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Risk assessment is a process of determining what could go wrong so as to put in place suitable control measures to prevent it from happening preventing losses, damages and injuries. Risk assessment is one of the steps in risk management. Risk itself is defined by the Department of Health’s (DH) 2000 report, ‘An Organization with a Memory’ (OWAM) risk is defined as: ‘The likelihood, high or low, that somebody will be harmed by a hazard, multiplied by the severity of potential harm.’(DH 2000: xii)
Risk assessment is important as it will look at the developments of improving patient safety within the National Health Service (NHS) through Government reports and incident reporting, the possible consequences and risk to the patient of omission of medication and how this risk can be reduced whilst examining various health and safety models.
My patient is a 93 year old woman, who will be known by the pseudonym Mrs. Johnson, to protect her identity and respect her confidentiality in accordance with the Nursing and Midwifery Councils (NMC) Code of Conduct (2008).
Mrs. Johnson has a medical history of sickness and has been admitted ten times to hospital in the past twenty years. She has a medical history of being admitted to hospital for long periods of time. On this occasion she was going down the stairs of her house and she fell.
The doctor diagnosed a fractured pubic ramous. The doctor diagnosed this because Mrs. Johnson fell down in a standing position. There was minimal past history of trauma and the doctor carried out a rectal examination where he observed a palpable fracture line on the bimanual observation, he also observed rectal bleeding, retroperitoneal bleeding with a bruised loin, neurological and vascular abnormalities in both legs and there was also a sign of urinal tract infection (UTI)
The doctor stated that it is a type B1 anteroposterior compression fracture causing the separation of the pubic symphysis and widening of both sacroiliac joints. The doctor prescribes minimized movements as these type of fracture is rotationally stable but vertically unstable, to avoid rolling the patient, a blood transfusion, angiography and nitrofurantoin to treat the urinal tract infection.
The patient is admitted to the ward and starts undergoing medication. The nurses at the hospital care and administer the required medicines well for the first three weeks. On the fourth week there is a motor accident involving three vehicles and there is an influx of patients in the hospital.
One lunch time, the nitrofurantoin medicine for the patient is still on the table but the drug chart is signed as administered. This is due to the nurse who had administered the drug previously had forgotten and signed the slot for administering the doze for lunch hour. The next dosage is administered correctly but the nurse fails to administer it with food. This is bad as Nitrofurantoin should be administered with food so as to improve the absorption of the drug by 45%.
This was due to the negligence of the nurse. As found out by The Harvard Medical Practice Study (Walshe & Boaden 2006) carried out throughout various countries in the late 1980’s including the United Kingdom (UK) was the first to look at patient safety. It found that nearly 4% of patients suffered an adverse incident whilst in hospital and 28% of this was due to negligence. In the UK attention to patient safety when the DH published an article ‘The New NHS: Modern, Dependable.’ (DH 1997) Which had a ten year plan of modernizing he NHS and improve patient care.
The patient started showing nausea, rash fever, stomach bleeding, pulmonary fibrosis, hypersensitivity pneumonitis, abdominal pain, headache and brown discolorization of urine. These symptoms were taken as normal side effects of the drug, nitrofurantoin, therefore, no action was taken to reverse the effects of the missed dosage.
The patient died, the morning of the following day. The incident was reported as a death through the fracture of the pubic ramous, but not due to the omission of the nurse to administer dosage and to administer it with food.
Through the mechanism put in place by the hospital for reporting incidents, the nurse offered a report explaining her omission to deliver the drug as required. A subsequent audit of the drug chart revealed that in deed the dosage during for lunch hour had not been administered. The commission assessed the case and many others like it, which had occurred in the hospital due to human error. The findings were forwarded to National Patient Safety Agency (NPSA) (Howells 2011).
The NHS commission analyses data available and comes up with final statistical measure of all the incidents and near misses that occurred in the hospital in a year due to human error and other reasons like, use of complicated technology by nurses and medical practioners, poor structural designs resulting in hampering efficient provision of services by nurses and physicians to the patients and other reasons like fatigue and burn out as in the case above and inadequate training and experience. This is in accordance with the organization that was set up the year 2000 by government experts ‘Organization with a memory’ (DH 2000)
There are three NPSA organs (NPSA online 2012). The NPSA was developed by the recommendation of a report by DH ‘Building a safer NHS for patients’ (DH 2001) to act on OWAM’s recommendations. The National Reporting and Learning Service (NRLS) is a voluntary and anonymous reporting system for patients, so as to reduce medical errors, which are then learned from and prevented from happening again. The second organ is The National Research Ethics Service (NRES) who protect the dignity and safety of those taking part in clinical trials and the third organ of NPSA is The National Clinical Assessment Service (NCAS) who respond to reports of bad practice by advising the involved organizations.
National Institute of Health and Clinical Excellence, (NICE) which was created in 1999 (NICE online 2012). Issues national guidelines for ensuring good care to the patient to patients in England and Wales, this was Part of the plan involved in introducing clinical governance the concept of making NHS organizations accountable for improving quality of care and maintaining
The World Health Organization (WHO) estimates that out of 10 patients receiving health care in the world, 1 person will lose his life to a health care error. The major causes of these medical errors include: human factors which include poor training and experience, fatigue, depression, and burn out of medical personnel. In 2005 the National Audit Office (NAO) investigated whether incidents were being reported in the NHS and whether lessons were being learnt. The report was called: ‘A Safer place for patients: learning to improve patient safety’ (NAO 2005). It discovered that one in ten patients admitted to hospital are unintentionally harmed and 50% of incidents could have been avoided if lessons had been learnt from previous incidents. It found that most trusts had introduced a reporting system and had reduced the blame culture; however, some trusts still experience this.
The public and medical practioners, were amazed by ABC’s program 20/20 in 1982, that reported that 6000 American lives are lost each year with others suffering brain damage due to use an aesthetics. Other causes include prolonged care in hospitals, intensive care and failures in communication and bad management resulting in unclear lines of authority among nurses, physicians and other health care providers.
Nurses have a professional responsibility to patients through the NMC’s Code of Professional Conduct (2008) including the care of the patient being their first concern, doing the best by the patient, providing a high standard of care at all times and producing accurate reports. In this case they were violated as the nurse did not care to the patient adequately. The reporting of the NPSA has ensured similar incidents may be investigated to see if they could be avoided in the future. With regard to the law concerning medication, Griffith (2002) states nurses, in their position of administering medication, are accountable to society through public law, to the employer through contract law, the patient through civil law and to the profession through the Nursing and Midwifery Order 2001.
The commission came up with a final report with the following recommendations: physicians, nurses and other health care practioners to be given frequent training on available and new technology in the hospital, more nurses to be employed to reduce the amount of patients that he or she has to cater for, automation and supervision of administering of medication, improving on the system for reporting incidents and near misses, educating the nurses on ways to reduce errors and coming up with better architecturally designed hospital to ensure efficient and convenient delivery of services by nurses and physicians.
Due to the death of the patient whose dosage of nitrofurantoin was omitted, the association came up with the report and it implemented successfully. Today, the cases of deaths have grown drastically due to omission as specifically the omission of a medication is classed as a medication error and more specifically by Dickens (2007). The NPSA (2007) found that omitted medications made up 17.1% of medication incidents reported. Of these in the acute setting 27 patients died, 68 suffered severe harm and 975 suffered moderate harm.
Risk management theory is a theory that is designed to reduce risks and therefore, reduce incidences of injury, damage and loss. They are a set of principles in place to reduce risk. It is a process of risk identification, assessment and prioritization. The risk management theory chosen by a facility should follow the following method: identify and assess threats, assess the vulnerabilities, determine the risk, identify way of reducing risk and prioritize the ways of minimizing risk.
The theory should have the following principles: systematic and structured, valuable, participative, take into account assumptions and uncertainty, dynamic, clear and be an integral part in decision making of the organization. It should also involve all the stakeholders in the organization as proposed by Vincent 2000, who emphasizes team work.
Part and parcel of the ways of risk management theory is risk analysis. There are three methodologies I considered to analyze the risks to patient safety. The three methodologies include qualitative analysis, tree based technique and method of analyzing dynamic systems. I chose to analyze the above root cause and contributory factors for the above incident through the cause consequence analysis in the tree based technique this can be related to Ichikawa (1979) fish bone diagram also called the Cause and Effect diagram
The initiating event is the fall of the 93 year old woman. Mrs. Johnson is found with a urinal tract infection, the doctor prescribes nitrofurantoin, and the nurses omit administering the prescribed medicine. This event leads to severe side effects in the patient which eventually leads to the death of the 93 year woman.
The method I have used tries to analyze is the root cause and contributory factors to incident of death of Mrs. Johnson is both easy and dynamic in nature. It is easy to understand and both efficient as it captures both factors. The cause consequence analysis captures both cause of a risk and the consequence of exposure to that risk. It shows both the consequences of the risk occurring and if it could have not occurred. This is the same as the one used by the NPSA to analyze the root causes of medical errors (NPSA 2008).
The analysis is both clear and simple. The management will find it easy to use this method for decision making. The management will find it easy to find the root causes and the contributory factors to the problem; they can then put in place the necessary mechanisms to prevent the consequences from occurring again. The analysis showed that that the cause to the death of the 93 year old woman is the omission to deliver medication during the lunch hour and also failing to give the medicine in the recommended manner, which is giving with food to increase the absorption of the medicine.
Ethics is the set codes and principles in a certain professional fields. There are many ethical issues violated in this incident of the 93 year woman. The general ethical issues in the risk assessment include:
Clinical ethics is a tool that enables physicians to identify, analyze and resolve ethical issues. The ethical issues in clinical care issues usually are: informed consent which requires that the patient is informed of all the risks in administering a given procedure and he or she gives an informed consent, based on the disseminated information. The consent should be free of any influence and coercion from the nurse or physician
Another ethical issue is pain relief. This brings in the much debated issue of voluntary euthanasia. This is the debate whether the patient has a right to will for her life to be terminated in order, to relief him or her from pain. Some countries like the Netherlands have legalized it but, it still remains an issue that will show up in the agendas of many debates.
Other ethical issues in clinical care practice include: patient confidentiality, where information is to be shared only between the physician and the patient. Patient rights where the rights of the patient are often not clearly defined, and end of life care. Most clinical care issues arise when there is difference in values between the physician and the patient. The moral values that commonly characterize the relationship between the patient and physician include honesty, trustworthiness, commitment and compassion. The clinical ethical issues are complex and dynamic and often have no definite set way of tackling them. Nurses and physicians should mostly analyze the situation and give a solution. The solution is usually required within a short period of time.
The example given in this essay violates and is in conflict with some of the clinical care ethics. The ethical risks in the example include: violation of patient’s rights. Patients have a right to receive quality and efficient clinical care from their nurses Frith (1999). Mrs. Johnson was denied quality care by her nurse, failing to give her the prescribed dosage of nitrofurantoin. The patient had a right to receive medication as prescribed by her doctor; the nurse negligently due to fatigue and burn out gave her the medicine without food to enhance absorption of the drug. This finally led to the death of Mrs. Johnson.
Another clinical issue that is violated is truth telling and informed consent. Mrs. Johnson had a right to know the side effects of her treatment. The physician should have revealed the side effects of vomiting, bleeding in the stomach, nausea, headache and fever of using nitrofurantoin in the treatment of urinal tract infection. The nurses should have been informed of the adverse effects of not administering the dosage by the physician. Due to the infringement of the patient’s right of informed consent. The patient lost his life.
The nurses have a commitment of ensuring that every patient gets the right of good clinical care Frith (1999). The nurses are entrusted by the patient the role of providing quality clinical care as per NMC’s Code of Professional Conduct (2008). This was not the case as the nurse on duty did not perform his task of administering medicine. The patients trust was further violated through; administering it the wrong way and further signing the drug register leading to no action being taken to save Mrs. Johnson, which ultimately led to the loss of human life.
The patient’s right to life was also denied in violation of a section of the Human Rights Act 1998, the patient lost his life negligently to human error Tingle (2002) which could be charged in a court of law. Her death was not natural. The nurse’s errors, ultimately led to the loss of the patient’s life.
There are many ethical notions in the clinical care field. These notions propose certain standards of behavior and attitudes that are morally appropriate to nurses, physicians and other health care providers. Therefore, these concerned parties should strive to meet these set of rules and principles, so as to meet the task entrusted to them by the patients.
The NPSA (2004) produced guidelines entitled the Seven steps to patient safety from recommendations by the DH’s report, Organisation with a memory (2000),and relevant patient safety literature. They aim, to improve patient safety within the NHS ensuring patients gets quality services.
Patient safety is a discipline that emphasizes reporting, analyzing and prevention of medical error that would result in health care problems like death. There are many organizations today that are committed to ensuring customer safety. The Institute for Healthcare Improvement (IHI) is an international organization, who work with healthcare professionals to ensure that people receive the best and safest care available (IHI online 2011). The Medicines and Healthcare Products Regulatory Agency (MHRA) is a government Agency established in 2003 who are responsible for ensuring that medicines and medical devices work (MHRA 2003 online)
National patient safety agency (NPSA online 2010) has put in place reporting mechanism to report adverse health care events and near misses. They have put in place policies to minimize the occurrence of such events. The policies include: ensuring the registration of nurses, Professional nurses play key role in pain management. Good assessment skills are necessary in nurses to identify and relieve discomfort especially where the patient has been verbally impaired.
Centers for Medicare and Medicaid services (CMS) have also set policies to improve quality and avoid unnecessary Medicare costs in the United Kingdom (CMS online 2011). The incentives include: reward to nurses and physicians for improving clinical care to the terminally ill through use information technology. Hospitals in the UK want to cut costs in wake of the recession, and are therefore lying off nurses with the Latest study showing that they could cut £421 million. Other recommendations by the CMS include payment for better home, hospital and office clinical care for patients with chronic diseases. Removing disincentives to provide quality health care and payment to hospitals to improve the quality of Medicare they offer.
Another policy is the bridging the gap between health and social care. For example, to test how nurses across the UK are coping with changes, nurses will be employed by NHS highland to start working in partnership with the highland council to provide integrated services to the population (NHS online 2012).
Knowledge on risk assessment has greatly impacted my professional knowledge. I have learnt that risk assessment is an important tool, for identifying, analyzing and priotization of risk. Through carrying out a risk assessment, will minimize the risks that face the patient. Risk analysis involves breaking down the risk into its root cause or contributory factors.
Mechanisms should be put in place, through reporting systems like, the National Patient safety agency (NPSA), so as to identify risks and provide a thorough analysis. It is only through identifying the root cause of an adverse health care event that we can effectively reduce or remove them completely.
After carrying out a risk assessment, considerable steps should be taken to reduce the occurrence of adverse health care events. The steps include professionalization of the nursing profession, better remuneration to the nurses to motivate them, integration of health care and social care, a better structure of line of authority and putting in place mechanisms for reporting the adverse health care events due to omissions and other medical errors.
Through taking the above steps would there be a positive and beneficial change in the clinical practice field. The changes would ensure better remunerated, motivated, socially responsible, committed and efficient personnel in hospitals, to ensure good health of our population.