Never Events Paper: General Information The term “Never Event” is used in the me
ID: 126388 • Letter: N
Question
Never Events Paper: General Information
The term “Never Event” is used in the medical community to describe medical errors that should never occur in the hospital. Some of them are medication errors, falls, pressure ulcers, and wrong-site surgeries. Never events and other hospital-acquired conditions are tracked for data purposes and with the intention for process improvement throughout the country.
Never events and hospital-acquired conditions are tied to reimbursement and impact patient safety and the delivery of quality care. Throughout this program, you will be asked to address critical issues related to patient safety and the role of the nurse in protecting patients from harm. For this assignment you will be asked to write a paper on the impact of a never event.
Instructions
Select one of the following types of hospital acquired conditions:
Then:
Foreign Object Retained After Surgery
Blood Incompatibility
Surgical Site Infections Following Orthopedic procedures e.g.
Spine/Neck (rodding or disc repair)
Shoulder/Elbow (arthroplasty)
Hip/Knee (arthroplasty, meniscotomy, ACL repair)
Long bone fracture repair (rodding/plating of femur, tibia-fibula, humerus, radius, ulna)
Briefly describe the incidence of the event you have selected (include references in APA format).
Briefly describe the causes of this event (include references in APA format).
Briefly describe the consequences of this event.
Describe strategies nurses can implement to prevent the occurrence of this event
Explanation / Answer
Blood incompatibility:
Briefly describe the incidence of the event you have selected (include references in APA format).
United States
Just 15% of the populace do not have the Rh erythrocyte surface antigen and are viewed as Rh-negative. Most by far (85%) of people are viewed as Rh constructive. Rh sharpening happens in around 1 for each 1000 births to ladies who are Rh negative. The Southwest United States has a rate roughly 1.5 times the national normal, which likely is caused by movement factors and restricted access to therapeutic care since blood writing is a standard piece of pre-birth mind. All things being equal, just 17% of pregnant ladies with Rh-negative blood who are presented to Rh-positive fetal platelets ever create Rh antibodies (Throp, 2008, p.112-115).
Mortality/Morbidity
Over the span of Rh contradiction, the baby is fundamentally influenced. The official of maternal Rh antibodies created after refinement with fetal Rh-positive erythrocytes brings about fetal immune system hemolysis. As a result, a lot of bilirubin are created from the breakdown of fetal hemoglobin and are exchanged through the placenta to the mother where they are hence conjugated and discharged by the mother. In any case, once conveyed, low levels of glucuronyl transferase in the newborn child block the conjugation of a lot of bilirubin and may bring about perilously hoisted levels of serum bilirubin and serious jaundice.
Somewhat influenced babies may have almost no pallor and may show just hyperbilirubinemia auxiliary to the proceeding with hemolytic impact of Rh antibodies that have crossed the placenta.
Decently influenced newborn children may have a mix of iron deficiency and hyperbilirubinemia/jaundice.
In extreme instances of fetal hyperbilirubinemia, kernicterus creates. Kernicterus is a neurologic disorder caused by statement of bilirubin into focal sensory system tissues. Kernicterus more often than not happens a few days after conveyance and is described by loss of the Moro (ie, startle) reflex, acting, poor nourishing, dormancy, a swelling fontanelle, a piercing ear-splitting cry, and seizures. Babies who survive kernicterus may go ahead to create hypotonia, hearing misfortune, and mental hindrance.
An intense dangerous condition saw in newborn children influenced by Rh inconsistency is erythroblastosis fetalis, which is described by extreme hemolytic frailty and jaundice. The most serious type of erythroblastosis fetalis is hydrops fetalis, which is portrayed by high yield heart disappointment, edema, ascites, pericardial emission, and extramedullary hematopoiesis. Babies with hydrops fetalis are to a great degree pale with hematocrits normally under 5. Hydrops fetalis regularly brings about death of the newborn child without further ado earlier or after conveyance and requires a developing trade transfusion if there is to be any shot of baby survival (Cardo, 2010, p.1121-6).
Briefly describe the causes of this event (include references in APA format).
The distinctive blood classifications are:
Type A
Type B
Type AB
Type O
Individuals who have one blood classification may shape proteins (antibodies) that reason their safe framework to respond against at least one of the other blood classifications.
Being presented to another kind of blood can cause a response. This is vital when somebody needs to get blood (transfusion) or have an organ transplant. The blood classifications must be perfect to stay away from an ABO inconsistency response.
For instance:
Individuals with sort A blood will respond against sort B or type AB blood.
Individuals with sort B blood will respond against type A or type AB blood.
Individuals with sort O blood will respond against type A, type B, or type AB blood.
Individuals with sort AB blood won't respond against type A, type B, type AB, or type O blood.
Type O blood does not cause a safe reaction when it is given to individuals with sort A, type B, or sort AB blood. This is the reason type O platelets can be given to individuals of any blood classification. Individuals with sort O blood are called all inclusive contributors. Yet, individuals with sort O can just get sort O blood.
Both blood and plasma transfusions must be coordinated to maintain a strategic distance from an insusceptible response. Before anybody gets blood, both the blood and the individual getting it are tried deliberately to maintain a strategic distance from a response. More often than not, a response happens on account of an administrative mistake making somebody get contrary blood (Herold, 2005, p.474-491).
Briefly describe the consequences of this event.
Most blood transfusion responses happen while you're accepting blood or promptly after. A specialist or medical caretaker will remain with you while you get the transfusion. They will check your imperative signs and look for indications that you might have a response.
Transfusion response side effects include:
Describe strategies nurses can implement to prevent the occurrence of this event
Nursing diagnosis for Rh contradiction
Objectives
NURSING CARE for Rh inconsistency DURING PHOTOTHERAPY