Patient Safety Issues Paper Example

Introduction

This paper presents research on evidenced-based practice using the ACE Star Model to provide solutions for patient issues. Various incidents including diagnostic errors, medication errors, and lack of safety in the health have resulted in injury to patients increasing patient's morbidities and mortalities (Farra, Miller & Hodgson, 2015). Evidenced-based practicing indicating the collaboration of healthcare practitioners together with patients and their families help to reduce this problem. The focus for nurses is to enhance for patients and healthcare provider.

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Change Model Overview

The ACE Star Model explains five main points that are involved in the transformation and application of knowledge. This model has been represented by a five-pointed star whose cycles starts at the top point which entails the discovery of knowledge. The new expertise discovered often represent the research process (Farra, Miller & Hodgson, 2015). The second point on the star represents the Evidence Summary. Production of sufficient evidence by the research facilitates the drawing of conclusions that helps to generate more knowledge for higher levels. The knowledge generated from the conclusion enables one to move to the next level (Translation) which is represented by the third star and in this stage is when the nursing guidelines, procedures, and protocols are developed. The fourth point of the star (Integration) is the stage in which the clinical guidelines and procedures are implemented. Additionally, this stage forms the change theory is used to create as well as sustain guideline implementation. The fifth point of the star (Evaluation) is when the quality assurance and performance improvement are evident to monitor the expected outcome.

As can be seen, this mode should be used by nurses to promote change. This model provides a comprehensive way of translating evidence into practice. Through this model, nurses regard the nature of knowledge as well as the knowledge on transformation which is very important in making appropriate decisions when providing care for the patient. Also, making the appropriate decision in clinical setting helps to ensure that safety measures and rights of a patient are protected which provides satisfactory results for the patients. This model also points out barriers as well as their solution for nurses when implementing evidence-based practice. Furthermore, the model promotes the uptake and utilization of new knowledge generated which further can be incorporated in nursing research to generate more knowledge and skills which generally promotes nursing services at the same time ensuring that only quality services are given to the patients and the communities.

The Scope of the EBP

The evidence-based practice occurs when the nurse makes a clinical decision basing on the available evidence that is updated, and his or her expertise in collaboration with the patient to provide nursing care that is optimum. In other words, the scope comprises three component which includes; clinical expertise, evidence, and patient preference. Clinical expertise encompasses the nurse's cumulated knowledge, experience, and skills which influences one decision-making process. Evidence entails any activity or information that has been proved to be real or valid while patient preference refers to the concerns, values, as well as expectation patient, brings in a clinical setting which must be regarded.

Non-adherence to evidenced-based practices has led to the emergence of safety issues for patients such as medical errors, diagnostic errors, lack of safety in the workplace as well as in the health facility, inappropriate discharging of patients in the health facility, emergence of superbugs, sepsis, reprocessing issues and mismanagement of patient's record.

According to data provided by the Agency for Healthcare Research and Quality indicated that medication errors the most common type of error which affects hospitalized patients. The report indicated that five percent of hospitalized patients are often affected by the adverse drug effects annually, and the errors were also seen in half of all the surgeries (Thom et al., 2016). According to the research carried out by Massachusetts General Hospital, medication errors occurred as a result of poor labeling of drugs, administration of inappropriate dosages for drugs and neglecting to treat the condition that patients presented with as well as poor documentation.

According to the National Patient Safety Foundation, patient diagnostic errors account for six to seventeen percent of diagnostic errors which occurs in the health facility. Furthermore, the research finds out that diagnostic errors accounted for about 10% of patient deaths. The Institute of Medicine (IOM) suggested that the reduction of diagnostic errors could be overcome by partnering with patients and their families as well as the fostering of teamwork among healthcare practitioners. Safety issues in the workplace occurred as a result of poor maintenance of buildings as well as the presence of compromised buildings (Thom et al., 2016). According to the report by Florida Agency for Healthcare Administration, indicated that one of the hospitals in Florida failed to control sewage leak as well as cleaning up of the sewage, failure to conduct the risk assessment, and rats on the ceiling which leaked condensation on the food preparation tables. As a result, it leads to the emergence of Legionella disease.

Inappropriate discharging of patients resulted in the development of an adverse event in 20% of patients who were discharged from the health facilities. The adverse events occurred three weeks after discharge. According to the researchers, this could be prevented (Thom et al., 2016). Again failure to implement measures of infection prevention led to the development and sepsis among the patients. Failure to implement privacy policies led to an increase in cyber crimes and hacking of medical equipment caused injury to patients.

As can be seen, the safety issues impact negatively on the healthcare by increasing risks for injury for patients as well as healthcare providers. This also leads to an increase in morbidity and mortality cases in health facilities.

Stakeholders

The stakeholders will comprise of a nurse, physician, pharmacists, and medical engineers. The nurse will perform a role as a coordinator of the team; the physician will be in charge of diagnosing and providing treatment plans in collaboration with a nurse. The pharmacist will take ensure safety in prescription and handling of drugs and the medical engineer will help in the designing and maintenance of medical equipment.

Evidence

The Institute of Medicine (IOM) suggested that the reduction of diagnostic errors could be overcome by partnering with patients and their families as well as the fostering of teamwork among healthcare practitioners (Boswell & Cannon, 2018). Safety issues in the workplace occurred as a result of poor maintenance of buildings as well as the presence of compromised buildings these can also be reduced by the coloration with medical engineers to ensures safety in the workplace. To prevent the breach of personal information for patients law should be established to enhance privacy (Farra, Miller & Hodgson, 2015). The evidence for this practice can be found in the; Institute of Medicine's report on clinical practice guidelines (IOM) and the National Guidelines for Clearinghouse (AHRQ). The strengths of this research include the provision of information on the guidelines on that help to improve service delivery in a healthcare facility.

The evidence for this practice can be found in the; Institute of Medicine's report on clinical practice guidelines (IOM) and the National Guidelines for Clearinghouse (AHRQ) will be used to prevent the occurrence of patient issues (Farra, Miller & Hodgson, 2015). The IOM guidelines will help to prevent diagnostic errors, medication errors, the occurrence of sepsis and enhance good working condition. Likewise, the National Guidelines for Clearinghouse will help to ensure that personal information of the patients, as well as medical equipment, will be protected.

Recommendations for Change Based on Evidence

Healthcare providers should collaborate with patients, their families as well as one another to prevent the occurrence of patient safety issues.

Policymakers should enact laws to protect medical equipment and personal information.

Action Plan

The project will be implemented within a week after informing all the stakeholders and will be evaluated two months after the implementation. The results after evaluation will be displayed on tables and graphs. The desired outcome is the reduction of patient's safety issues. The plan will be implemented on a large scale through the involvement of the healthcare providers across the nation and around the globe through the distribution of the findings from the research for implementation of the recommended findings. These findings will be disseminated through online publication and print media such as magazine

Conclusion

Patient safety, as well as the safety of healthcare providers, requires the collaboration of healthcare workers, patients, and their families. Additionally, the establishment of policies by policymakers helps to protect health information for patients and medical equipment.

References

Boswell, C., & Cannon, S. (2018). Introduction to nursing research: Incorporating evidence-based practice. Jones & Bartlett Publishers.

Farra, S. L., Miller, E. T., & Hodgson, E. (2015). Virtual reality disaster training: Translation to practice. Nurse education in practice, 15(1), 53-57.

Thom, K. A., Heil, E. L., Croft, L. D., Duffy, A., Morgan, D. J., & Johantgen, M. (2016). Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations. Journal of interprofessional care, 30(6), 819-822.