Disseminating Results
nurseo
module5submittedpresentation.pptEVIDENCE BASED PROJECT
RECOMMENDING AN EVIDENCE-BASED PRACTICE CHANGE
HEALTH CARE ORGANIZATION
- JOHN HOPKINS HOSPITAL TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE PATIENTS
- HAS THE CULTURE FOR EMBRACING THE DESIRED CHANGE FOR THE LONGTERM PROSPERITY
- HAS THE CULTURE FOR IMPROVING THE HEALTH AND SAFETY OF THE PATIENTS
John Hopkins hospital has always been focused to provide quality healthcare services to the patients and the hospital has the culture for embracing the desired change for the long term prosperity. John Hopkins hospital has the culture for improving the health and safety of the patients and in any case if there is need to embrace change for the achievement of this objective, the management of the hospital cannot delay.
*
CURRENT PROBLEM
INCREASED CASES OF MEDICATION ERRORS AMONG THE HEALTH PRACTITIONERS.
OCCUR DUE TO INCREASED FATIGUE AMONG THE NURSES
ALSO CAUSED BY POOR COMMUNICATION BETWEEN THE PHYSICIAN AND THE PHARMACIST
ALSO CAUSED BY LIMITED INFORMATION AMONG THE PATIENTS ON THE RIGHT DOSAGE
Recently there have been increased cases of medication errors among the health practitioners (Institute for Healthcare Improvement, 2017). This has resulted in adverse effects to the patients ranging from increased hospitalization due to health complications and even death. Medical errors may occur due to increased fatigue among the nurses, where long working hours with limited shifts may result in the administration of the wrong medication to the patients. Medical errors are also caused by poor communication between the physician and the pharmacist resulting in the administration of the wrong dosage to the patient. Medical errors are also caused by limited information among the patients on the right dosage resulting in an overdose or under dose.
*
DESCRIPTION OF THE CIRCUMSTANCE
- ROBERTSON, AN EIGHTEEN-MONTH-OLD LITTLE BOY, WAS ADMITTED TO JOHN HOPKINS HOSPITAL.
- HAD SUFFERED FROM BURNS
- WAS DENIED A DRINK DESPITE HIS REQUEST FROM THE MOTHER
- THE NURSE INSTRUCTED THAT THE CHILD SHOULD NOT DRINK ANYTHING.
- WHEN THE MOTHER WAS BATHING HIM, THE CHILD APPEARED TO SUCK THE WASHCLOTH IMMENSELY
- THE DOCTOR ASSURED THE MOTHER THAT EVERYTHING WAS OKAY.
- THE DOCTOR INSTRUCTED THAT NO NARCOTICS WERE SUPPOSED TO BE ADMINISTERED TO THE CHILD
- THE NURSE DECIDED TO ADMINISTER METHADONE TO THE CHILD AT AROUND ONE O'CLOCK DESPITE BEING AWARE THAT THE DOCTOR HAD INSTRUCTED NO NARCOTICS WAS TO BE ADMINISTERED
- DOLPHIN SUCCUMBED TO SEVERE DEHYDRATION AND MISUSED NARCOTICS.
Robertson, an eighteen-month-old little boy, was admitted to John Hopkins Hospital in February 2003 after suffering from first and second-degree burns. The injury was caused by his act of climbing in a hot bathtub. The child did spend over ten days in the intensive care unit, after which he was referred to the step-down unit to commence the discharging process. The child was denied a drink despite his request from the mother, and the nurse instructed that the child should not drink anything. When the mother was bathing him, the child appeared to suck the washcloth immensely; an aspect that made her mother worried and consulted the doctor to ascertain the root cause of the behavior. The doctor assured the mother that everything was okay, and it was reasonable for the child to behave the way he did. The mother left and went home but made regular calls to ascertain the progress of the child, and the following day, Dolphin was not excellent.
The health care team administered medication to the child, which comprised of two doses of Narcan. After the medication, the child drank a liter of juice, after which he started to feel better. The doctor instructed that no narcotics were supposed to be administered to the child. That morning, the mother felt that the nurse was acting quite strange and told the doctor who agreed with her.
The nurse decided to administer methadone to the child at around one o'clock despite being aware that the doctor had instructed no narcotics was to be administered. The mother tried to intervene, but her pleas fell into deaf ears after the nurse told her that the initial instructions were null and void. After two days, Dolphin succumbed to severe dehydration and misused narcotics.
*
EVIDENCE BASED PRACTICE APPROACH FOR THE ISSUE.
THE RIGHT MEDICATION SHOULD BE ADMINISTERED ALL THE TIME
THE NURSE SHOULD HAVE ADHERED TO THE DOCTOR’S INSTRUCTIONS.
NURSES SHOULD BE TAUGHT ON THE NEED TO ADMINISTER QUALITY MEDICATION.
THE NURSE SHOULD HAVE ADVISED THE MOTHER TO GIVE THE CHILD WATER.
The medication error would have been prevented because Quality patient care is what should have occurred (Mills, 2016). As nurses, we are always taught to check our orders to make sure nothing had been changed. Nurses are taught to maintain five checks before the administration of any medication. Medication should be administered to the right patient to avoid medication errors. The right medication should be administered all the time in the right dosage at the right time. The nurse should not have administered the wrong medication to the patient but The right medication should be administered all the time. The nurse should have advised the mother to give the child water, which might have reduced the extent of dehydration that was one of the major causes of his death.
*
PLAN OF KNOWLEDGE TRANSFER TO ERADICATE MEDICATION ERRORS
THE NURSES SHOULD USE THE HALT METHOD TO AVOID THE POTENTIAL CAUSES OF MEDICAL ERRORS.
WOULD HELP THE HEALTH PRACTITIONERS TO SCRUTINIZE THEMSELVES BEFORE THE ADMINISTRATION OF THE MEDICAL CARE TO THE PATIENTS
SHOULD NOT WORK WHEN HUNGRY, ANGRY, AND LATE OR TRIED TO AVOID THE POTENTIAL MEDICAL ERRORS
REGULAR TRAINING FOR THE HEALTH PRACTITIONERS.
The nurses should use the HALT method to avoid the potential causes of medical errors as an improvement plan to eradicate the medical errors that have adverse effects on the patients (Joint Commission, 2018). The method would help the health practitioners to scrutinize themselves before the administration of the medical care to the patients. The method would help them to ensure that they provide medical care to the patients when they are okay, implying that a nurse should not work when hungry, angry, and late or tried to avoid the potential medical errors. The hospital should ensure that the health practitioners are competent by aligning each illness with the right medical practitioner for the reduction of the potential medication errors. Effective training should also be scheduled regularly for the health practitioners to help them cope with changes in how various ailments are diagnosed and treated.
*
MEASURABLE OUTCOME UPON THE IMPLEMENTATION OF CHANGE
THE PERFORMANCE APPRAISAL SHALL BE CONDUCTED AMONG THE HEALTH PRACTITIONERS.
RECODING CASES ON MEDICATION ERRORS
ENSURING THAT NURSES EAT THEIR MEALS ON TIME.
INTERACTION WITH PATIENTS TO ASCERTAIN ANY NEW HEALTH COMPLICATIONS.
The departmental heads would be in charge of the plan. They would ensure that all nurses eat their meals on time, those who appear to be stressed or angry given time to overcome their situation before their administration of medication to the patients (Gimbutas, Lamb, K& Quigley, 2017). The performance appraisal shall also be conducted to ascertain the extent of medical errors among the nurses to ascertain the scope of improvement as far as the administration of medication to the patients is concerned. The cases on medication errors shall also be recorded and the results would be crucial to determine whether the desired change has been realized in the hospital.
*
LESSONS LEARNED FROM THE JOURNALS
THE ROLE OF PARENTERAL NUTRITION FOR THE WELL-BEING OF THE PATIENTS.
THE VALUE FOR SUPPORTING THE INDIVIDUALS WITH NUTRITIONAL PROBLEMS IN THE SOCIETY
The peer reviewed journals enhanced my understanding of the value for supporting the individuals with nutritional problems in the society. Parenteral nutrition plays a significant role the reduction of metabolic abnormalities among the children and adults with nutritional challenges.
*
LESSONS LEARNED FROM COMPLETING THE TABLE
I APPRECIATED MY ABILITY IN ANALYZING THE ARTICLES
HAD THE DETAILED UNDERSTANDING OF THE ARTICLES
By completing the evaluation table i appreciated my ability in analyzing the articles and presenting the information according to the format that was outlined ranging from the conceptual framework to the key findings and outcomes.
*
REFERENCES
GIMBUTAS, S., LAMB, K. V., & QUIGLEY, P. (2017). FALL REDUCTION AND INJURY PREVENTION TOOLKIT: IMPLEMENTATION OF TWO MEDICAL-SURGICAL UNITS. MEDSURG NURSING, 26(3), 175–179, 197.
HTTPS://WWW.JOINTCOMMISSION.ORG/STANDARDS_INFORMATION/NPSGS.ASPX
INSTITUTE FOR HEALTHCARE IMPROVEMENT. (N.D.)(2017). WHY IS REDUCING HARM – NOT JUST ERROR – IMPORTANT TO PATIENT SAFETY? [VIDEO]. RETRIEVED FROM HTTP://WWW.IHI.ORG/EDUCATION/IHIOPENSCHOOL/RESOURCES/PAGES/ACTIVITIES/BATES-REDUCING-HARM-IMPORTANT-TO-PATIENT-SAFETY.ASPX
JOINT COMMISSION. (2018). TWO THOUSAND EIGHTEEN NATIONAL PATIENT SAFETY GOALS. RETRIEVED FROMJOURNAL, 103(6), 636–639.
MILLS, E. (2016). THE WAKEWINGS JOURNEY: CREATING A PATIENT SAFETY PROGRAM. AORN
