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Submission Instructions:
You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.
All replies must be constructive and use literature where possible.
Discussion #1
“Never Events” & My Clinical Project
“Never events” are serious, preventable medical errors that should never occur while a patient is under the care of a healthcare professional in any healthcare setting. An example of a “never event” is wrong-site surgery, meaning that surgery was performed on the wrong body part or patient. This can lead to unnecessary complications and harm. I experienced this same exact situation with a colleague of mine. Prior to becoming an RN, I used to work in a multi-specialty clinic as an LPN. That day was OB/GYN clinic and in that office, minor and non-invasive surgical procedures were performed. Our first patient of the day was scheduled to have a loop electrosurgical excision procedure (LEEP). During a LEEP, a wire heated by electric current is used to remove abnormal cells and tissues in a woman’s cervix. There was one lady waiting in the waiting room and another one being registered. My colleague, also an LPN, called the patient who was having the LEEP, and the lady in the waiting room stood up. The names were not even remotely close so to this day, I still do not understand why the patient stood or say that she was not the correct patient. The LPN failed to check the arm band, assuming that she was the correct patient, and proceeded to take her to the room and prepare her for the procedure. The doctor then comes in, she did not verify that it was the correct patient either, and signed the consent with the patient. They performed the LEEP on the incorrect patient. When the lady who was being registered is sent to the waiting room, is when I realized that the LEEP was being done on the wrong patient. Long story short, thankfully nothing happened to the patient and her health was not affected, but the LPN got fired for failure to properly identify a patient and for allowing a “never event” from occurring. Even though the doctor was also at fault, the LPN paid the consequences. This an example of why nurses should always be extra careful with everything, because we are the first ones at fault.
Patient falls is another “never event” that may also occur in a hospital or healthcare institution. Failing to prevent patient falls, especially those resulting in serious injuries, can prolong hospital stays and impact long-term health. Infections acquired during a hospital stay due to inadequate hygiene or sterile procedures is called hospital-acquired infections (HAIs). HAIs is another example of “never events.” They can complicate the patient and prolong hospital stay, as well costing the patient and hospital money. The impact of “never events” in a hospital is profound, affecting patient safety, trust in healthcare providers, and the overall repuation of the institution. It can lead to legal consequences, financial burdens, and emotional distress for patients and their families. Hospitals strive to prevent these events through rigorous protocols, training, and quality improvement measures (Yoder-Wise, 2019).
For my clinical project, one clinical issue for quality improvement that I am considering is reducing hospital readmissions for heart failure patients. This issue is significant because frequent readmissions can impact patient outcomes, increase healthcare costs, and indicate potential gaps in care (Fadol et al., 2019). I believe that a quality improvement project in this area might focus on implementing better discharge planning, patient education, and follow-up strategies to enhance heart failure management and reduce the likelihood of readmission. The goal would be to improve patient care, satisfaction, and overall healthcare efficiency.
Discussion #2
Discuss specific examples of “never events” and their impact in your workplace.
Never events are a category of patient safety incidents that are preventable and so critical that they should never occur (Bowman et al.,2023). “Never events” can refer to preventable medical errors or wrong site for surgery because these can cause serious damage or even be fatal. One horrific example of a never event is performing surgery on the wrong body part or patient. The impact on the patient is severe. Patients may experience physical harm, potential complications, and psychological distress. The consequences for healthcare providers and institutions include legal consequences and damage to reputation. When avoidable mistakes occur to the patients, trust in the healthcare system is undermined. A second example is foreign objects remaining in the patient, such as surgical instruments, sponges, or other foreign items after surgery. This can lead to internal injuries, infections, and the need to perform an additional surgery to remove the item. This results in potential lawsuits, increased healthcare costs, emotional distress, prolonged hospitalization, and the risk of getting an infection.
There can be a discrepancy in any of the five rights of medication administration. Medication errors include administering the wrong medication, route, or dosage of medication (Wondmieneh et al.,2020). The consequences range from adverse drug reactions to the risk of potential toxicity and even death. Medication errors can result in a deterioration of a patient’s condition. Falls in a healthcare facility can lead to serious injuries or fatalities. These incidents can lead to increased days at the hospital, and increased morbidity. Falls that can be prevented can lead to legal actions, especially if the hospital facility failed to implement adequate preventive measures such as bed alarms.
Another “never event” is failure to prevent pressure ulcers or bedsores due to inadequate care. Patients may experience discomfort, infections, and a slower rate of recovery from these avoidable illnesses. Pressure ulcers can lead to legal actions and negatively impact the hospital’s reputation and bring negative attention to the hospital. The nurse and patient care technicians can also gain a negative reputation and risk their license due to inadequate care. Lastly, patient elopement refers to patients leaving the facility without the authorization to or a discharge order. The impact is increased risk of harm to the patient and concerns about patient safety protocols.
What issues are you considering for your clinical project and why?
For my clinical project I am going to focus on medication errors. Medication errors can happen because of a discrepancy done by the doctor, pharmacist, or nurse. Some of the most system errors include inaccurate recording of the order by the nurse or pharmacist when getting orders from the physician, not inquiring about medication allergies, inadequate order verification, the wrong patient, and errors in the drug order tracking. There are many opportunities where medication errors can occur, therefore it is imperative for nurses to be thorough and careful. The five rights of medication administration can be used, and the three checks for medication administration can be used to ensure safe delivery of medication to patients.
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7th Edition
Reference Guide for Journal Articles,
Books, and Edited Book Chapters
Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.
Journal
Article
Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title. Also
capitalize proper nouns. Do not italicize. End with a period.
Author, A. A., & Author, B. B. (Year). Title of the article.
Name of the Periodical, volume(issue), #–#. https://doi.org/xxxx
Capitalize all major words in the
periodical name. Follow with a
comma. Italicize the periodical
name (but not the comma after).
Italicize the volume number. Do not
put a space between the volume
number and the parentheses
around the issue number.
Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.
Book
Place the year
in parentheses.
End with a period.
Do not italicize the issue number or
parentheses. Follow the parentheses with
a comma. No issue number? That’s okay.
Follow the volume number with a comma.
Place the copyright year
in parentheses. End with
a period.
Include the article page
range. Use an en dash; do
not put spaces around the
en dash. End with a period.
Does the article have a
DOI? Include a DOI for all
works that have one. Do not
put a period after the DOI.
Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title. Also
capitalize proper nouns. Italicize the title. End with a period.
Author, A. A., & Author, B. B. (Copyright Year). Title of the book (7th ed.).
Publisher. DOI or URL
Include the name of the publisher, followed
by a period. Do not include the publisher
location. Are there multiple publishers?
If so, separate them with a semicolon.
Does the book have a DOI? Include a DOI if available.
Do not include a URL or database information for works from
academic research databases. Include a URL for ebooks from
other websites. Do not put a period after the DOI or URL.
Does the book have an edition or volume number? If so, include
the number in parentheses after the title but before the period. If both,
show edition first and volume second, separated by a comma. Do
not put a period between the title and the parenthetical information.
Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.
Place the copyright year
in parentheses. End with
a period.
Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title.
Also capitalize proper nouns. Do not italicize. End with a period.
Author, A. A., & Author, B. B. (Copyright Year). Title of the book chapter.
Chapter in
an Edited Book
In A. A. Editor & B. B. Editor (Eds.), Title of the book (2nd ed., pp. #–#).
Publisher. DOI or URL
Write the word “In” and the initials
and last name (not inverted) of
each editor. Use “(Ed.)” for one
editor or “(Eds.)” for multiple
editors. End with a comma.
Include the name of the publisher followed
by a period. Do not include the publisher
location. If there are multiple publishers,
separate them with a semicolon.
Provide the title of the book in which
the chapter appears. Capitalize only
the first letter of the first word. For a
two-part title, capitalize the first word
of the second part of the title. Also
capitalize proper nouns. Italicize the
book title.
Does the book have a DOI or URL? Include a DOI if available.
Do not include a URL or database information for works from
academic research databases. Include a URL for ebooks from
other websites. Do not put a period after the DOI or URL.
More information on reference variations not shown here (e.g., in-press articles, articles with article numbers, articles without DOIs, books with titled volumes,
audiobooks) can be found in the Publication Manual of the American Psychological Association (7th ed.) and in the Concise Guide to APA Style (7th ed.):
Journal articles and other periodicals
Books and reference works
Edited book chapters and entries in reference works
Section 10.1
Section 10.2
Section 10.3
Include the chapter page range. End with a period.
Does the book have an edition or volume
number? If so, include the number in parentheses
before the page range. If both, show edition
first and volume second, separated by a comma,
before the page range. Do not put a period
between the title and the parenthetical information.
SOURCE: American Psychological Association. (2020).
Publication manual of the American Psychological
Association (7th ed.). https://doi.org/10.1037/0000165-000
CREDIT: MELANIE R. FOWLER, FLORIDA SOUTHERN COLLEGE
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