Health Care Paper

Clinical Scenario Analysis

Contents

Introduction. 2

Description of the Incident. 2

Outcome. 2

Clinical Analysis. 3

Applying Systems Theory. 4

Mistake-Prone Procedures. 5

Conclusion. 6

References. 9

Introduction

 In this clinical scenario analysis, several objectives need to be considered when assessing the case study with staff and likening them to adverse conditions at a clinical amenity. First, it is essential to note that user amenities need to consider the possible devices and individuals involved in the incidence. This case study is significant in helping staff members understand the importance of being keen to prevent a bad incident. Medical facilities need to teach their staff how best to report on patient incidents within the facility(Walley, & Wright, 2014).

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Description of the Incident

This incident involves Mrs. Jones who had come in for a minor surgery, her operation went well, and post-operation she seemed to be doing well. On examination the doctor stated that she would need antibiotics, and specified the type of antibiotic that should would need to take. The doctor then went on ahead to examine other patients. The pharmacist then came to the room to give her medicine, she seemed pre-occupied, but she still asked Mrs. Jones whether she had any allergies, to which Mrs. Jones clearly specified that she was allergic to Penicillin. Mrs. Jones said that she gets a bad rash when exposed to the drug, and the pharmacist seemed to have understood. However, the pharmacist gave Mrs. Jones Augmentin, which is an antibiotic that contains Penicillin.

Outcome

            The result of this incidence is that Mrs. Jones came out with a minor harm and recovered. The incident was reported, since the outcome could have been catastrophic.

Safety Assessment Code

Actual ConsequenceThe actual consequence of the incidence is minimal damage
LikelihoodLess Likely
SAC4

Clinical Analysis

When working in the hospital, it is imperative to ensure the right processes and practices; the use of safety process will help limit risks when dealing with hazards. Safety in the hospital emphasizes the reporting, evaluation, and prevention of clinical mistakes that often cause adverse incidents. Further, from having severe harms to the patient, medical mistakes translate to large sums of money being wiped out from the global and national economy. Human mistakes and unsafe processes and equipment make up a majority of the hazards that occur. However, mistakes form part of being human.

            Good clinicians make mistakes; however, crucial incidents are hardly ever caused by one individual as in the incident illustrated. Yet conventionally, the reaction has been to blame the people involved and fail to put proper structures in place to protect against the same issues and mistakes in the future(Barton, 2009). This means that the health care staff have a habit of not reporting mistakes, with the fear that they may be blamed or penalized. This implies that senior medical staff does not get the information required to make the services safer. When the same form of errors happens continually, this is a hazard and a gross failure of the care that needs to be offered for patients.

Applying Systems Theory

 There has been a substantial shift in the safety culture, and it is vital to understand incident causation in the health structure to apply the systems theory and human factors. Using the systems theory and social factors principles can help answer the questions that arise from the case study by focusing the evaluation on the system-based contributing elements(Rausand, & Haugen, 2020). Practically, human factors offer the instruments, techniques, and theories to approach this case study. When applying social aspects, the objective is to not only concentrate on the human or the system alone, but the contact between the human and the system, and to understand the elements that affect this interaction. These contributing factors may relate to the task, the patient, and the environment to add to the integral human aspects and restrictions.

            Different human factors can be implemented at this phase to answer the question of how and why the incidence happened. They range in intricacy, resources, and time required. Working safely with hazardous materials needs efficiency and focus. Maintenance and consistent inspection of the drugs given to patients is a significant part of the process. From this case, it is clear that there are reports of exposure to penicillin. From this analysis, it is vital to provide recommendations relating to safety and acquiringconcerns for drug reactions. Clinical facilities should use the following safety dealings to evade issues comparable to the one described.

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            An adverse reaction to a drug is described as an unwanted reaction related to the application of a drug that either compromises healing effectiveness, and augments toxicity or even both. This adverse reaction can be revealed through constipation, diarrhea, headache and other nonspecific symptoms. One of the difficulties presented by adverse drugs reactions is that prescribers may attribute the opposing effects to the patient’s causal situation and fail to identify the age of the patient, and the number of medications as the contributing element. A lot of attention needs to be directed to these reactions, and ways to prevent the reaction, which range in severity from insignificant to fatal.

Mistake-Prone Procedures

            There are numerous phases of the medication procedure; the first one is prescribing, the second one is transcribing and verifying, the third one is administration, then monitoring and reporting. Monitoring and reporting represents a new stage, and there is little examination of the same. Research shows that one of every three medication mistakes can be credited to either a lack of information concerning the medication or a lack of information about the patient. Of the phases the prescribing stage most often pledges a sequence of mistakes that result to the patient getting the wrong medication. In this phase, the wrong drug can be ordered to which the patient has known allergies. The information concerning the prescribed drug, workload, the attitude of the prescriber is substantially related with adverse drug reactions. Moreover, when the nurses or pharmacists question the prescriber concerning the order, they can be met with hostile conduct. This may hinder with future questioning and seeking interpretation. The share of medication mistakes that can be attributed to the prescribing phase range from seventy-nine percent to three percent.

            In certain instances, medication orders are recorded and then delivered for nurse administration. With specific situations, the nurses and the pharmacists are each involved in writing down, verifying and dispensing the medications. Yet mistakes of these two phases have been predominately researched for nurses and pharmacists. Pharmacists play a critical role in preventing and intercepting ordering mistakes. Research shows that while dispensing mistakes makes up fourteen-percent of the total adverse drug reactions, it is seen that pharmacists interrupted seventy percent of all physician ordering mistakes. In the management of medication, nurses are primarily involved in the management of medications across settings. It is important to note that nurses can also be involved in the preparation and dispensing of prescriptions, such as drawing up a measured quantity for injections and crushing pills.

            Working conditions can simplify medication mistakes. Research shows that health care physicians need to be aware of recurring patterns of medication mistakes and near misses to offer insight on how to evade future mistakes. The system strategy to safety gives emphasis to the human condition of unreliability and expects that mistakes will occur. It is important to look at the predisposing elements within the working environment or the structure that leads to mistakes. There are three conditions that predicate a mistake; the first one is latent conditions, the next one is error-producing conditions and active failures. The risk to medication safety comprise of miscommunication among health care providers, drug information that is not available or up to date, poor method, confusing directions and insufficient patient information.

Conclusion

            Medical safety is a substantial issue in hospitals and in the healthcare setting. There is need for great improvements and hospitals need to be engaged in efforts to limit mistakes and increase this element of patient safety. Regrettably, there is little evidence on which to base interventions. Based on this case study it is evident that voluntary self-reports of medication mistakes are not valid. Based on the increasing reliance on medication treatment as the main intervention for most disease, patients receiving medical attention are exposed to possible harm together with the benefits. The benefits comprise of efficient management of the disease, with slowed development of the disease and enhanced patient results with little to no mistakes. Injury from the medications can come about from accidental results or medication mistakes.

            Lack of adequate education concerning patient safety and quality staffing insufficiencies, excess workloads and flawed dispensing structures form some of the issues that challenge the lack of ability for patients to get the correct medication. This case study brings into perspective medication safety in relation to nursing share. The study indicates an adequate and consistent information base of medication mistake reporting and distribution across different stages of the medication process.

From this assessment, amenities need to look for and assess the connections between their personnel and the occurrence of an incident. This case study examines the possible root causes of the issue. Even though medical device cases are often forthright, the device that is first considered in reviewing a hazard incident is frequently not the device to which the incident is eventually attributed. The primary objective of this case study is to assist a user facility  in understanding how and if an adverse incidence was attributable to the dubious instrument or instruments, including the instructions, labeling, and whether other substantial factors are involved(Joern, 2016).

In assessing this case study, medical amenities need to look at the investigational methods that relate to assessing the performance of their personnel, searching informational sources that may be applied when coming to conclusions concerning the cause of the event. Regarding the reason, medical amenities need to note that a patient is a flexible biological structure.(Hughes, United States, & Robert Wood Johnson Foundation, 2008) In some instances, what seems to be a small issue, may cause a lot of damage to the patient, based on the patient’s response to an otherwise standard set of conditions of use and conduct for the dubious instrument. Adverse incidents that do not cause harm to the patient are referred to as close calls(Flott, Nelson, Moorcroft, Mayer, Gage, Redhead, & Darzi, 2018). The case study illustrated starts with a case abstract; there is also an illustration of the instruments that need to be considered by individuals involved in the incident. This evaluation looks at the medical administration sfaety, the investigative outcome, and the problem being examined.

            Safety is a crucial element in the provision of quality healthcare services. This assessment has great potential to enhance the safety processes in healthcare amenities(Abdel-Aleem, 2009). This will also help individuals understand safety measures that need to be taken to perform a system-based evaluation of safety incidents. This is a critical part of shifting the organizational culture from that of blame to learning, understanding, and improving. Medical facilities are encouraged to consistently dedicate time and resources to assess the functions of the incident evaluation. When describing the quality method, medical amenities should focus on the unintended outcome from different factors. The quality of incident evaluation is critical in restoring trust and rebuilding associations among all the elements involved in the incident and creating a safe culture.

References

Abdel-Aleem, S., & Abdel-Aleem, S. 2009. Design, execution, and management of medical device

            clinical trials. Hoboken, N.J, Wiley.

Barton, A. (October 01, 2009). Patient Safety and Quality: An Evidence-Based Handbook for

            Nurses. Aorn Journal, 90, 4, 601-602.

Downloads.hindawi.com. 2020. [online] Available at:

            <http://downloads.hindawi.com/journals/jamc/1991/756323.pdf> [Accessed 31 October   2020].

Flott, K., Nelson, D., Moorcroft, T., Mayer, E. K., Gage, W., Redhead, J., & Darzi, A. W. (2018).

            Enhancing Safety Culture Through Improved Incident Reporting: A Case Study In

            Translational Research. Health Affairs. 37, 1797-1804.

Hughes, R., United States., & Robert Wood Johnson Foundation. (2008). Patient safety and

 quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare

Research and Quality.

Joern, B. 2016. Measuring Vulnerability to Natural Hazards: Towards Disaster Resilient

            Societies. Shibuya-ku, United Nations University Press.

https://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=282195.

Perry, A. G., Potter, P. A., & Elkin, M. K. 2012. Nursing interventions & clinical skills. St. Louis,

            Mo, Mosby.

Rausand, M., & Haugen, S. 2020. Risk assessment: theory, methods, and applications.

https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&

            AN=2377349.

Safety requirements for electrical equipment for measurement, a., 2020. IEC 61010-2-020:2016 |

            IEC Webstore. [online] Webstore.iec.ch. Available at:

            <https://webstore.iec.ch/publication/24959> [Accessed 31 October 2020].

Tim Fetherston. 2015. The importance of critical incident reporting – and how to do it. Community

            Eye Health Journal. 28, 26-27.

Vlayen, Annemie, Marquet, Kristel, Schrooten, Ward, Vleugels, Arthur, Hellings, Johan, De Troy,

            Elke, Weekers, Frank, & Claes, Neree. 2012. Design of a medical record review study on

            the incidence and preventability of adverse events requiring a higher level of care in

 Belgian hospitals. BioMed Central.

Walley, J., & Wright, J. 2014. Public Health: an action guide to improving health. Oxford, OUP

Oxford. http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=4702286.

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