Tag Archives: patient safety

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Society

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.

References

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Academia, Culture, Health Care, Society

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.

References

The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health, Society

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.

References

Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Academia, Clinical, Culture, Emergency Management, Emergency Medical Services, Health Care, Public Health, Technology

Patient Safety Considerations for EMS

 In the out-of-hospital emergency care setting, patient safety is paramount. Initially, victims of trauma or illness are already suffering in an uncontrolled environment. It is this same environment where first responders, emergency medical technicians, and paramedics must operate to stabilize and transport the victim to the hospital, a more controlled environment. Unfortunately, there is little research in the area of patient safety in this setting (Meisel, Hargarten, & Vernick, 2008; Paris & O’Conner, 2008).

Importance

Focusing on patient safety and developing processes to ensure optimal safety would allow the study of inherently dangerous, yet potentially beneficial therapies, such as rapid sequence intubation where the clinician uses a series of medications to rapidly sedate and paralyze a critical patient for ease of inserting a breathing tube. Focusing on safety, an EMS department in Maryland successfully instituted such a program (Sullivan, King, Rosenbaum, & Smith, 2010).

With more research in this area, the Emergency Medical Services (EMS) can improve the care they seek to deliver to their patients.

Challenges

There are many challenges facing EMS as they seek to deliver safe and effective care to their patients. Motor vehicle accidents (including air transportation accidents), dropped patients, medication and dosage errors, other inappropriate care, and assessment errors all contribute to the number of adverse events in the EMS out-of-hospital care setting (Meisel et al., 2008). Unfortunately, it has proved difficult to identify both the existence and the cause of each event (Meisel et al., 2008; Paris et al., 2008). Additionally, there are adverse events that are impossible to track, such as the iatrogenic exposure to a pathogen. It would be very difficult to distinguish how and when a patient was first exposed to the infecting pathogen without considering community-acquired infections and hospital-acquired infections, which are both equally difficult to ascertain (Taigman, 2007).

Strategies for improvement

As EMS seeks to increase the professionalism among its ranks, the stakeholders must acknowledge responsibility for providing evidence-based processes to ensure patient safety.

References

Meisel, Z. F., Hargarten, S., & Vernick, J. (2008, October). Addressing prehospital patient safety using the science of injury prevention and control.Prehospital Emergency Care, 12(4), 4-14.

Paris, P. M. & O’Connor, R. E. (2008, January). A national center for EMS provider and patient safety: helping EMS providers help us. Prehospital Emergency Care, 12(1), 92-94.

Sullivan, R. J., King, B. D., Rosenbaum, R. A., & Shiuh, T. (2010, January). RSI: the first two years. One agency’s experience implementing an RSI protocol. EMS Magazine, 39(1), 34-51.

Taigman, M. (2007, July). We don’t mean to hurt patients. EMS Magazine, 52(4), 36-42.