Analyzing Errors In Healthcare Essay Example

I work at clinics and medical offices where we focus on diagnosing and treating outpatients. The primary goal of this facility is to offer preventative care and other essential diagnoses at the convenience of a patient. The quality metric that our clinics focus on and monitor is analyzing errors. As Vahidi et al. (2018) claim, medical errors can occur at every phase of diagnosis and treatment, posing a severe healthcare problem and impending patient safety. Atanasov et al. (2020) further indicate that these errors are the key cause of patient morbidity and mortality, whereas medical errors are the third cause of death in the US. Our facility analyzes errors via root cause analysis (RCA), a structured method of analyzing serious adverse events. The principle of RCA is to ascertain the causal factors that contribute to and increase the prospect of errors while circumventing the ruse of focusing on mistakes by persons. The importance of this analysis is that it utilizes a systems approach to identifying both active and latent errors. Therefore, analyzing errors is crucial to identifying the underlying factors that cause an error and approaches that can be used to reduce the associated risks.

Existing data prove that medical errors are common in most healthcare facilities and have adverse effects on patients. According to Vahidi et al. (2018), medical error is the underlying cause of deaths and disabilities of millions of patients globally, and most of these errors are preventable. Medical errors also contribute to increased health costs by $17 to $19 billion annually. Zhou et al. (2018) report that medication errors are the primary cause of adverse drug events (ADEs), which causes unnecessary hospital admissions, patient dissatisfaction, and patient harm. Such alarming data calls for an effective way of preventing these errors. Consequently, the ability to analyze the underlying factors that encourage these errors is key to their prevention.

Analyzing errors in healthcare is paramount since it identifies the various types of errors, their impact on patient care, contributing factors, and the existing counteractive and preventive strategies for these errors. The two major types of analyzing errors metric focus on are active and latent errors. Active errors occur at a point in the line between people and a complex system, while latent errors are the existing problems within the healthcare system that lead to adverse events. Further, analyzing errors identifies the impact that medical errors have on patients. For instance, Atanasov et al. (2020) posit that apart from causing patient suffering and harm, medical errors result in emotional and mental effects on the patient’s relatives and the healthcare givers. Analyzing errors is also crucial to identifying the causative factors such as the work environment, staffing, team environment, patient characteristics, and task-related issues that can stimulate medical errors. Preventive measures against healthcare errors include integrating technology in patient treatment for ease of accessing their information, encouraging patients to speak up if they have a concern or a question, and having the patient accompanied by a family member or a friend when they are seeking medical care.

The ability to analyze errors has positive effects on patient care. This metric enhances patient safety by alerting patients from suffering adverse outcomes when seeking medical care (Karande et al., 2021). Thus, executing an RCA on healthcare errors aims to investigate the cause of the error and ways of enhancing the system and processes to reduce the odds of recurrence. Besides, analyzing errors aids in identifying and reducing the causative factors of errors in the future for better and improved patient safety. This comes in line with our hospital’s policy of prioritizing patient safety by minimizing cases of errors throughout their treatment.

I interviewed doctor C. Ying (personal communication, January 30, 2022), a nurse manager in our work, on the use and efficiency of analyzing errors at our place of work. C. Ying (personal communication, January 30, 2022) claimed that they had used the analyzing errors metric for five years. The hospital has used the RCA method to monitor compliance with this quality metric. Rodziewicz et al. (2021) argue that RCA is key to identifying the contributing factors that cause disparities in performance. Similarly, C. Ying (personal communication, January 30, 2022) insisted that RCA aids them in identifying the hidden cause of errors and their source. The hospital also relies on an RCA team whose work focuses on the systems and processes that yield errors to ensure that they comply with the metric. C. Ying (personal communication, January 30, 2022) also added that the team collects data on changes within the systems and processes that will enhance performance and reduce errors in healthcare. Complying with this metric allows the organization to identify causative factors of both active and latent errors, which significantly affect compensation. C. Ying (personal communication, January 30, 2022) claimed that their ability to identify the sources of errors, such as staffing, helps them determine the number of nurses that should be working at a certain time, which influences their workforce. C. Ying (personal communication, January 30, 2022) confirmed that they are accountable to the Joint Commission, which requires them to conduct an RCA after every sentinel event. In an instance where they report poor performance, the Joint Commission executes onsite reviews to identify the cause of the error that threatened a patient’s health and safety (Peerally et al., 2017). C. Ying (personal communication, January 30, 2022) further claimed that their established goal with analyzing errors metric is to promote patient safety by identifying factors that escalate the probability of errors occurring and eliminating them for better healthcare delivery. For the past two years, C. Ying (personal communication, January 30, 2022) posited that they had achieved their set goals of reducing patient harm, unnecessary admissions, and reduced morbidity and mortality rates associated with medical errors. (C. Ying, personal communication, January 30, 2022).

There are various provider-specific metrics for nurse practitioners (NP) in every healthcare institution. Patient care is one of the metrics used to assess the efficiency of analyzing errors. NPs should focus on the quality of care by following the standards set by the insurance companies that reimburse medical fees depending on the standards set. These compliances are set to ensure that NP’s perform well and their earnings depend on their care to both inpatients and outpatients. Besides, the clinical skills of the NPs are used to assess the efficiency of analyzing errors. NPs should have a skill set to perform various procedures or diagnose illnesses without making errors (Kleinpell & Kapu, 2017). Lastly, NPs should work on enhancing their relative value units (RVUs) as a measure of their improved productivity level. NPs should focus on developing their RVUs while promoting a patient’s well-being by avoiding errors. This way, they promote patients’ safety while increasing the productivity and profit generated to the institution.

An instance when RCA was used is when a 4-year-old girl with a brain tumor was given 600 mg of methotrexate after the tumor was removed. The girl developed seizures and later died. It was later noted that the prescription was wrong, as methotrexate was 20 times great for this patient. The doctor who administered this dosage was unaware that it applied to the intravenous drips only. The case was conveyed to The Joint Commission, which led to the RCA investigation. The outcome was to educate the entire medical staff on drug administration and dosage.

A problem area that exists in the RCA is the use of poorly designed risk controls. RCA focuses on preventing similar events from recurring. To come up with counteractive measures, the RCA team settles for weaker solutions, such as administrative ones and not the latent causes of the error, such as the used technology (Peerally et al., 2017). I would improve on this by offering sufficient guidance to the affected practitioner or department. Throughout the module, I have learned that caregivers must improve the care process by learning how to provide the existing therapies effectively to improve patient outcomes. As an adult gerontological nurse practitioner (AGNP), I have learned that promoting patient safety is crucial to their wellness. Therefore, as an AGNP, I will identify the risk factors that may affect the health status of my patients. I will educate them on ways of enhancing their health outcomes by being cautious of the treatment process to identify or prevent any medical error that can threaten their welfare. Similarly, as a registered nurse (RN), I will be keen when assessing and identifying patients’ needs. I have discovered that misdiagnosis of errors can occur during the initial treatment stage, which is a common medical error (Kleinpell & Kapu, 2017). Thus, I will ensure that I am extra cautious when diagnosing my patients, especially when dealing with those high-risk diagnoses such as cancer and heart diagnoses.

References

Atanasov, A. G., Yeung, A. W. K., Klager, E., Eibensteiner, F., Schaden, E., Kletecka-Pulker, M., & Willschke, H. (2020). First, do no harm (gone wrong): Total-scale analysis of medical errors in scientific literature. Frontiers in Public Health, 8, 639.

Karande, S., Marraro, G. A., & Spada, C. (2021). Minimizing medical errors to improve patient safety: An essential mission ahead. Journal of Postgraduate Medicine, 67(1), 1.

Kleinpell, R., & Kapu, A. N. (2017). Quality measures for nurse practitioner practice evaluation. Journal of the American Association of Nurse Practitioners, 29(8), 446-451.

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417-422.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical Error Reduction and Prevention. In StatPearls [Internet]. StatPearls Publishing.

Vahidi, S., Mirhashemi, S. H., Noorbakhsh, M., & Taleghani, Y. M. (2018). Clinical errors: Implementing root cause analysis in an area health service. International Journal of Healthcare Management, 1-12.

Zhou, S., Kang, H., Yao, B., & Gong, Y. (2018). Analyzing medication error reports in clinical settings: an automated pipeline approach. In AMIA Annual Symposium Proceedings (Vol. 2018, p. 1611). American Medical Informatics Association.

“The Creation Of Adam” By Michelangelo As Inspiration

Rethinking the past is beneficial for idea generation, so turning to the universally recognized masterpieces for inspiration is a common practice. The Creation of Adam by Michelangelo, one of the key tourist attractions of the Vatican, is among such thought-provoking pieces. This paper presents a drawing inspired by Michelangelo’s painting and analyzes the two works comparatively with attention to themes, the elements of design, and tools.

Inspiration Piece

The inspiration piece is one of Michelangelo’s signature works – The Creation of Adam. The approximate date of creation is between 1508 and 1512, and the place of origin is the ceiling of the Sistine Chapel in the Vatican City State (Buonarroti Simoni, 1508-1512). As Figure 1 demonstrates, the fresco painting aims to illustrate the story of humanity’s creation interpreted from the Book of Genesis and captures the moment when Adam receives the gift of life. Its underlying message has diverse interpretations due to some elements resembling the human brain and the uterus.

The creation of Adam
Figure 1. The creation of Adam (Buonarroti Simoni, 1508-1512).

Student’s Art Piece

The art piece is a pencil drawing named When Machines Start to Think. The work shown in Figure 2 reflects on the life creation narrative by placing it in the context of modern realia and exploring humankind’s potential as “creators’ ‘ apart from giving birth to children. Specifically, the piece places humanity in the creator’s position, whereas advancements in robotics and artificial life stemming from the ongoing scientific progress are symbolized by the programmable robotic arm. The piece represents humanity’s emerging role in creating new life and the responsibility for any of its consequences. However, it should not be interpreted as the statement of people’s omniscience or omnipotence.

When machines start to think.
Figure 2. When machines start to think.

Connection

The pieces utilize different media but are closely intertwined thematically. Regarding thematic proximity, the drawing borrows the central element of Michelangelo’s painting, the touching hands, and uses it to explore what “life creation” might mean today if not tied to the religious worldview. In the original painting, God creates the first person in his likeness and image. Similarly, today’s researchers apply the knowledge of how the brain processes information and sends signals to the body to create advanced robotic systems that are pre-programmed or even capable of mimicking human thinking and behavior.

The development of humanoids that utilize machine learning and artificial intelligence technologies to learn to react just like humans is a prominent robotics field aside from industrial and medical robotics (Pagliarini & Lund, 2017). As for art media, Michelangelo’s masterpiece uses plaster and paint, whereas the student’s materials are paper and a graphite pencil. By causing the lack of color in the student’s work, this difference influences the degree of realism as perceived by the viewer. Finally, thin pencil strokes could make it easier to place accents and keep the theme’s depictions abstract and simplified.

The similarities and differences relate to multiple points of analysis, including themes, media, and design elements. Both pieces depict the touching hands as a metaphor for breathing life into inanimate objects and accentuate the link between the creator and the creation, but they are dissimilar in terms of art media. Also, both works use tone differences/shades to create an illusion of three-dimensional objects and have visual rather than actual textures. Other design elements also reveal numerous differences; Michelangelo uses horizontal or curved lines and irregular shapes, whereas the student’s piece features diagonal and horizontal lines and both circular and irregular shapes.

Regarding color and patterns, the inspiration piece uses diverse pastel colors and repeatable lines to represent clothing folds, whereas the student’s piece is monochromatic and features homogeneous horizontal lines in the background. For composition, in Michelangelo’s work, the left and the right parts represent different but relatively independent worlds, with the touch connecting them. The student’s work centers the touching fingers and accentuates this part by means of shades. Therefore, the pieces are rather different even though the drawing makes a clear reference to Michelangelo’s painting.

References

Buonarroti Simoni, M. L. (1508-1512). The creation of Adam [painting]. The Sistine Chapel, the Vatican City State. Web.

Pagliarini, L., & Lund, H. H. (2017). The future of robotics technology. The Journal of Robotics, Networking and Artificial Life, 3(4), 270-273. Web.

Immigration In Crisis In Episode 10 Of The NASW Podcast

The NASW podcast was centered on the immigration rules in the U.S. and their impacts on social workers. Immigration became an issue of concern after President Trump’s administration imposed the “zero tolerance” rule (NASW, 2018). Considering the weight of the problem on social workers and the southern border concerning the separation of children from their parents, such a talk was essential to unveil the deep concerns raised by Trump’s immigration policy. The NASW is one of the largest bodies of professional social workers; hence, it was qualified to hold such a talk.

The talk involved professionals with experience in the matters of immigration whose aim was to analyze the immigration policy and develop a clear strategy for addressing the repercussions thereof. First, Greg Wright, the public relations manager, noted that the “zero-tolerance” immigration rule had angered social workers for inflicting suffering on immigrants (NASW, 2018). Mel Wilson, the social justice and human rights manager, confirmed that the rule criminalized seeking help, which Guadalupe confirms and adds that it contributes to racism.

In response to the talk, I believe the podcast highlighted the crucial factors that affect social workers. Although they are expected to fight for human rights, justice, and aid in creating efficient human relations, social workers are limited by the immigration rules set by the government. Guadalupe and Mel agree that social workers must continue speaking out the facts and campaigning for the rights of immigrants, especially the children who are in dire need of support (NASW, 2018). Essentially, the podcast highlighted the need for a legislative fix to the immigration issue that will contribute to healing and restoration to the immigrants. In conclusion, NASW podcast ten on the immigration crisis was well constituted, with experts discussing the need for the intervention of all stakeholders to stand against the discriminatory rules comprised in Trump’s “zero tolerance” policy.

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