Discussion Board

Quality improvement case study

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A 64-year-old man came to the hospital who was facing trouble while breathing. He was also dealing with numerous health issues and that hospital was not new for him. However, he was not treated well and he did not receive the quality treatment. The care team did not provide him quality treatment that caused unnecessary harm to the patient. Moreover, there were number of medication errors that made his stay much prolonger than anticipated. These outcomes for the patient can be changed if he was provided with the quality and standard treatment ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6S5EYSXf","properties":{"formattedCitation":"(Hoyer et al., 2016)","plainCitation":"(Hoyer et al., 2016)","noteIndex":0},"citationItems":[{"id":2409,"uris":["http://zotero.org/users/local/KZl8ZL3A/items/4CBWAVPF"],"uri":["http://zotero.org/users/local/KZl8ZL3A/items/4CBWAVPF"],"itemData":{"id":2409,"type":"article-journal","title":"Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality‐improvement project","container-title":"Journal of hospital medicine","page":"341-347","volume":"11","issue":"5","author":[{"family":"Hoyer","given":"Erik H."},{"family":"Friedman","given":"Michael"},{"family":"Lavezza","given":"Annette"},{"family":"Wagner‐Kosmakos","given":"Kathleen"},{"family":"Lewis‐Cherry","given":"Robin"},{"family":"Skolnik","given":"Judy L."},{"family":"Byers","given":"Sherrie P."},{"family":"Atanelov","given":"Levan"},{"family":"Colantuoni","given":"Elizabeth"},{"family":"Brotman","given":"Daniel J."}],"issued":{"date-parts":[["2016"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hoyer et al., 2016). Furthermore, the health care team was also required to report the adverse event so that timely action can reduce the patient stay and suffering at hospital.

If the care team did not lack quality improvement and communication, the patient stay could be reduced. When the patient was admitted to the emergency due to his wheezing and having trouble breathing, he was diagnosed with COPD exacerbation. However, he did not get the standard treatment for the illness and the admitting doctor had not ordered prophylaxis for DVT ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3BYFkFGT","properties":{"formattedCitation":"(Curtis & Ramsden, 2015)","plainCitation":"(Curtis & Ramsden, 2015)","noteIndex":0},"citationItems":[{"id":2410,"uris":["http://zotero.org/users/local/KZl8ZL3A/items/HKAJMGR4"],"uri":["http://zotero.org/users/local/KZl8ZL3A/items/HKAJMGR4"],"itemData":{"id":2410,"type":"book","title":"Emergency and trauma care for nurses and paramedics","publisher":"Elsevier Health Sciences","ISBN":"0-7295-8346-5","author":[{"family":"Curtis","given":"Kate"},{"family":"Ramsden","given":"Clair"}],"issued":{"date-parts":[["2015"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Curtis & Ramsden, 2015). He was required at this stage to have any blood thinner to prevent blood clotting during his stay at the hospital.

Moreover, there was also a communication issue among the health care team that made patient stay prolonged at the hospital. He got seizure as a result of not getting the levetiracetam earlier in the day (Hilliard, n.d). There was a notation in the medication administration record about the unavailability of medicine but nurses did not further communicate that to physicians. If the patient had received prophylaxis timely he might not have gotten a blood clot. Furthermore, his seizure activity was the result of negligence and lack of communication.

Upon his admittance to a hospital in an emergency, the admitting doctor did not give him prophylaxis to thin his blood. Thus, the doctor made the error of omission and missed the required medication. There were also errors in communication when nurses did not update the surgeons about the non-availability of the required medication.

References

ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Curtis, K., & Ramsden, C. (2015). Emergency and trauma care for nurses and paramedics. Elsevier Health Sciences.

Hoyer, E. H., Friedman, M., Lavezza, A., Wagner‐Kosmakos, K., Lewis‐Cherry, R., Skolnik, J. L., … Brotman, D. J. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality‐improvement project. Journal of Hospital Medicine, 11(5), 341–347.

Hilliard, R. (n.d.). An Extended Stay. Retrieved July 2, 2019, from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/CaseStudyAnExtendedStay.aspx