Latoya Crockeractive Health Records In Acute Setting Db8collapsetop O ✓ Solved

LaToya Crocker Active Health Records in Acute Setting DB#8 COLLAPSE Top of Form Surgery is one area of health care in which preventable medical errors and near misses can occur. However, until the 1999 Institute of Medicine report, To Err Is Human , clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses, because there was no process for recognizing, reporting, and tracking these events (Mulloy, 2008). The 2015 article written by Nwosu describes two cases from a Nigerian trauma center in which wrong-site surgeries were performed. In case one, a 75-year-old female was injured in a traffic accident. She sustained a central right hip dislocation with an acetabular fracture.

During the procedure, the surgeon performed a reduction of the left hip with pin placement. Upon reevaluation, it was discovered that the surgery was performed on the incorrect extremity. Case two involved a 43-year-old bus driver following a traffic accident unable to bear weight bilaterally. Radiographs revealed bilateral femur fractures and a left tibial fracture. Neither incident was officially reported to the hospital for review.

Upon analysis of both cases, the surgeon's inexperience does not play a role in wrong-site surgery error. The factors identified as causes of wrong-site surgeries include distraction, incomplete preoperative assessment, and insufficient patient information in the operating room, policy issues, and the lack of operating room checklists (Nwosu, 2015). In my opinion, both cases were due to a lack of attention to detail and a lack of teamwork and communication, specifically in the second case study. The anesthesiologist brought his concerns to the surgeon's attention several times without a "time-out" to regroup and ensure the correct procedure was performed. The Joint Commission (TJC) publishes yearly National Patient Safety Goals.

These goals are designed to improve patient safety. The goals focus on problems in health care safety and how to solve them. The 2021 safety goals include several goals, including identifying patients correctly, improving staff communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery (jointcommission.org, 2021). Although all these goals are essential, we will focus on preventing mistakes in surgery for this discussion. There were two programs described in the article implemented to improve hospital patient safety.

The Joint Commission introduced the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery in January 2003. The Universal Protocol applies to all surgical and non-surgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include general anesthesia or deep sedation, although other procedures may also affect patient safety (jointcommission.org, 2021). Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the procedure's correct site. The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety.

The Universal Protocol is based on the following principles (jointcommission.org, 2021): · Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented. · Using a multiple and complementary strategy to always conduct the correct procedure on the correct person at the correct site. · Active involvement and the use of effective methods to improve communication among all members of the procedure team are essential for success. · Patient and family involvement in the process, as much as possible. · Implementation of a standardized protocol is most effective in achieving safety Another program designed to reduce surgical errors was the World Health Organization (WHO) Surgical Safety Checklist.

The checklist consisted of "sign-in, time-out, and sign-out." The protocol also promotes safe anesthesia, teamwork, and the prevention of surgical infections (Nwosu, 2015). Unfortunately, in many parts of Africa, Asia, and Europe, as of 2015, the TJC "Universal Protocol" and the "WHO Surgical Site Safety Checklist" were not being utilized. The registration process must be both accurate and efficient. Failure to meet both of these goals can lead to adverse outcomes. Slow registration can hinder care by delaying the processing of orders of tests or delaying access to existing medical records and, in the long run, not providing adequate emergency care (Hakimzada, 2008).

Inaccuracy in gathering information can lead to errors, including lack of access to existing medical records, inability to contact a patient after discharge, and even implementation of an incorrect treatment regimen with dangerous consequences to the patient's safety. Biblical integration: John 15:12, "My command is this: Love each other as I have loved you." God loves us in an incredible way. It's up to us to find ways to bring that love into our community. References: Hakimzada, A. F., Green, R.

A., Sayan, O. R., Zhang, J., & Patel, V. L. (2008). The nature and occurrence of registration errors in the emergency department. International journal of medical informatics , 77 (3), 169–175.

Hospital: 2021 National Patient Safety Goals. The Joint Commission . Retrieved on March 8, 2021, from . Mulloy DF, Hughes RG. Wrong-Site Surgery: A Preventable Medical Error.

In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 36. Available from: .

Nwosu, A. (2015). The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria. Patient Safety in Surgery, 9:6, DOI 10.1186/s. Bottom of Form 16 hours ago Catherine Spivey Disc #8 COLLAPSE Top of Form As a pre-operative and post-operative care nurse, wrong-site surgeries and patient safety protocols surrounding surgery and consent are at the forefront of my everyday practice. In my facility, patients are asked to confirm their identity with their name and date of birth as well as their surgical site by no less than four people prior to transfer to the operating room.

The surgeon is also required (when applicable) to mark the site with their initials prior to leaving the pre-operative area. The two cases presented in the article took place in Nigerian hospitals, however these events are present in facilities all over the world. As written in the article, “JCAHO [has] identified risk factors of wrong-site surgery to include emergency cases, physical deformity, multiple surgeons and multiple procedures being performed during a surgical session… root cause analysis [of these events have] implicated distraction factors, incomplete preoperative assessment, non –availability of pertinent information in the operating room, policy issues such as surgical site marking and verification checklist in the operating room†(Nwosu, 2015).

The United States has implemented a Universal Protocol since 2004 to mitigate these risk factors and decrease incidence to a rarity. Using accurate and complete information when registering a patient is also imperative, as this information is used to safety check every step of the surgical/operative process. In a literature review completed in 2015, “the median incidence estimate for wrong-site surgery across 7 US studies reporting general per-procedure estimates was 0.09 vents per 10,000 surgical procedures†(Hempel et al, 2015). The same literature review found that the most frequently reported causes of wrong-site surgery were “communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality†(Hempel et al, 2015).

Communication issues were most frequently cited, “accounting for 21% of the total†(Hempel et al, 2015). In addition to adhering to safety protocols, addressing communication issues amongst surgical teams is vital. Simulation can be an effective tool in addressing poor communication amongst health team members. Simulation “has [a] demonstrated effectiveness as a method to train practicing nurses for new procedures, communication processes, and both skill-based and non-skill-based techniques†(Aebersold & Tschannen, 2013). Utilizing it to “address miscommunication and other sources of error, especially in the context of team training and systems-based practice†is beneficial to error prevention and communication improvement (Motola et al, 2013).

Simulation is a no-risk no-harm situation, which may help team members feel more incline to share their concerns. Empowering team members to speak up as well as training the care team to stop and listen when a concern is raised is beneficial to the overall effectiveness of the team; further contributing to error prevention. “Open your mouth, judge righteously, defend the rights of the poor and needy†(English Standard Version, 2001, Proverbs 31:9). When patients enter the healthcare system, they put their full trust in the team caring for them. It is imperative that each member of that team feel able to voice their concerns on behalf of the patient, and that their concerns will be heard and investigated.

References Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing , 18 (2). Hempel, S., Maggard-Gibbons, M., Nguyen, D. K., Dawes, A.

J., Miake-Lye, I., Beroes, J. M., ... & Shekelle, P. G. (2015). Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA surgery , 150 (8), .

Motola, I., Devine, L. A., Chung, H. S., Sullivan, J. E., & Issenberg, S. B. (2013).

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Medical Teacher , 35 (10), e1511-e1530. Nwosu, A. (2015).

The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria. Patient safety in surgery , 9 (1), 1-4. Bottom of Form

Paper for above instructions

Overview of Safety Protocols and Error Prevention in Surgical Settings

Surgical settings are critical environments where precision and adherence to safety protocols can mean the difference between successful patient outcomes and devastating errors. Wrong-site surgeries, while drastically reduced in recent years, remain a concern that various organizations strive to mitigate through standardized protocols. This paper will explore the significance of active health records, error prevention, safety protocols like the Universal Protocol and the World Health Organization (WHO) Surgical Safety Checklist, as well as the importance of communication and teamwork within surgical teams.

Understanding Wrong-Site Surgeries

Wrong-site surgeries encompass errors such as operating on the wrong body part, performing an incorrect procedure, or even conducting surgery on the wrong patient. According to the Institute of Medicine's report, "To Err Is Human," medical errors are a significant factor contributing to patient morbidity and mortality (Mulloy, 2008). In the cases presented by Nwosu (2015), two incidents of wrong-site surgeries at a Nigerian hospital highlighted systemic issues rather than individual surgeon errors. Both cases demonstrated that distractions, incomplete preoperative assessments, and insufficient patient information contributed substantially to these blunders.

Implementing the Universal Protocol

The Joint Commission (TJC) introduced the Universal Protocol in 2003 as a means to prevent wrong-site surgeries through a structured approach. This protocol includes three essential components: sign-in, time-out, and sign-out procedures (Joint Commission, 2021). The “time-out” is especially critical, as it serves as a pause before surgery to confirm the patient's identity, the procedure to be performed, and the surgical site (Joint Commission, 2021). Evidence suggests that hospitals with a culture of teamwork and open communication are more successful in implementing the Universal Protocol (Joint Commission, 2021).

WHO Surgical Safety Checklist

In parallel, the WHO introduced its Surgical Safety Checklist, which incorporates elements aimed at enhancing surgical safety, including aspects of communication, anesthetic safety, and infection prevention measures (Nwosu, 2015). Research indicates that the use of these checklists has significantly reduced surgical complications and mortality (Haynes et al., 2009). Despite their effectiveness, many healthcare facilities around the world, particularly in developing nations, have been hesitant to adopt such protocols, leading to ongoing concerns about surgical safety (Nwosu, 2015).

The Role of Communication and Teamwork

One of the most significant contributing factors to surgical errors is ineffective communication within surgical teams. According to Hempel et al. (2015), miscommunication among team members accounted for approximately 21% of reported wrong-site surgeries. Consequently, fostering an environment where team members feel comfortable voicing concerns is paramount for reducing mishaps. Simulation training has emerged as a crucial educational tool to enhance communication and teamwork, allowing healthcare professionals to practice protocols in low-stakes situations (Aebersold & Tschannen, 2013).
Simulation training, as highlighted by Motola et al. (2013), not only enables practice of technical skills but also offers a platform for teams to develop communication strategies, emphasizing the significance of speaking up when potential errors arise. This training environment cultivates a team dynamic that encourages proactive problem-solving and reflective practice, ultimately leading to improved patient safety outcomes.

Active Health Records and Their Importance

Accurate and timely patient information is critical in avoiding surgical errors. As noted by Hakimzada et al. (2008), both inaccuracies and inefficiencies in patient registration can lead to serious complications, including delays in care and access to medical records. Hospital systems must employ effective health information technology to enhance record accuracy and accessibility, as this supports all aspects of patient care, thus preventing errors during surgical procedures.
In modern healthcare, electronic health records (EHRs) offer a unified platform for storing and accessing patient data, which can help address some of the risks associated with human error. Bolstering these systems with robust checks and balances can enhance patient safety – ensuring that the right information is available at the right time thereby aiding surgical teams in their decision-making processes (Buntin et al., 2011).

Biblical Perspective on Patient Care

From a biblical perspective, the core teaching of “love” underscores the moral and ethical dimensions of patient care. As stated in John 15:12, “My command is this: Love each other as I have loved you.” In the context of surgical care, this illustrates the profound responsibility healthcare providers have in ensuring the safety and well-being of their patients. Integrating this ethos within healthcare practices aids in instilling a deeper commitment to patient advocacy and error prevention.

Conclusion

In summary, while the occurrence of wrong-site surgeries has diminished, robust error prevention strategies remain imperative. The Universal Protocol and WHO Surgical Safety Checklist serve as foundational tools in enhancing surgical safety, but they must be coupled with effective communication and teamwork. The utilization of active health records ensures that surgical teams have the correct information at their fingertips, supporting informed clinical decision-making. Ultimately, the implementation of these protocols, combined with a steadfast commitment to fostering positive team dynamics and patient care culture, is essential for preventing medical errors and ensuring optimal patient outcomes.

References

1. Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing, 18(2).
2. Buntin, M. B., Burke, M. F., Hoaglin, M. C., & Blumenthal, D. (2011). The benefits of health information technology: A review of the recent literature shows predominantly positive results. Health Affairs, 30(3), 464-471.
3. Hakimzada, A. F., Green, R. A., Sayan, O. R., Zhang, J., & Patel, V. L. (2008). The nature and occurrence of registration errors in the emergency department. International Journal of Medical Informatics, 77(3), 169–175.
4. Haynes, A. B., Weiser, T. G., Berry, W. R., et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine, 360(5), 491-499.
5. Hempel, S., Maggard-Gibbons, M., Nguyen, D. K., et al. (2015). Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surgery, 150(8), 1-10.
6. Joint Commission. (2021). Hospital: 2021 National Patient Safety Goals. Retrieved from [Link]
7. Motola, I., Devine, L. A., Chung, H. S., Sullivan, J. E., & Issenberg, S. B. (2013). Simulation in healthcare education: a best evidence practical guide. Medical Teacher, 35(10), e1511-e1530.
8. Mulloy, D. F. (2008). Wrong-Site Surgery: A Preventable Medical Error. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality.
9. Nwosu, A. (2015). The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria. Patient Safety in Surgery, 9(1), 1-4.
10. World Health Organization. (2009). WHO surgical safety checklist and implementation manual. Geneva: WHO Press.