantifiable research question was indicated to find out how to reduce errors when administrating Heparin Drip. The findings help to illustrate the hypothesis supporting your study.
In Figure 1 demonstrates the highest 46 percent was from the reports that involved the patients receiving the Heparin Drip for Strokes and TIAs. It was a possible expected result since the majority of the patients admitted in this floor the diagnosis is for Strokes and TIAs. So the vulnerability will be higher in this type of population when the first line of medication management is the Heparin Drip.
In Figure 2 establishes that between the most common errors Bag Replacement and Wrong weight have the highest incidents so we need to focus our attention in those to found out a solution and give one answer to our research question.
In Figure 3 the highest incident of 6 nurses is related to the Wrong weight, so next step to correct will be pay attention in the first phase of the Protocol Initiation when the nurses are starting the Drip; analyze how the nurses are weighting the patients and the frequency to recheck it.
References
Brennan TA, Leape LL, Laird NM. et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. Pages: 324(6):370–6.
Thomas EJ, Studdert DM, Burstin HR. et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. Pages: 38(3):261–71.
TK Gandhi, DL Seder, DW Bates. (2000). Methodology matters. Identifying drug safety issues: from research to practice. International Journal for Quality in Health Care. Vol. 12, Pages 69-76, https://doi.org/10.1093/intqhc/12.1.69
Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101.
Wrong weight Aptt out of time Adiministration line Transfer patient 0.46 0.09 0.18 0.27
Diagnosis Reason
Wrong weight Aptt out of time Administration line Tranfer patient Bag replacement 3 2 2 1 3
No. of Incident Report
Wrong weight Aptt out of time Adiministration line Transfer patient Bag Replacement 6 4 2 2 3