Patient Safety in HealthCare Setups
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Patient Safety in HealthCare Setups
One of the important aspects of health care management is to ensure the safety of patients under any circumstances. Patient safety can be compromised during different situations and may be attributable to patient dependent factors and patient independent factors. The various patient dependent factors that hamper safety in them include age, dementia or different mental conditions. On the other hand, the patient-independent factors are attributed to the fallacy and inadequacy of the health care systems and associated persons who are associated with caregiving. Moreover, certain pharmacological and interventional complexities also lead to interference with patient safety. Such types of issues include adverse drug interactions, decreased toleration profile for a drug, development of post-operative surgical infections and extension of inadequate and inappropriate care by caregivers. Hence ensuring the safety of each individual who depends on healthcare systems is one of the important challenges all across the world (Brennan, Leape & Laird, 1999).
The importance and maintenance of patient safety are of prime concern, for ensuring positive health outcomes in an individual. Patient safety is a priority for various healthcare organizations and also the regulatory bodies associated with healthcare. The safety of a patient is compromised at various junctions during the health care delivery process. There has been a global awareness in ensuring patient safety. However, compromise with safety concerns of a patient is one of the major causes of treatment failure and impaired prognosis. Various initiatives based on clinical and administrative aspects are being taken, to ensure the safety of patients, all across the world (Brennan, Leape & Laird, 1999).
Safety of a patient is compromised all across the world and across different health care set-ups. Studies have been carried out in Australia and America to understand the extent of the issue. Such studies have indicated that, one out of ten individuals admitted in a hospital, suffers from some sort of adverse event. Such adverse events may be pharmacological or non-pharmacological. It was concluded that some adverse events are caused due to the normal treatment procedures, which are documented in the treatment guidelines. It was noted that, half of such adverse events, which occurred due to complications of treatment, might have been avoided. Such statistics indicates that one out of twenty admitted patients may have a preventable adverse event. Therefore, the focus should be to prevent adverse events in such individuals (Brennan, Leape & Laird, 1999)
Healthcare and Financial Burden
It has further been documented that out of preventable adverse event category, 8% of individuals may eventually face death. This indicates that one out of two hundred individuals admitted for treatment will eventually die due to an adverse event. Considering the millions of admissions which occur all across the globe, death due to adverse events remains an alarming issue. It is a significant cause of morbidity and mortality. Thus, an individual may at risk of life-threatening due to factors associated with the treatment itself. Hence, extreme care and caution must be ensured at all levels of health care, to provide safety to a patient (Wilson et al, 1995).
A data published by the National Health Scheme, United Kingdom indicated that considering 8.5 million admissions, 4, 00,000 individuals suffer from adverse events and 34, 000 death occurs due to such events. In Australia, it is predicted that almost 10,000 individuals die every year, due to preventable adverse events. In the United States, approximately 98, 000 individuals meet the similar fate in a particular year. The extent and domain of the issue indicate the challenging situation faced by healthcare organizations, all across the world (Wilson et al, 1995).
Apart from the negative healthcare outcomes in patients, various emotional aspects and economical aspects are associated with such events. They include mental anguish in patients and their family members and also the loss of man days in the employment sector. The NHS survey indicated that prolonged hospital stay due to adverse events increases the cost of healthcare by 2 million pounds. This accounts for 5% of the total annual spending on NHS. Moreover, hospital acquired infections and post operative surgical infections, add to another 1 million pound per year. Apart from that, clinical negligence also accounts for another 500 million pounds and costs to the NHS every year. Therefore, approximately 3.5 million pounds are imposed on the NHS, without any real value addition to a patient’s therapeutic needs (Wilson et al, 1995).
Factors Influencing Safety of Patients
There are various factors that impact the safety of patients in the healthcare settings. Some factors are related to interventional issues, and other factors are related to personal issues (Kaushal & Bates, 2001). The factors that increase the probability of adverse events and interfere with patient safety are:
Adverse Drug Interactions
In a tertiary healthcare treatment plan, a patient has to thrive on different medications that increase the chances of drug-induced side effects. These adverse events are common and are also documented in medical literature. However, various studies have indicated that patients are not adequately screened or monitored before administering a specific therapeutic intervention, which leads to the chances of increased drug-related adverse events. For example, before administering an antibiotic it is mandatory to assess the liver and the kidney functions. This is because various pharmacological agents are excreted through these two systems as the final product of drug metabolism. Hence, an antibiotic which primarily follows the renal route of excretion will accumulate in patients, if such patient has an impaired kidney function (Kaushal & Bates, 2001).
This will lead to drug-induced toxicity in the patient and delay healthcare outcomes. To prevent drug-induced toxicities, screening of kidney and liver functions must be made mandatory and should not be left to the choice of attending physician or the consultant. This should be maintained as an essential therapeutic protocol and non-compliance to such protocols should be effectively addressed by the hospital administration. Wherever possible antibiotics must be selected which have dual routes of excretion, to avoid the possibilities of drug accumulation and decrease the probabilities of drug toxicity.
Toleration profile is another issue that should be addressed appropriately. A specific therapeutic regime might not be equally tolerated across the different patient population. Therefore, physicians and nursing personnel should be vigilant, regarding the toleration profile of such patients to such therapeutic regimes. Titration of a dose of the drug should be effectively ensured. This means the titrated dose of the drug or the entire therapeutic schedule must meet the therapeutic goals of the patient and at the same time must ensure a safe toleration profile (Kaushal & Bates, 2001). For example, JNC VI guidelines have recommended the use of a combination of antihypertensive drugs for the management of hypertension.
The philosophy of such guidelines was based on the fact that increased dose of a single anti-hypertensive medication will exhibit its class effect to its maximum. This means that the medication will indeed exhibit its potential therapeutic benefits but will also increase the chances of dose dependent side effects. Therefore, the combination of two molecules will exclude the necessity of administering a single hypertensive in very high doses (Kaushal & Bates, 2001). At the same time, the combination of two drugs would act at different anatomical locations to exert a tight control of hypertension and reduce the chances of cardiovascular morbidity and mortality.
Adverse drug interactions can also occur between different drugs which are administered to a patient. Hence, the patient should be monitored for such drug-drug interactions, or drug-food interactions and steps should be immediately intervened, to address such issues. If it is warranted, the particular class of drug which is suspected to cause side effects must be withdrawn. However, such drugs must be replaced with alternate class of drugs, which are recommended as per evidenced based literature and therapeutic guidelines, to ensure and maintain the quality of care.
Medication errors are also an area of concern, which compromises the safety in patients. It is noted that medications with similar brand names are often mistaken as the same pharmacological agent. This causes mistake and lapse in therapeutic delivery from the level of pharmacy to the nursing personnel and even till the level of physicians. Hence, medications that are dispensed to the patients or in the in-house admission departments must be cross checked several times by the pharmacy personnel, before it is dispensed to the appropriate individuals.
Once the medication is indented to the respective departments, the nursing personnel should again cross check whether the medication matches the actual intent and if there is a deviation, it should be immediately returned to the pharmacy. The nursing personnel should not blindly accept such medications and administer the same in their patients, which may lead to serious adverse events including death. Further, if a specific prescribed brand is not available in the pharmacy, it should be brought into the immediate notice of the consulting physician. This is because even if the molecule remains the same, the art of drug delivery varies with individual brands that can lead to decreased toleration profile (Kaushal & Bates, 2001).
For example, prazosin hydrochloride is available in two forms in the market. In one form the drug is delivered through the unique Gastrointestinal Therapeutic Delivery system, which controls its rate of absorption and ensures its half-life for effective control of hypertension during the 24 hour period. The controlled absorption technology prevents prazosin from inducing issues of postural hypotension. Postural hypotension or sudden fall in blood pressure is a common documented side effect of prazosin. However, this technological advancement has reduced such chances manifolds and has increased the therapeutic potential of alpha adrenergic blockers in the management of hypertension. On the other hand, prazosin in its traditional dosage form may cause postural hypotension that may lead to accidental falls in a patient and delay his or her healthcare outcomes. Therefore, if the specific brand of prazosin is not available, and the nursing personnel administers the traditional prazosin that is available in the pharmacy, may lead to potential adverse events. Moreover, prazosin in the traditional form may require a twice a daily dosage due to its shot half-life, to produce effective control of blood pressure. However, if such prazosin brand is administered in a once a day schedule (as because the prazosin in GITS technology is recommended to be used once a day), it will lead to ineffective control of blood pressure and may cause fatal cardiovascular risks.
Adverse drug interactions may also occur if the health care providers do not comply to change in therapeutic regulations (Brennan, Leape & Laird, 1999). For example, nimesulide has been banned in a number of occasions or has been recommended for the classification of restricted use, in managing pain and inflammation. This is because the drug imposes potential risk in individuals who suffer from gastritis. The drug was once recommended for reduction of severe pain and inflammation, even in cases of pain in cancer patients. Therefore, nimesulide should only be recommended as a second-line therapy, when treatment with other non-steroidal anti-inflammatory agents, does not exhibit appropriate therapeutic response. Guidelines may also change in the administration of infusions and the solvents used to prepare such infusions. Therefore all the healthcare providers who are associated with the treatment regime must keep themselves updated, in order to ensure the safety of a patient.
Guidelines may also change in relation to an entire therapeutic segment. For example, The Survival Sepsis Campaign is a dynamic recommendation that changes virtually each year. This is due to to the resistance in the antibiotic patterns, which is a menace all across the world. Hence, healthcare providers who are associated with critical care must have the requisite knowledge in a change in Sepsis Management Guidelines. Such an issue is important to ensure safety and quality of care of a treatment regime. If the changed guidelines are not complied, it may lead to unnecessary administration of antibiotics that might have become resistant. Management of sepsis depends upon the initial antibiotic selected, and if the antibiotic has been documented to exhibit resistance, it will lead to adverse health outcomes in individuals and impact prognosis.
Failure to identify risk factors
The risk factors of a patient are often neglected which also leads to negative health outcomes in individuals and impact prognosis (Brennan, Leape & Laird, 1999). The risk factors of the patients may be neglected due to ignorance of updated knowledge or independent decisions of the caregiver. It’s a fact that Deep Vein Thrombosis may occur in patients all across the world, irrespective of gender and race. However, some developing countries argue that such phenomenon is a westernized concept due to the westernized lifestyle. Studies done in South East Asian countries have indicated that there exists a high risk of deep vein thrombosis in special patient populations. DVT is a physiological phenomenon and rarely may be linked to demographic variables. A patient who has a deficiency of clotting factors, patients who are overweight and are immobilized will carry the risk of DVT all throughout the world. However, it is the ignorance of physicians in such countries, that DVT prophylaxis is neither administered in surgical or medical patients. The patient experience fatal consequences of pulmonary embolism and varicose veins, which often develops into life-threatening conditions. Therefore, appropriate regulations should be framed, and compliance must be ensured in administering DVT prophylactic regimes.
Patients may be administered either pharmacological or non-pharmacological interventions for ensuring prophylaxis against DVT. Pharmacological interventions may include low molecular weight heparin or warfarin. On the other hand, nonpharmacological interventions may include administration of general compression stockings or ensuring the patient to become ambulatory as fast as possible. This is where the supportive care providers have an important role to deliver. Patients should be encouraged to become ambulatory either independently or with the support of health care providers. Such care provisions may drastically reduce the risk of DVT and ensure the safety of the specific patient population.
Patient safety may also be compromised when there is inefficiency in documenting the history of a patient. Even after such documentations, the physician may overlook the risk factors and the history, which imposes health care risks in a patient. Minimal access surgery is one of the recommended modern surgical techniques, which reduces the chances of prolonged hospital stay and development of post-operative infections. However, the process involves the infusion of carbon dioxide in the abdominal cavity of a patient. Individuals, who suffer from chronic obstructive pulmonary disease or asthma, might not tolerate this procedure and may have fatal consequences. Hence, the history of a patient is extremely important in ensuring the safety of a patient (Brennan, Leape & Laird, 1999).
Risks can also be imposed on patients due to the process and quality of caregiving. Elderly and challenged individuals have their own individual needs in carrying out activities of daily living. Therefore, the care providers must be apprised of such situations and should align themselves across such needs, in order to ensure the safety of a patient (Landrigan, Rothschild & Cronin, 2004).
For example, individuals who are old and are admitted in the orthopedic units may also suffer from dementia. Although, they might be treated efficiently and judiciously for the orthopedic problems, care of dementia may be undermined or compromised. This can lead to accidental falls in the care units and may aggravate orthopedic issues in a patient. Nursing personnel must ensure person-centric approach in adding such patients in their daily activities. Moreover, certain modifications may need to be implemented in the care facilities, to ensure the safety of patients. One such implementation is the demarcation of the hospital floors and the washroom floors with specific colors and keeping the patients appraised of the same.
Person-centric care also helps to understand the psychological condition of a patient. It is often noted that patients who are admitted to a care setting does not comply with therapeutic schedules. This might include refusal of medications, refusal of food or refusal of specific procedures and interventions. All such issues decrease the quality of care, causes increased safety concerns and impairs prognosis in a patient. Nursing personnel and supportive healthcare staff must counsel the patient appropriately, either independently, or with the help of their family members, to ensure treatment compliance (Landrigan, Rothschild & Cronin, 2004).
Prolongation of Hospital Stays and Nosocomial Infections
Individuals who are admitted in critical care units are susceptible to secondary infections from hospital settings. These individuals are normally immunocompromised and have a reduced immune status. Hence, the pathogens like bacteria can easily cause the secondary infection in these patients. Such issues impair prognosis and leads to negative healthcare outcomes. There are instances where the hospital stay of patients, has been prolonged due to adverse events or post-surgical complications. Increased stay in hospital settings has been positively correlated to the development of nosocomial (hospital-acquired) infections. Hence, adequate measures must be ensured to prevent surgical complications or adverse events, which prolong hospital stay. Procedures like fumigation of operation theaters and post-surgical wards must be efficiently carried out, in order to maintain appropriate sepsis in the hospital settings. Such measures will reduce the chances of nosocomial infections, and improve the safety profile of patients (Kaushal & Bates, 2001).
Compromise on medical ethics
It is true that the health care providers are overburdened with a range of responsibilities and the diverse demands of care, across various healthcare facilities. However, they must ensure adequate time for their patients in assessing their health conditions and planning appropriate interventions. One such dilemma arises, in providing ethical treatment intervention. It is always necessary that the patient must be provided with the adequate autonomy of selecting the choice of treatment or intervention. Further, interventions should always aim at providing a healthcare benefit to a patient. This philosophy is referred as “beneficence” in medical ethics. Apart from beneficence, care should be taken in providing non-maleficence to a patient. This means even if the therapeutic regime may not provide the appropriate clinical outcomes in a patient, it should never expose the patient to additional harm or risk. Therefore, care providers must be extremely careful in judging the risk-benefit ratio of a specific therapeutic regime, before they are administered to patients. The deviation is disregarding autonomy, beneficence and non-maleficence may jeopardize the safety of patients.
Technical issues may impose risk and burden on the safety of patients. For example, nursing personnel are overburdened due to the complexity of care in healthcare systems. It might happen that there may be a lapse in adjusting the rate of infusion, changing the infusion vials that are all related to the safety and quality of care in a patient. Such processes are very time bound and essential to be replaced or modulated at specific frequencies. Deviation from such adjustments may impose healthcare risks in a patient.
Patients are also exposed to risk, during the change of shift schedules of nursing personnel. Change of shift schedules or length of shift schedules imposes psychological stress on nurses. Such stress may lead to mistakes in the administration of drugs, or documentation of the last treatment schedule rendered to the patient or any other issues. They must also keep records of the issues, which the patient might have faced due to treatment interventions. Nurses may also fail to document the specific care needs at the time of change of shift schedules. Therefore, the head nurse and the nursing manager must ensure zero tolerance of such practices. Effective staffing solutions, engagement of qualified nurses, and building upon reflection on practice are some of the ways to ensure the quality of care and prevention of such deviations (Infusion Nursing Society, 2000).
v. Inadequate and Updated Knowledge
Evidenced-based practice is the hallmark of quality care provisions across all healthcare institutions. However, it is noted that adequate CMEs and training programs are not incorporated by various healthcare institutes as a part of professional development. Such issues lead to the gap in knowledge in both physicians and nurses. This leads to a risk of the safety concerns of patients. Therefore, each and every healthcare institution must ensure the adequate professional development of the care providers associated with that organization. The healthcare management system may make it mandatory to attend certain credit hours, in developing self-proficiency that will help in ensuring efficacy and safety of treatment interventions.
Healthcare systems are challenged with an influx of patients and discharges thereof. Each and every member of the healthcare chain has to maintain a certain degree of alertness and care, in order to ensure the smooth transition of a patient from one care unit to another or from the healthcare facility to the home. Therefore, care should be exerted that the correct discharge recommendations are provided for each and every patient. This is because if the deviation occurs at times of discharge, it may prove more fatal to the individual patient. Since, the patient will be discharged to their home; he or she will not get access to the emergency support systems if any adverse events occur. Therefore, the hospital administration must ensure a follow-up treatment schedule or take feedback from the patient or their families over the telephone or email, regarding the health conditions of the patient.
Discussion and Conclusion
From the discussions and analysis it is evident that safety of patients may be compromised on different aspects in healthcare set-up. Patients are dependent on healthcare setups not only to ensure their efficacy of treatment, but they are equally dependent on issues of safety. The patient and their family members access health care facilities to ensure peace of mind. Hence, health care management systems and the administration must recognize the risk factors that lead to a compromise on patient safety. They should formulate effective strategies, protocols and recommendations, which ensures the quality of care and provides adequate safety to a patient.
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