Standards of Care Violation Incident and Risk Management in Healthcare

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Table of Contents

Introduction
Case Study Summary
Standards of Care or Practice Violated in the Case Study
Risk Management Steps Prior to the Incident
Risk Management Steps After the Incident
Conclusion
References

Introduction

Healthcare is one of the sectors most controlled and regulated by laws and regulations. Healthcare providers, including nurses and doctors, must adhere to laws and standards designed by their professional bodies. For instance, nurses have a code of conduct that defines their roles and responsibilities and guides them in delivering safe and quality services to patients. However, medical errors, that are not intentional, may occur due to some factors beyond or within care providers’ control. Medical errors are detrimental to patients’ well-being and can cause death in the worst cases. It is imperative for nurses to strictly follow standards of care to prevent and mitigate the adverse effects of medical errors. This paper discusses a case study focusing on the violation of standards of care and the role of the nurse practitioner in managing risks.

Case Study Summary

The case involves a 21-year-old female who was studying to be a music conductor and was admitted for chemotherapy. An infusion pump was used to administer mitomycin by intravenous infusion, after which the IV was dislodged. A registered nurse (RN) notices the incidence, discontinues the infusion, informs the physician, and attends the infusion site. The patient was groggy and could not identify the nurse. IV infiltration occurred, and the patient developed necrosis of the hand, which treatment led to permanent loss of function and deformity in her third, fourth, and fifth fingers. The risk manager noted a staff shortage, nurses working double shifts, and the use of float nurses in several units.

Standards of Care or Practice Violated in the Case Study

Standards of practice outline a competent level of care in the nursing process. According to the American Nurses Association (2021), the standards of care are an instrumental tool that directs and maintains a safe and quality nursing practice. They help nurses evaluate their colleagues and themselves to guarantee clinically proficient and safe care services. Standards of care in nursing are a framework for evaluations for employers and clinical units. Further, they function as a comparison tool to assess care services provided by nurse practitioners if they are suspected of having developed unsafe work habits that violate acceptable guidelines established by healthcare organizations or federal and state laws. In the case study, the RN and the nurse practitioner violated standards of care, which can lead to disciplinary and legal actions.

The standards of care the RN violated include communication, education, and resource utilization. According to the American Nurses Association (2021), RNs need to employ effective communication in all areas of practice. Effective communication among healthcare providers and patients is one factor that facilitates safe and quality services. Sibiya (2018) adds that nurse-patient communication allows the care provider to know their client’s concerns, health issues, and needs. Nevertheless, the RN in the case study violated this important standard of care by failing to inform the patient what had transpired. The patient was groggy, possibly because of her condition or administered medication and the only way to allow her to understand what happened was through communication.

Education and resource utilization are other standards of nursing practice that enhance the quality and safety of care. RNs should ensure they have appropriate knowledge and competence, educate patients, and use suitable resources to provide safe and effective care services (American Nurses Association, 2021). Mitomycin is a vesicant agent, and its extravasation can cause adverse health effects, as evident in the case study (Mieczkowska et al., 2021). The RN lacks adequate knowledge about the vesicant agent, failing to administer proper post extravasation care. Equally, the RN did not educate the patient about how she could have continued caring for the infusion site after being discharged from the hospital. Such measures could have minimized risks for developed necrosis of the hand. The RN should have used guidelines for managing extravasation and notified the pharmacist to provide a suitable antidote for the vesicant.

The standards of care violated by the nurse practitioner are assessment, diagnosis, communication, and evidence-based practice. An assessment is a fundamental approach used in nursing to ensure patient safety. The standard of care requires the Nurse Practitioner (NP) to collect pertinent information and data related to situations and patients’ health (American Nurses Association, 2021). However, the NP violated this standard of care by failing to collect the information about the IV infusion. The NP reported the incident to the physician and attended the infusion site. For any incidence, regardless of whether it is harmful, NP should write a report that includes basic information about the occurrence. Important elements that the NP could have included in the report are date, time, location, name of the facility and address, patient’s name, and the NP’s name. Other information includes details of what happened, the name of the physician notified, and corrective actions that were taken. It is clear from the case study that the NP never collected information about the incident.

The assessment would have facilitated appropriate diagnosis regarding the extent of the IV infiltration and, consequently, the adoption of evidence-based approaches to managing the situation and preventing exacerbation. Moreover, NPs failed to follow evidence-based medication administration procedures to alleviate dislodgement risks. According to Dagne and Beshah (2021), evidence-based practice minimizes the risks of errors and enhances the quality of care. Further, the NP did not use appropriate and effective care for infiltration with mitomycin. Failure to document the incident violated communication since other care providers would not know what happened to the patient, who was there, and the corrective measures that were taken.

Risk Management Steps Prior to the Incident

Risk management approaches are vital since they alleviate the possibility of medical errors. The risk management steps that would have been taken before the incidence are education and adherence to medication guidelines. The RN and NP should have been provided with educational materials regarding policies for administering chemotherapy medications and infiltration. Adhering to the infusion guidelines would have prevented the IV dislodgement and infiltration.

Risk Management Steps After the Incident

Risk management is a continuous process, implemented even after an incident, to prevent re-occurrence. The appropriate risk management steps after the incident are a detailed recording of what happened, increasing staffing, and training. The record would help review factors that contributed to the medical error and take corrective measures. The risk manager noted there was short-staffing and the use of float nurses. Inadequate nurse staffing increases the risks of medical errors due to fatigue and burnout (Drennan & Ross, 2019). Therefore, the facility should increase the number of healthcare staff working double shifts and alleviate rooms for errors. Equally, all staff should be trained to ensure they have adequate knowledge to deliver safe and quality care.

Conclusion

Medical errors are detrimental to patients’ well-being and result in permanent disability, death, and legal litigation against practitioners and healthcare facilities. Violation of standards of care is the main factor that increases the risks of committing errors, as in the case study. If the RN and NP had followed the standards of care outlined by the ANA, IV infiltration would not have occurred, and the patient could not have suffered permanent loss of function and deformity. Implementing appropriate risk management steps such as training and adequate staffing is vital to prevent such incidences.

References

American Nurses Association. (2021). Nursing: Scope and standards of Practice (4th ed.). The Publishing Program of ANA.

Dagne, A. H., & Beshah, M. H. (2021). Implementation of evidence-based practice: The experience of nurses and Midwives. PLOS ONE, 16(8), 1–12. Web.

Drennan, V. M., & Ross, F. (2019). Global nurse shortages—the facts, the impact and action for change. British Medical Bulletin, 130(1), 25–37. Web.

Mieczkowska, K., Deutsch, A., Amin, B., Mir, A., Abraham, R., Balagula, Y., Blasiak, R., Mann, R. E., Patel, P., Musaev, T., Zhu, T. H., Kalnicki, S., Packer, S. H., & McLellan, B. N. (2021). Mitomycin extravasation injury: A case series. JAAD Case Reports, 15, 69–72. Web.

Sibiya, M. N. (2018). Effective communication in nursing. Nursing, 19–35. Web.

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