Nursing Strategies for Adverse Events Within an Acute Environment

The purpose of this essay is to critically evaluate current research about adverse events within an acute environment. The aim is to examine nursing strategies that can be implemented to prevent adverse events in a hospital by discussing the role of inter-professional practice in promoting patient safety, barriers that may arise during a Registered Nurses practice and how to overcome these barriers.

 An Adverse Event (AEs) is an injury or unintended complication in which results in harm to a patient, resulting in mortality, disability, psychological distress or prolonged admission during a patients stay in hospital. (Hoogervorst-Schilp, Langelaan, Spreeuwenberg, Bruijne, & Wagner, 2015)

Incidents of adverse events are one of the major challenges that health care facilities face on a regular basis today. These events have a negative impact that can further cascade and create adverse occurrences on the patients quality of life, thus heavily impacting on their family members or carers, as well as costly hospital admissions that could potentially be avoidable. (Ghaferi, 2015) The rate and continuity of adverse events within hospital can greatly reflect how well patient safety is managed and maintained. Adverse events most commonly identified in healthcare facilities  are; falls, medication errors, malnutrition, incontinence and skin integrity, pressure injures and hospital inquired infections.  (Kang, Kim, & Lee, 2014)

While time constraints are high when providing care to multiple patient as a Registered Nurse (RN), Inadequate funding to healthcare services resulting in increased workload, lack of efficient equipment and inappropriate placement of patients in the incident of depletion of available bed space can further increase the potential of adverse events occurring. (Adel-Mehraban, Karimi, & Moeini, 2018) (Rochefort, Buckeridge, & Abrahamowicz, 2015) (Bae, 2014)

 Within Western medicine , medication is the most commonly used method of treatment and can greatly improve one’s health, when used adequately and appropriately. As medications are the most commonly used form of treatment this can hold a higher prevalence of errors associated when administering. (Armstrong, Dietrich, Norman, Barnsteiner, & Mion, 2017)

RNs are responsible and accountable for patient care and safety for all patients within their care when administering medications. Although medication errors can be made throughout all phases of the medication process involving all inter-professional practice team members such as Doctors and Pharmacists, RNs within healthcare facilities are more at risk of unintentionally causing a medication error. This is largely due to the RNs role to administer medication at the bedside. RNs must have adequate knowledge and maintained particular set skills during the administration process. However,  medication errors have recently become more complex and convoluted. (Mostafa, Sabri, El-Anwar, & Shaheen, 2019)

Polypharmacy is among the most evident in the elderly community and is potentially due to the rate of co morbid diseases in an increase population of the aging person.  (Urfer, Elzi, Dell-Kuster, & Bassetti, 2016 & Ferreira, Martins, & Fernandes, 2016)

Once a medication error has been made the consequences may range from  no notable effects to mortality. Medication errors may cause an arise of new conditions, temporary or permanent, physiological or neurological changes resulting in disability and decline, and psychological damage to the patient. (Kang, Kim, & Lee, 2014)

Amid adverse event within the hospital setting, psychological trauma based on detrimental professional outcomes can be experienced by healthcare professionals. Previously observed adverse events and outcomes can lead to potential long-term side-effects including increased stress and dissatisfaction in regards to the professional’s job, poor coping mechanisms and the avoidance of potential situations at both home and in the workplace due to a fear of incompetence. (Schrøder, Lamont, Jørgensen, & Hvidt, 2018)

 Detrimental professional outcomes both impose, as well as dwindle the level of trust and rapport that has been developed with patients and their family members. This can result in damage to the reputation for the facility in question, weaken the trust in hospital systems and subsequently possible avoidance to seek help in medical situations. (Guinane, 2017 & Chan, 2016)

A patients psychological wellbeing is impacted upon when the establishment of a strong professional rapport has failed to have been built. Post an AE, failure to openly disclose information and lack of perceived accountability can diminish the patients trust in not only in the RN but also other healthcare clinicians. (Watson, 2014) Patients may feel isolated, embarrassed, or feel as though their wishes have not been adequately addressed given the impact of psychological stress post AEs. This can also result in financial hardships and place a strain on family structures. These financial hardships can arise when the patients hospital stay has been extended, thus also increasing the financial cost to the facility and potentially exposing the patient to AEs, such as hospital acquired infections. (Southwick, Cranley, & Hallisy, 2015)

 Interprofessional communication is crucial as it promotes and boosts the development of team member satisfaction and patient outcomes. Routine team meetings increase interprofessional communication skills and provides the opportunity for discussion and input between various healthcare clinicians to ensure the patients needs, both perceived and expressed, are being met in collaboration with shared decision making. Throughout a patients hospitalisation, routine team meetings aid in ensuring a safe and effective environment, thus increasing consistent care that is applied throughout their stay, minimising patient AEs and failed discharges. (Baessler, 2016)

Communication can be described as a complex and dynamic process, and is seen as a key element in providing high quality nursing care. Effective communication improves patient rapport, a patients attitude towards their health and enhances patient outcomes, multidisciplinary support and input.  However, When communication break down or poorly communication occurs among health clinicians, patients and family members can corresponds to unavoidable and potential harm to patients and may be responsible for adverse reactions to occur.   (Tingle, 2018, Cox, 2014 & Norouzinia, Aghabarari, Shiri, Karimi, & Samami, 2015)

Shared decision making model has been implemented and encouraged throughout many health care facilities. Shared decision making is defined as a collaborative approach involving health care professionals, the patient and their family members. Misalignment in communication breakdowns can occur during these collaborative approaches.  Respecting and developing a professional work relationship within healthcare professional can improve patient outcomes,  avid patient trust within healthcare facilities increasing future patients engagement and reduce potential adverse reactions. (Elwyn et al., 2017 & Hoffmann & Mar, 2014)

 RNs should work alongside multidisciplinary team members, such as doctors and pharmacists to collaborate, discuss and plan appropriate management of medications prior to the commencement of the medication process. This can decrease the chain of AE occurring and causing potential inadvertent harm to a patient during the administration of drugs by the RN. To aid in the reduction of medication related allergic reactions, the RN should enquire if the patient has ever received this medication before, and if not, providing the patient with information regarding the new drug, as well as the opportunity to ask any further questions or express concerns in relation to administration of the drug. If the patient seeks further assistance, a referral may be made to the pharmacist to aid concerns and questions expressed by the patient. (Marvanova, 2017& Koberlein-Neu, 2016)

Nurses are faced with ever changing practices, policies and knowledge requirements within their scope of practice. RN’s are now also provided with a diverse and broad range of drugs used for treatment. Given the frequency of changing practice and knowledge requirements, medication errors may arise due to inadequate or poor knowledge in regards to adverse interactions, common side effects, names, abbreviations, dose and frequency changes. This can be seen as a Nursing barrier as it poses risk to not only the RN but compromised patient safety.  (Marvanova, 2017)

To overcome this barrier and ensure adequate patient safety is being achieved an RN can perform and introduce various medication safety habits.  

Ensuring that the six rights of medication administration are performed and reducing interruptions during medication rounds produces avocation for patient safety.  (5. Pharmacology, Nursing; The ultimate study guide 2015)

When administering Intravenous drugs, using pumps with safe guards may lower the potential in compromising a patient by possible overdose or by an RN using an incorrect mixing solution.  Before administering any medication an RN may have inadequate knowledge of said drug, using the Monthly Index of Medical Specialities (MIMS) or The Australian injectables drug handbook (AIDH) can provide RNs with vast information on a particular drug before administering to a patient. (Medication Safety 2015)

Pharmacy educators can also provide education to enhance knowledge and maximise patient safety. Pharmacy educators are known as experts in the medication field and can offer an RN an abundance of information about adverse affects, common side-effects, information on preparation and correct storage of medications. (Marvanova, 2017)

In conclusion adverse events are still seen as one of the major challenges that health care facilities face on a regular basis. Adverse events can cause detrimental professional outcomes that both diminish trust and rapport within patients and their family members, as well the healthcare facility. Interprofessional  practice of interprofessional communication using  shared decision making  and interprofessional collaboration with multidisciplinary promotes patient safety and can reduce the likelihood of adverse events occurring.

References

• Adel-Mehraban, M., Karimi, A., & Moeini, M. (2018). Occupational stressors in nurses and nursing adverse events. Iranian Journal of Nursing and Midwifery Research, 23(3), 230. doi:10.4103/ijnmr.ijnmr_253_15
• Armstrong, G. E., Dietrich, M., Norman, L., Barnsteiner, J., & Mion, L. (2017). Nursesʼ Perceived Skills and Attitudes About Updated Safety Concepts. Journal of Nursing Care Quality, 32(3), 226-233. doi:10.1097/ncq.0000000000000226
• Bae, S., & Fabry, D. (2014). Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2), 138-156. doi:10.1016/j.outlook.2013.10.009
• Baessler, F., Weiss, C., Juenger, J., & Moeltner, A. (2016). Good Communicators and Their Failure in Interprofessional Communication. Journal of Psychosomatic Research, 85, 54-55. doi:10.1016/j.jpsychores.2016.03.133
• Cox, J., Thomas-Hawkins, C., Pajarillo, E., Degennaro, S., Cadmus, E., & Martinez, M. (2015). Factors associated with falls in hospitalized adult patients. Applied Nursing Research, 28(2), 78-82. doi:10.1016/j.apnr.2014.12.003
• Elwyn, G., Durand, M. A., Song, J., Aarts, J., Barr, P. J., Berger, Z., . . . Weijden, T. V. (2017). A three-talk model for shared decision making: Multistage consultation process. Bmj. doi:10.1136/bmj.j4891
• Ferreira, A., Martins, S., & Fernandes, L. (2016). Comorbidity and polypharmacy in elderly living in nursing homes. European Psychiatry, 33. doi:10.1016/j.eurpsy.2016.01.1720
• Ghaferi, A. A., & Dimick, J. B. (2015). Understanding Failure to Rescue and Improving Safety Culture. Annals of Surgery, 261(5), 839-840. doi:10.1097/sla.0000000000001135
• Guinane, J., Hutchinson, A. M., & Bucknall, T. K. (2018). Patient perceptions of deterioration and patient and family activated escalation systems-A qualitative study. Journal of Clinical Nursing, 27(7-8), 1621-1631. doi:10.1111/jocn.14202
• Hoffmann, T. C., & Mar, C. B. (2014). Shared decision making: What do clinicians need to know and why should they bother? The Medical Journal of Australia, 201(9), 513-514. doi:10.5694/mja14.01124
• Hoogervorst-Schilp, J., Langelaan, M., Spreeuwenberg, P., Bruijne, M. C., & Wagner, C. (2015). Excess length of stay and economic consequences of adverse events in Dutch hospital patients. BMC Health Services Research, 15(1). doi:10.1186/s12913-015-1205-5
• Jones, A., & Johnstone, M. (2017). Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: Four case scenarios. Australian Critical Care, 30(4), 219-223. doi:10.1016/j.aucc.2016.09.005
• Kang, J., Kim, C., & Lee, S. (2014). Nurse-perceived Patient Adverse Events and Nursing Practice Environment. Journal of Preventive Medicine and Public Health, 47(5), 273-280. doi:10.3961/jpmph.14.019
• Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159-165. doi:10.12968/bjon.2017.26.3.159
• Köberlein-Neu, J., Mennemann, H., Hamacher, S., Waltering, I., Jaehde, U., Schaffert, C., & Rose, O. (2016). Interprofessional Medication Management in Patients With Multiple Morbidities. Deutsches Aerzteblatt Online. doi:10.3238/arztebl.2016.0741
• Matin, B. K., Hajizadeh, M., Nouri, B., Rezaeian, S., Mohammadi, M., & Rezaei, S. (2018). Period prevalence and reporting rate of medication errors among nurses in Iran: A systematic review and meta-analysis. Journal of Nursing Management, 26(5), 498-508. doi:10.1111/jonm.12579
• Mannix, T., Parry, Y., & Roderick, A. (2017). Improving clinical handover in a paediatric ward: Implications for nursing management. Journal of Nursing Management, 25(3), 215-222. doi:10.1111/jonm.12462
• Marvanova, M., & Henkel, P. J. (2017). Collaborating on medication errors in nursing. The Clinical Teacher, 15(2), 163-168. doi:10.1111/tct.12655
• Medication Safety. (2015). Journal of Pharmacy Practice and Research, 45(4), 450-458. doi:10.1002/jppr.1170
• Mostafa, L. S., Sabri, N. A., El-Anwar, A. M., & Shaheen, S. M. (2019). Evaluation of pharmacist-led educational interventions to reduce medication errors in emergency hospitals: A new insight into patient care. Journal of Public Health. doi:10.1093/pubmed/fdy216
• Norouzinia, R., Aghabarari, M., Shiri, M., Karimi, M., & Samami, E. (2015). Communication Barriers Perceived by Nurses and Patients. Global Journal of Health Science, 8(6), 65. doi:10.5539/gjhs.v8n6p65
• Rochefort, C. M., Buckeridge, D. L., & Abrahamowicz, M. (2015). Improving patient safety by optimizing the use of nursing human resources. Implementation Science, 10(1). doi:10.1186/s13012-015-0278-1
• Schrøder, K., Lamont, R., Jørgensen, J., & Hvidt, N. (2018). Second victims need emotional support after adverse events: Even in a just safety culture. BJOG: An International Journal of Obstetrics & Gynaecology, 126(4), 440-442. doi:10.1111/1471-0528.15529
• Singh, N. R. (2015). 5. Pharmacology,. In Nursing: The ultimate study guide (p. 129). New York: Springer Publishing Company.
• Singh, N. R. (2015). Nursing: The ultimate study guide. New York: Springer Publishing Company.
• Southwick, F. S., Cranley, N. M., & Hallisy, J. A. (2015). A patient-initiated voluntary online survey of adverse medical events: The perspective of 696 injured patients and families. BMJ Quality & Safety, 24(10), 620-629. doi:10.1136/bmjqs-2015-003980
• Tingle, J. (2018). Communication breakdown in healthcare settings. British Journal of Nursing, 27(20), 1204-1205. doi:10.12968/bjon.2018.27.20.1204
• Urfer, M., Elzi, L., Dell-Kuster, S., & Bassetti, S. (2016). Intervention to Improve Appropriate Prescribing and Reduce Polypharmacy in Elderly Patients Admitted to an Internal Medicine Unit. Plos One, 11(11). doi:10.1371/journal.pone.0166359