The Quality Of Care A Patient Receives

In the United States alone there are 98,000 deaths per year caused by low quality health care (Ignatavicius & Workman, 2013, pg. 2). This statistic is disturbing because the errors that resulted in death were errors that were preventable. The intent of this chapter is to bring awareness to health care providers that are able to make a change in the quality of health care. In current practice patients are subjected to medication errors, preventable hospitalizations, premature death, and poor care provided due to racial, ethical, or low-income factors.

Every one of us has relied on a medical professional at least a few times in our lives. When we get seriously ill, or suffer a serious injury, we put our health in the hands of doctors, nurses, and pharmacists, fully expecting to be treated with a certain degree of professionalism and safety. Unfortunately, sometimes the expected care is not given, or not given to the extent which the ailment requires. In these situations, we can feel blindsided, confused, even taken advantage of.

November, 1999 brought about a release of a report prepared by the prestigious National Academy of Science’s Institute of Medicine (IOM) making medical mistakes and their magnitude of the risks to patients receiving hospital care to common public knowledge. The IOM concluded that between 44,000-98,000 deaths occur annually because of medical errors. Among a general agreement was that system deficiencies were the most important factor in the problem and not incompetent or negligent physicians and other caregivers (Sultz & Young, 2010). An excellent example of a system deficiency that leads to a crisis and sentinel event was the highly publicized overdose of Heparin to Dennis Quaid’s newborn twins in 2007.

It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.

This journal talks about it takes failure to resolve medications across changes in care is an important cause of harm to patients. There is not a lot to known about medication discrepancies before patients are admitted to a skilled nursing facilities. To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. Cross-sectional study. Patients admitted to SNF for subacute care. Number of medication discrepancies upon admission to the SNF setting. Cross-sectional study. Patients admitted to SNF for subacute care. Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient

Many patients leave hospitals not fully healed or receive indequate care wherever they end up as with the case of Diana Turner. Diana Turner was a patient at Seaside Healthcare, a mental health facility in Lousiania. Ms. Turner was diagnosed with schizophrenia and was dependent on insulin. She was released into the care of Jefferson Healthcare who gave her an overdose of insulin which led to her death. Ms. Turner's daughter, Jamie Broussard, claims Seaside Healthcare should have known that Jefferson Healthcare wasn't qualified to administer insulin shots and filed a lawsuit against the health care organization. Ms. Turner's death was a result of medication error which can reduced through stragetic planning and attention to detail. Every medical facility has a moral obligation to avoid serious mistakes like medication error or negligence. The behavioral health center has an ethical responsibility to make sure accidents like medication error never happen. A way to ensure this would be to use technology and strict adherence to the rules and regulations. Procedures must be followed routinely so that it becomes habit to medical staff and they naturally follow protocol. Following a rountine makes the procedure easier and more natural to the staff similarly to the way a musician becomes more proficient at an instrument through practice and

The third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

The act of not informing the patient about this can cause several errors in taking the medication. An example

In an article published by Consumer Reports in 2011, 660 physicians were questioned regarding “What Doctors Wish Their Patients Knew.” (Chesanow, 2014). The topic that gained first place in the list was concerning patient noncompliance to medication and treatment. (Chesanow, 2014). It is reported that about 50% of the medications are not taken as prescribed by clinicians (Brown & Bussell, 2011). As a matter of fact, the number of noncompliant patients have significantly risen to levels considered as an epidemic (Chesanow, 2014).

A physician could make mistakes in prescribing, the pharmacy could send the wrong medication, but who actually gave it to the patient is accountable for the consequences. For this reason, it’s our responsibility to implement change in our practice based on the evidence in order to ensure safe patient care.

“Nursing is an art, and if it is to be made an art, requires as exclusive a devotion, as hard a preparation, as any painter’s or sculptor’s work...” (Nightingale, 1868)

In this case study, there are two problems which caused confusion between the mother of a young boy who was sick and the Doctor. These include language barrier and understanding field expressions (the mother of the sick child did not understand the meaning of the expressions used in the health field). For example, when the doctor stated that, “we’ll try something a little different”, he was not telling her to stop giving the sick child the medication which was recommended for him. Thus, this caused miscommunication between them.

Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to

patients and the overall community may not be paid as much attention as needed. Over the years,

Opener: Approximately 80% of healthcare errors are due to lack of communication. Whether that is patient to nurse, nurse to nurse, nurse to provider, provider to patient, provider to provider, these errors are likely to have life-long effects on patients and their family members.