Healthcare Harm

In the medical field, healthcare harm refers to unintended injuries acquired by a patient from the medical practitioners leading to additional treatment. In the movie, Dennis Quaid narrates that his twins nearly succumbed to an overdose of heparin by the medics. The overdose, which resulted from human error, was almost fatal to the lives of young ones. Human error is responsible for healthcare harm in instances where the patients suffer from physical injuries or administration of the wrong dosage, as evident in the film. In some cases, the errors might emanate from negligence, where the practitioner fails to consult in case of challenges. The medic relies on his knowledge in administering the drugs leading to an overdose. Other examples resulting from negligence include infection of the patients due to poor cleaning. Therefore, the cause of the error is due to neglect and human error.

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The first competence exhibited by nurses in minimizing errors is patient-centered care. The treatment seeks to focus on the needs of the clients without violation of their cultural beliefs. In this case, the practitioner involves the patient in all the decisions made to minimize the errors. Secondly, nurses need to work in groups for effective decisions. Reviewing the treatment plans allows them to eliminate the programs that are not productive and a replacement with better approaches. The review minimizes errors by making collective decisions based on the expertise of the team (QSEN, 2019, P. 1). Thirdly, Evidence-Based Practice uses scientific data and research in making decisions about the patient. The practice does not rely on methods without scientific backgrounds when dealing with patients. The practice minimizes errors by ensuring that all the decisions made reflect on scientific evidence.

The fourth competency for nurses is quality improvement concerning the condition of the patient. In this competency, nurses record and analyze the progress of patients to assess the effect of the medication on the well being of the patient. Any negative improvement is an indicator of the need to change the treatment, while a positive outcome signifies progress. Nurses have the primary responsibility of ensuring safety for the patients (QSEN, 2019, p. 1). For example, the nurses have a duty of reporting any errors for immediate rectification to avoid further damage. Any effort to conceal the mistake would expose the patient to additional suffering that might be tragic. Lastly, nurses need to understand the use of information technology in improving their competency. Using technology, nurses can learn how to design treatments that match the needs of the clients. Understanding of new machines within the profession enhances service delivery to the patients and an improved outcome.

The best competencies in the profession are the use of technology and quality improvement. In the video, the doctors confused between the medicines due to their close similarity in the color of their label. Storage of the drugs using technological appliances would keep the two bottles far apart to minimize any chances of error. Secondly, the quality improvement would indicate to the nurses that the drugs are not delivering the expected outcome. In such cases, the nurses would realize the mistake and employ corrective measures to reverse the effect of the drugs. Alternatively, the nurses would work in groups to minimize the errors (Alfredsdottir & Bjornsdottir, 2008, p. 33). For example, if the nurses were in a group of four or five people, they would realize that the medicine used in the children was not the correct one. However, working in isolation led to the use of the wrong medicine twice, exposing the lives of the twin to danger.

The most significant impediment to the culture of safety is the lack of effective leadership. Exemplary leadership in healthcare should prioritize the safety of the patient irrespective of the circumstances. For example, misdiagnosis is widespread in the medical field. In the movie, the nurses told Pat that he had a tumor at the base of the spine leading to surgery. However, six months later, the pain returned, and the diagnosis revealed that he had cancer. Instead of taking responsibility for the misdiagnosis and rectifying the situation through better medical procedures, many organizations consider the case as a liability and invest in avoiding a legal suit from the patient (Cherry & Jacob, 2016, p. 142). Therefore, the organizations fail to take responsibility for their actions exposing the patient to more adverse effects of the misdiagnosis. The healthcare facilities need to improve the culture of safety by taking responsibility for their actions and prioritizing the safety of the patient in case of misdiagnosis.

The culture of safety is applicable in an environment where an inter-professional team works together to minimize risks and give the patients the best care possible. In the group, each member would provide additional knowledge towards the treatment of the patient with keen attention to the medicine to eliminate any errors. In the movie, Julie Thao administered the wrong medication to a woman in labor due to the fatigue of working double shifts (Quaid, 2012, p. 1). On a material day, the nurse slept in the hospital to avoid going home since the second shift was starting in a few hours. Instead of administering the antibiotic to the expectant lady, the nurse administered the epidural. The two drugs had the same tubing, and the fatigue affected her attentiveness to the error. The composure of a professional team would ensure safety by preventing nurses from overworking.

More so, the team would take part in the preparation of the medicine, reducing any chances of mistakes. In this clip, if part of the team prepared the antibiotic while the other prepared the epidural, the error would be avoidable. Some of the errors made by the nurses emanate from the close resemblance of the medicine (DeBourgh & Prion, 2011, p. 50). In the case of the twins, the doctors administered the wrong dose due to the close similarity of the bottles. Therefore, the application of technology is essential to place the drugs in different places to avoid confusion. Patient harm emanating from the mistakes has the power to affect the lives of the patients immensely. As a nursing practitioner, the best principle applicable in the elimination of healthcare harm is working in teams. Firstly, group work minimizes fatigue. Sharing of duties among the members allows the practitioners to fulfill the intended roles within a short time and without overworking any of the members.

Secondly, working in teams improves the competencies of each member. For the junior members in the profession, working with the experienced nurses gives them great exposure that enhances their abilities. Lastly, it is easier for a team to realize a mistake as opposed to an individual. During the errors covered in the video, all the nurses were working in isolation devoid of any assistance. Therefore, it became hard for them to realize the mistake and rectify the problem immediately. Working in teams provides an extra set of hands, eyes, and ears with the ability to point out a mistake before it occurs (Fuhrman & Zimmerman, 2016, p. 14). More so, the team can rectify a mistake faster and use the experience of the group in salvaging the situation. Therefore, the highest competency in the nursing profession is working in groups to eliminate errors and improve the capabilities of each member.

 

References

Alfredsdottir, H., & Bjornsdottir, K. (2008). Nursing and patient safety in the operating room. Journal of advanced nursing61(1), 29-37.

Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management. Elsevier Health Sciences.

DeBourgh, G. A., & Prion, S. K. (2011). Using simulation to teach prelicensure nursing students to minimize patient risk and harm. Clinical Simulation in Nursing7(2), e47-e56.

Fuhrman, B. P., & Zimmerman, J. J. (2016). Pediatric Critical Care E-Book. Elsevier Health Sciences.

QSEN. (2019). QSEN Competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas/

Quaid, D. (2012, August 3). Chasing Zero: Winning the War on Healthcare Harm [Video file]. Retrieved from https://www.youtube.com/watch?v=MtSbgUuXdaw&t=17s

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