Page 65 - ACCCN's Critical Care Nursing

42 S C O P E O F C R I T I C A L C A R E

improvement activities or clinical research. In summary, About 18,000 hospital deaths per year are associated with
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by developing, using and evaluating clinical practice AEs and generally occur as a result of system errors. Half
guidelines, nurses may improve patient care and out- the AEs were deemed preventable with such strategies as
comes. Additionally, use of CPGs should ensure that improved protocols, better-quality monitoring, enhanced
nursing practice is based on the best available evidence. training and opportunities to consult with specialists or
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peers on clinical decisions. Studies have identified spe-
QUALITY AND SAFETY MONITORING cific contributing factors for adverse events related to
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patient airway and intra-hospital transports. 19
This section discusses unit-level measures used to evalu-
ate the quality and safety of care for critically ill patients. A number of methods for reporting AE such as direct
Quality and safety in healthcare is commonly described observation chart audit and self or facilitated reporting
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in terms of Donabedian’s approach with three major can be used; each has its strengths and limitations.
domains: Trained observers report more unintended events but this
method is expensive, labour intensive and vulnerable to
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1. Patient outcomes – the results of care in terms of the Hawthorne effect. Both chart audits and incident
recovery, restoration of function and/or survival reporting only reflect what is charted or reported, but
(e.g. mortality, health-related quality of life). even when chart audit, incident reporting, general prac-
2. Process – the practices involved in the delivery of titioner reporting and external sources, such as coronial
care (e.g. pressure ulcer prevention strategies). review, are used together, some adverse events will be
3. Structure – the way the healthcare setting and/or missed. Importantly, self or facilitated reporting, such as
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system is organised to deliver care (e.g. staffing, the Australian Incident Monitoring Study (AIMS) 22,23 are
beds, equipment). routinely used surveillance methods in many countries.
More recently, a fourth domain of culture or context has Medication administration is the most common inter-
been suggested specifically for patient safety models to vention in health care, but the medication management
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evaluate the context in which care is delivered. The process in the acute hospital setting is complex, and
contemporary model for healthcare improvement recog- creates risk for patients. As a result, medication-related
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nises that the resources (structure) and activities carried events are the commonest AE for hospitalised patients.
out (processes) must be addressed within a given context Adverse drug events (ADEs) are common in Australian
(culture) to improve the quality of care (outcome). The hospitals, with preventable, high-impact events involving
overall aim of quality improvement (QI) is to provide anticoagulants, anti-inflammatories and cardiovascular
safe, effective, patient-centred, timely, efficient and equi- drugs (over 50% of ADEs), as well as antineoplastics,
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table health care. QI activities identify and address gaps opioids, steroids and antibiotics (commonly used in criti-
between knowledge and practice. Importantly, these cal care units). Events are clinically significant in 20%
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activities need to reflect the most recent and robust clini- of cases. A number of strategies have been instituted in
cal evidence to improve patient care and reduce harm. Australia under the auspices of the National Medicines
The most common approach used for rapid improvement Policy, including the quality use of medicines (QUM)
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in healthcare is the plan–do–study–act (PDSA) method framework. There, however, remains a lack of consensus
where four essential steps are carried out in a continuous on how to measure medication safety – either by error
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fashion to ensure processes are continually improved: or adverse event – where:
1. Plan – identify a goal, specify aims and objectives ● error is a failure in clinical management, resulting in
to improving an area of clinical practice, and potential harm to the patient
how that might be achieved (i.e. how to test the ● adverse events relate to actual patient harm (injury). 17
intervention).
2. Do – implement the plan of action, collect relevant The actual incidence of both measures is higher than
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information that will inform whether the interven- what is reported. Fortunately, most healthcare errors
tion was successful and in what way, taking note do not result in patient harm because of safety-net pro-
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of problems and unexpected observations that cesses. Despite this, it has been estimated that one
arise. potentially serious intravenous drug error occurs every
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3. Study – the results of the intervention, particularly day in a 400-bed hospital. Approximately 5% of medi-
its impact on practice improvement, noting any cation errors relate to infusion pumps. These pumps
strengths and limitations of the intervention. are used to administer high-impact medications, such as
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4. Act – determine whether the intervention should inotropes, heparin or antineoplastics. It is therefore
be adopted, abandoned or adapted for further important to evaluate interventions that can reduce the
rapid cycle testing recommencing at the Plan phase. incidence and impact of adverse intravenous drug events,
particularly in critical care settings. 29,30 Recent evidence
A variety of specific activities have been used in the ICU suggests that nurses who are interrupted whilst admini-
setting to translate findings from the literature to improve stering medications may have an increased risk of making
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clinical practice. Quality monitoring includes measure- medication errors, prompting calls for all healthcare
ment of, and response to, the incidence and patterns of workers to make concerted efforts to reduce interruptions
adverse events (AEs). Adverse events occur in up to 17% to clinical tasks. Other activities examining quality
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of all hospital admissions, and cost the Australian of care include the analysis of incident reports such as
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healthcare system an estimated $2 billion per year. the Australian Incident Monitoring Study (AIMS), 22,23