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Dec 6, 2023
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Adverse Event or Near-Miss Analysis
Capella University
NURSFPX-6016
Dionne Gibbs
January 30, 2022
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Adverse Event or Near-Miss Analysis
Adverse occurrences at healthcare facilities result in avoidable morbidity, putting an additional strain on patients, families, and healthcare facilities. Some of these occurrences are sentinel, resulting in significant anguish, disability, or fatalities among the stakeholders. Mentally
ill patients in the psychiatric hospital setting are subjected to manual restraints to manage behavioral outbursts. Unfortunately, this is an undesirable but common process. It is characterized by tense times and quick actions that rely on team chemistry, thorough planning, and a keen assessment of the situation while applying the necessary holds in a timely and proper manner. Preventable adverse events continue to be a problem in healthcare (Rafter, 2017), and the resulting patient damage is a primary source of morbidity and death across the world. Patient
harm is defined by the World Health Organization as "an incident that causes harm to a patient, such as impairment of body structure or function and/or any deleterious effect arising from or associated with plans or actions taken during the provision of healthcare, rather than an underlying disease or injury, and may be physical, social, or psychological (e.g. disease, injury, suffering, disability, and death)." Patient harm is also a significant financial burden for healthcare
systems across the world. The direct consequences of healthcare-related patient damage are projected to consume 10-15% of healthcare spending (Panagioti, 2019).” In the literature to follow, the stages leading up to this near-fatal avoidable adverse event will be reviewed. Also discussed will be the evaluation of the quality improvement technologies related to the event that
are required to reduce risk and increase patient safety. Additionally, this essay will incorporate relevant adverse event metrics to support the need for improvement and will outline a quality improvement initiative to prevent the recurrence of an adverse event for all stakeholders.
Analysis of the Event
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One of the basic expectations for both children receiving inpatient mental health service as well as the providers of this service, is the safety of the environment. The creation of a safe therapeutic environment is the result of many things: a culture that values and enhances communication, staff that works together as a team to recognize and prevent violent behavior, and the adoption of an approach that treats crisis situations as therapeutic opportunities. A key component of these approaches is a well-structured team that effectively responds to prevent and manage crisis situations. Rockland Children Psychiatric Center’s (RCPC) crisis team is called the “Redstone Team”. The Nursing Supervisor coordinates the crisis episode. Their role is to assess the progression of the crisis towards de-escalation of the child. If a doctor or nurse orders a physical intervention, it is the Nursing Supervisor who initiates and coordinates this action. On this day during the evening shift, there were two simultaneous crisis codes. The crisis team were
on another unit managing a previously called code. The Nursing Supervisor was present at the first crisis code, and therefore not available to direct the subsequent code. The second code also necessitated a manual restraint as a result of imminent danger to the other patients on the unit. The patient was physically attacking staff and the other patients. However, there were an insufficient number of staff remaining as a result of the others responding to the initial crisis code. The remaining staff were new to their positions and were inadequately trained. They incorrectly applied a manual restraint which resulted in asphyxiation to the patient who fell unconscious. Fortunately, the patient survived, and suffered no obvious physical ill effects. Implications of the Adverse Event on Stakeholders
Adverse incidents involving patients are unavoidable, but they can be traumatic for everyone involved. There are three sorts of victims of patient-related adverse events; the patients and their families, the healthcare professionals participating in an adverse event, and the
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healthcare organizations in which an adverse event happens (Liukka, 2020). The incident itself, as well as how it is managed, causes harm to patients and their families. This incident was a result of poor planning and oversight of the facility which resulted in trauma for both the family and patient. This was primarily because the facility did not want to pay overtime coverage to ensure the safety of the patients and staff alike. Healthcare practitioners, such as doctors, nurses,
and therapy aides who participated in the event were also traumatized. While they played no direct role in the reason for the adverse event occurrence, they were affected negatively. Their short-term effect was to be hesitant to go hands on for other restraint episodes regarding any patient. This resulted in the safety of the milieu being compromised. There were several instances where patients were injured by aggressive patients due to the hesitancy and delay. The long-term effects for some of these staff were to resign. Third-party victims, or healthcare companies where the adverse event happens, face challenges such as efficacy, reputation, legality, and cost. This facility was subject to increased oversite by the Center for Medicaid Services and the Joint Commission. Instead of being surveyed every three years, the facility w received six month follow ups.
Evaluation of Quality Improvement Technologies
As with any quality improvement initiative, beginning with a framework to reduce adverse events are the basis for success. To help minimize this type of occurrence in the future the quality assurance department implemented several strategies. The quality assurance department determined that due to the lack of sufficient staffing this episode resulted in being more serious that it should have been. The interventions include, implementing basic staffing ratios based on unit acuity, utilizing ancillary support staff such as the facility’s safety
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department in assisting with multiple simultaneous Redstones at any given time. The final intervention included establishing a rule where staff who have not gone through the facility restraint training is not allowed to be among the patients. These interventions have proved to be very appropriate for the situation. Since the implementation there have been several times where there have been multiple crises on different units. The guidance provided by the quality assurance department have resulted in these situations being as minimally detrimental to the patient and staff alike. Now if a Redstone is called when another crisis is in progress an “all-
available” staff page goes out. When the ancillary staff hear this, they respond to the paged location. This includes the safety department, administrators, and anyone else available who has been adequately trained.
Relevant Metrics of Quality Improvement
Another quality assurance initiative was to retrain the staff every year to make sure they are competent in the application of manual restraint. In addition, the training encompasses other aspects to help mitigate the actual occurrence of a manual restraint. This includes being aware of the early warning signs of possible psychiatric dysregulation and decompensation and improving
the verbal interventions and de-escalation techniques that have proven effective in avoiding manual restraint. If an employee is unable to complete the training successfully, they are not permitted to work in patient care until they are able to do so. For the New York State Office of Mental Health (OMH) this is an agency wide approach for every facility under the OMH umbrella. There have been incidents in other facilities prior to the one at RCPC that were never addressed. Being the fact that this was an adolescent brought to light the need for much stricter oversight. The interventions by the quality assurance department have proven to be very successful. The incidence of manual restraints since everyone was retrained has gone down
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significantly. For the year prior to the intervention there was an average three manual restraints per day. Currently the average is one restraint every three days. This can be attributed to the training and the constant follow ups. There now are more codes where staff intervene early where they noticed the warning signs of a particular episode and verbally teach or deescalate the patient. The staff now feel more confident in their ability to manage crisis situations and to avoid them completely. The improvement of staff being more diligent with their active supervision and identifying early warning signs have resulted in the environment being a more therapeutic and safer milieu. One thing that I would recommend to the facility is to interview each patient and ascertain what they believe are their triggers and what has been done in the past to help them regain control. This should be done on admission and routinely followed up at treatment plan meetings. This should be distributed to the staff who work hands on with the patients. This gives everyone a game plan on what effectively has worked in the past. In addition,
should someone observe a new technique or a new skill or strategy they can let the primary therapist know or the psychiatrist so that the calming plan information can be updated.
Table 1.
Conclusion
A positive factor of a Quality Assurance intervention is that everyone participating in the healthcare delivery system is working toward the same objective, and it's difficult to find someone who doesn't think quality improvement and patient safety are important. Nurses in the inpatient setting have challenges because they are responsible for caring for patients with complicated care requirements in a high-stress, fast-paced environment. To foster a culture of
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patient safety and excellent health care, we must rely on technology, staff education and up-to-
date trainings, and open communication among stakeholders.