Improvement
NURS FPX 4020 Improvement Plan In-Service Presentation CM
Practical and effective analysis tool is to identify the cause of the contributing error and then to implement preventative measures
The root cause of in-home medication errors after hospitalization that either did cause harm or will cause harm that was conducted at the hospital
Discharge
It is becoming increasingly important to older Americans to want to stay home longer to be able to “age in place”
The next several years the elder population is to be predicated at 25%
The older people get the more likely it is to experience higher rates of chronic illnesses and that will increase medication
Having the elderly at hone longer most generally alone means they are at higher risk for adverse effects caused by medication errors
Discharge
Medication changes often occurs during hospital stays which can be confusing or not communicated effectively resulting in poor patient safety and home errors
Hospitals across America are working to decrease the length of hospital stays but communication and education often falls through the cracks
Because of the increased risk of morbidity and morbidity in elderly caused by hospital errors after hospital discharge, Community hospitals are conducting root analysis on 15 reported cases of post discharge medication error over a 12-month period
Discharge
The root analysis was conducted to understand the reason for these errors
It was conducted by an inter-professional team that consisted of physicians, nurse supervisors, patient educators and social workers
The 15 cases data was gathered by the quality improvement team and entered for the analysis
The errors were described as wrong dose or wrong medication the patients sustained adverse effects such as over sedation, fluid retention with 4 cases resulting in in re-hospitalizations
It was also determined that these errors occurred at home with elder living alone or with an elderly spouse
NURS FPX 4020 Improvement Plan In-Service Presentation CM
Discharge
Elderly often have comorbidities ( congestive heart failure, or simpler fluid around the heart) dementia, and many more that are often affected by medication changes
Failure to this will result in the elderly failing at being at home where they are more comfortable so not taking these medications correctly for just one chronic condition will act like the domino effect.
Patients going home with new medication is roughly 80% elderly patients and 60% lived at home alone and were sent home without written or verbal education.
Strategies
Considering most of these medications occurred after medication changes with little to no on-going engagement and education
Developing a transition of care team that initializes education while in the hospital but has the capabilities to continue the education at home would be effective medication error prevention strategies.
Strategies such as patient engagement along with proactive and ongoing education can empower our patients to play an active role in their health care decisions
Empowering the patient and the family and care giver while in the hospital and at home after discharge will ensure our patients can live safer, longer, healthier lives at home and this can be achieved with proper and ongoing changes
Best Strategies
The improvement plan involves developing and improving our transition of care staffs effectiveness in coordinating patient education and implementing ongoing post discharge education
Education tab had been added to our discharge binder that is sent home with the patient
A name and phone # and been added as well so that the patient has a familiar person that they can call and talk with about any questions or concerns
The team has implemented “call Backs” where the patient will receive a phone call to see how things are going at home
And education system had been implemented so the patient will receive educations about the whole process
This education system can be available to the patient as well as caregiver or family member to help the patient be more successful at home
Conclusion
Community hospital has an existing education system that is accessible to the patient at bedside
This system will be utilized to its fullest extent to provide education to the patient and their families
Nursing staff will follow up to ensure the patient doesn’t have and questions or concerns and they the questions have been answered if they do have any
The hospital are already using discharge binders that is sent home with patients that have an added education and phone number tab
The transition of care nurse will follow up with a phone call that will review medication administration to ensure patient safety at home
Last but most importantly the community hospitals education system will now reach the patient at home after discharge and provide ongoing education and empower elders to live happier healthier lives at home
References
NURS FPX 4020 Improvement Plan In-Service Presentation CM
Balakrishnan, K., Brenner, M. J., Gosbee, J. W., & Schmalbach, C. E. (2019). Patient
Safety/Quality Improvement Primer, Part II: Prevention of Harm through Root Cause Analysis and Action (RCA2). Otolaryngology–Head and Neck Surgery, 161(6), 911–921.
Rosenwohl-Mack, A., Schumacher K., Fang M.L., Fukoka, Y.
Experiences of aging in place in the United States: protocol for a systematic review and meta-ethnography of qualitative studies syst. Rev., 7(1) (2018, p. 155 tps://doi.org/10.1177/0194599819878683
Curle, B. W., & Maduro, R. (2020). Discharge unit efficiency. American Nurse Today, 15(9), 85–88.
Lafreniere, A., Purgina, B., & Wasserman, J. K. (2020). Putting the patient at the centre of
pathology: an innovative approach to patient education—MyPathologyReport.ca. Journal
of Clinical Pathology, 73(8), 454-455. http://dx.doi.org/10.1136/jclinpath-2019-206370of
pathology: an innovative approach to patient education—MyPathologyReport.ca. Journal
of Clinical Pathology, 73(8), 454-455. http://dx.doi.org/10.1136/jclinpath-2019-206370
