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PDSA/CA Cycle for Quality Improvement [Process or Issue You Plan to Improve]

Rolandra Calloway

IHP 604 Healthcare Quality Improvement

1/24/2021

SNHU

Diagnostic Errors PDSA/CA Cycle

The PDSA is an important concept in the field of health because it helps in the finding the best ways to understand the changes and conducting of research within the health standards. It is important to impose the PDSA cycle to help keep track of the changes bound to happen within the health institution and thus help in the improvement of the standards. The major concern in the recent years in health is the diagnostic errors which are a major problem since there are numerous patients and the professionals are bound to give a wrong diagnosis, delay or even miss a certain symptom that influences the entire results and treatment of the patient. The cycle seeks to help understand the extent of the diagnostic errors in health institutions and ways of helping to reduce them and improve the quality of the healthcare. The research should take between three and six months to help come up with conclusive responses on how to deal with such issues which is bound to help improve the quality of healthcare.

Plan

Diagnostic errors involve the delayed, missed or wrong diagnosis of the patients and their conditions in the health institutions. It is evident that diagnostic errors account for approximately 17% of the potential preventable errors in the health sector. Diagnostic errors have been bound for a long time and technology and improvement of the training of the health experts is helping reduce them but it is still bound to happen. The long working hours, poor training, lack of proper supervision, few working personnel influence the performance of the nursing practitioners which makes it a major challenge in the maintaining proper health quality. The concept is an issue because it leads to bad calls for the doctors which are bound to lead to wrongful deaths, long term health misdeeds to the patients and escalation of the health issues among others.

Brief Literature Review

Research proves that approximately 17% - 20% of the potential preventable errors in the health sector is a result of the diagnostic errors (Khullar & Jena, 2016). The health professionals are human and bound to make errors but with the health calls they might result in the wrongful death of the patients or even development of a permanent health issue which should not be the case. It is important to understand that the wrong deeds of the health professionals are a major concern because it is leading to loss of numerous innocent lives and thus it is important to find the proper positive measure to help contain the situation (Khoo, Sararaks, Lee, Liew, Cheong, Samad, Hamid, 2015).). It is evident from the autopsy that numerous people die each year from diagnostic errors that go undetectable for a long time and thus it is only revealed after the error is irreversible. The concept is a major concern because the move might escalate to the issues of doctors breaking their solemn vows to their patient’s health and to their profession which involves protecting their patients lives. According to Berger, Brito, Ospina, Kannan, Hinson, Hess, Newman-Toker (2017), the diagnostic errors might be a small detail that the doctors can miss because they have numerous patients especially in the large and busy institutions. However, in some situations it is evident that some professionals are just clumsy and commit the mistakes without having a second thought which might end up as a case of manslaughter. In addition, it is evident that the health institutions lack proper supervision of the health professionals that then make it a problem especially for the nurses or doctors in training that leaves them without the proper effects which is a major concern for the ethical standards in the health institutions (Chen, Liang & Lin, 2016). It is bound to introduce intervention methods that include proper interventions, the need for clogging in the patient information and details at the same time of diagnosis, proper supervision of the doctors to help with follow ups and interacting with patients and also making sure that the health professionals are held strictly to their code of conduct.

Recommended Actions

The plan to help introduce supervision and clogging all the details of the patients into the system is bound to help reduce the percentage of the preventable diagnostic errors that are increasing in the health institution. The health institution is bound to input the various committees that include the members of the public to help in the formation of the supervision team and oversee the activities of the health professionals. The concept of the team building is bound to be introduced because it will help in making sure that the health professionals interact. The collection of data will involve the use of the online platform, online surveys, questionnaires and surveys, focus groups and interviews.

Do

The introduction of the pilot plan was bound to start after the identification of the problem which is within the first one month. The pilot plan will take place in the health institution because it should be a practical plan that is essential for their performance which is vital for their interactions. The collection of the data will take place between the second and fourth month of the research period that is bound to take six months. It is evident that diagnostic errors in the health institutions is a major problem and addressing it requires the contribution of all the branches of the health institutions. Research proves that proper supervision and clogging in details of the doctors is a positive move towards managing and controlling the diagnostic errors. The first month of the research will involve interacting with patients, the victims of the diagnostic errors and their families, the interaction with the doctors will be the second month and then the management of the health institution while the last three months will be tabling the results.

Study/Check

The data proves that it is evident that there are higher cases of diagnostic errors that contribute to controllable deaths in the health institutions. It is also evident that most of the deaths are not detectable until autopsy which implies that follow ups and supervision is not a common topic and subject in the health institutions. The validation of the results is from the victims, their families, other professions, their records and working conditions in the health institutions do prove that there is a major problem in the management of the patient’s health. The intervention strategies were working for the first three months of the implementation, but in the departments that had fewer nurse to patient ratio it was a major problem. The interventions were focusing on helping to curb the unnecessary deaths and thus it was bound to be positive for the environment which is vital for their performance.

Act

It is important to come up with a positive strategy that will see the introduction of a policy that will see the maintenance of the proper patient-doctor ratio. It is important to come up with the strict routine of making sure that the doctors and nurses do clog the patients details and progress and slight prognosis to make sure that the supervision and follow-ups is swift and helps in making sure that they conduct the positive treatment options. The plan will need to take a longer duration that will see the proper understanding of the issue and experimenting well with the interventions that will see the best options. It will be easier to implement the changes from the management level and then making sure that it is a collaborative strategy that will see the participation of all the parties to help reduce the conflict of interests in the institution.

References

Berger, Z., Brito, J., Ospina, N., Kannan, S., Hinson, J., Hess, E., Newman-Toker, D. (2017). Patient centered diagnosis: Sharing diagnostic decisions with patients in clinical practice. BMJ: British Medical Journal, 359. doi:10.2307/26951708

Chen, W., Liang, Y., & Lin, Y. (2016). Is the United States in the middle of a healthcare bubble? The European Journal of Health Economics, 17(1), 99-111. 

Khoo, E., Sararaks, S., Lee, W., Liew, S., Cheong, A., Samad, A., Hamid, M. (2015). Reducing Medical Errors in Primary Care Using a Pragmatic Complex Intervention. Asia Pacific Journal of Public Health, 27(6), 670-677. 

Khullar, D., & Jena, A. (2016). Reducing prognostic errors: A new imperative in quality healthcare. BMJ: British Medical Journal, 352. doi:10.2307/26944306