Patient safety is an integral part of value-based healthcare. Ensuring patient safety can lead to faster recovery times, which, in turn, leads to lower costs of care. When combined, these factors result in improved patient satisfaction. Ensuring patient safety requires professional nurses to be proactive in identifying potential safety concerns and proposing evidence-based solutions to mitigate those concerns across the healthcare continuum.
Your goal for this task is to clearly and concisely propose a recommendation that addresses an identified systems-level safety issue that affects patients within a healthcare setting, such as your practice or a colleague’s practice, using convincing evidence to promote the necessity for change.
A. Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the following:
- Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.
- Analyze background (B) information about the concern by doing the following:
a. Describe the data that support or would support the need for change.
b. Explain how one or more national patient safety standards apply to this situation.
- Assess (A) the impact of the safety concern on the patient(s), staff, and the organization as situated in the identified healthcare setting.
a. Explain how the safety concern affects value for the patient(s) and the healthcare setting.
- Recommend (R) an evidence-based practice change that addresses the safety concern.
a. Discuss how this recommendation aligns with the principles of a high-reliability organization.
b. Describe two potential barriers to the recommended practice change.
c. Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.
d. Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation.
Full Answer Section
Background (B):
- Data Supporting Change: Studies indicate that medication errors are a leading cause of preventable harm in healthcare settings [1]. Even minor medication errors can lead to extended hospital stays, additional medical interventions, and increased costs. b. National Patient Safety Standards: The Joint Commission International (JCI) Standard LD.03.04.01 directly addresses medication safety [2]. It emphasizes the need for accurate medication administration and a culture of safety reporting.
Assessment (A):
- Impact on Value: Medication errors significantly impact value for patients and the healthcare setting. For patients, errors can cause harm, lead to additional procedures, and erode trust in the healthcare system. For the healthcare setting, errors increase costs, lengthen hospital stays, and potentially result in lawsuits.
Recommendation (R):
Implement a barcoding medication administration system: This system utilizes barcodes on both medications and patients' wristbands. Before administering medication, nurses scan the barcodes to ensure a match. This evidence-based practice has been shown to significantly reduce medication errors [3].
Alignment with High-Reliability Organizations (HROs):
Barcoding medication administration aligns with HRO principles:
- Preoccupation with Failure:The system actively seeks to prevent errors before they happen.
- Deference to Expertise:Nurses rely on the system as an additional safeguard.
- Reluctance to Simplify:The system acknowledges the complexity of medication administration.
Barriers:
- Cost: Implementing a barcoding system requires an upfront investment in equipment and software. b. Workflow Integration: Nurses may initially resist changes to their routine medication administration process.
Interventions to Minimize Barriers:
- Cost-Benefit Analysis: Demonstrate how the system saves money in the long run by reducing errors. b. Training and User-Friendly Technology: Provide comprehensive training and user-friendly technology to ensure smooth integration into the workflow.
Shared Decision-Making:
Shared decision-making with relevant stakeholders is crucial for successful implementation. This includes nurses, pharmacists, hospital administration, and IT staff. Involving these stakeholders:
- Promotes buy-in and ownership of the new system.
- Ensures all concerns are addressed and solutions are developed collaboratively.
- Leads to a more effective and sustainable change.
By implementing a barcoding system and adopting HRO principles, hospitals can significantly reduce medication errors, improve patient safety, and enhance overall value in healthcare delivery.