Non-Tunneled Central Line Case Study

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

The following are the National Patient Safety Goals for 2016: improve the accuracy of patient identification, improve the effectiveness of communication of caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections, and for the hospital to identify safety risks inherent in its patient population (Hudson 2016 page 2). Under each category there are specific goals, such

Lewis et al. explain in Medical-Surgical Nursing, a central line is a catheter placed into a large blood vessel for a patient who requires frequent or long-term access to the vascular system. The authors explain that catheters are used for the administration of high volume fluids, medications that are irritating (such as chemotherapy), long term pain medication, blood products, parenteral nutrition, and hemodialysis. Kaiser policy states four different types of central line used for patients: Centrally inserted catheters, peripherally inserted catheters, injection implanted ports and hemodialysis catheters. Centrally inserted catheters

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

The Joint Commission has instituted a number of goals nationally; the aim is to improve patient’s safety. The goals selected look at areas that are of concern in the healthcare industry particularly how it affect patients safety and make recommendations how to reduce if not eradicated these. The Joint Commission is the governing body that accredited hospitals and other health care organizations. The two hospitals that this paper will be comparing, using the goals and criteria recommended by the Joint commission, is Holy Cross Hospital located at 1500 Forest Glen Road, Silver Spring, MD and Shady Grove Hospital situated at, 9901 Medical Center Drive, Rockville, MD.

When the Institute of Medicine came out with a report called To Err Is Human it drew a lot of attention to the media on patient safety because of the statistics that the report found. One of the big things that this report found was that "between 44,000 and 98,000 people died each year in the United States hospitals due to medical errors and adverse events" (Bonacum, 2017, p. 3). This was also one of the reasons why the Healthcare Research and Quality Act of 1999 passed. This act allowed research to be done using scientific evidence and report things such as effectiveness, outcomes, costs, quality, etc. in the health care field ("Healthcare Research and Quality Act of 1999," 2014). It is a good thing that the Institute of Medicine came out with this report because it made patient safety a very important issue that needed to be resolved, it was definitely an eye opener. The above number of people dying because of medical errors is surprisingly high, if I did my math correctly that’s about 122-272 people dying each day. Wow! There are other factors that

The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from

Chosen for root cause analysis is case study number 18, titled “Not for IV Use: The Story of an Enteral Tubing Misconnection” from the book Case Studies in Patient Safety: Foundations for Core Competencies. Root cause analysis is a process whereby error producing system factors are identified and reviewed to assist in the formatting and implementation of solutions to prevent similar errors from reoccurrence (Wachter, 2012). This accounting of the patient’s experience located in the Systems-Based Practice (SBP) section also highlights various code of ethics violations such as autonomy, beneficence, nonmalfeasance, and veracity. The SBP approach in healthcare requires that personnel recognize how patient care connects to the entire health care system and how to utilize successfully system resources to improve both quality and patient safety. There are specific core competencies that assist with this process. Some of which include the ability to work effectively in the delivery-care setting, perform responsibilities according to role, ability, and qualification, advocate for quality patient care and resources, and participate in error identification and solution implementation (Johnson, Haskell, & Branch, 2016). This patient’s story demonstrates an apparent failure of these core competencies.

2012 Joint Commission Patient Safety Goals. (n.d.). Retrieved January 2014, from Captain James A. Lovell Federal Health Care Center: www.lovell.fhcc.va.gov/about/2012PatientSafetyGoals.pdf

Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission

A PICC line (peripherally inserted central catheter) is a thin tube that is inserted in a vein in a patient’s arm and is advanced toward the heart until it reaches the superior vena cava. A chest x-ray confirms the placement of the PICC line. It is used for IV administration of medications and antibiotics. Chemotherapy and TPN (total parenteral nutrition) can also be administered and blood samples can be drawn. The PICC line can last up to a year. Trained professionals such as PICC-certified nurses are able to do both insertion and removal. Do not put a blood pressure cuff on the same arm as the PICC line because it could fracture the IV line.

Issues related to a lack of patient safety have been going on for a lot of years now. Throughout the first decade of the 21st century, there has been a national emphasis on cultivating patient safety. Patient safety is a global issue, that touches countries at all levels of expansion and is one of the nation's most determined health care tests. According to the Institute of Medicine (1999), they have measured that as many as 48,000 to 88,000 people are dying in U.S. hospitals each year as the result of lapses in patient safety. Estimates of the size of the problem on this are scarce particularly in developing countries; it is likely that millions of patients worldwide could suffer disabling injuries or death every year due to unsafe medical care. Risk and safety have always been uninterruptedly been significant concerns in the hospital industry. Patient safety is a very much important part of our health care system and it really