Patient Safety Portfolio: Analysis of Nursing Practices and Errors

This portfolio delves into critical aspects of patient safety within healthcare settings, examining various modules that address key areas of concern. Module 1 focuses on patient identification and medication administration errors, emphasizing the importance of proper protocols and reporting mechanisms to prevent life-threatening situations. Module 2 highlights the significance of a clean healthcare environment and the use of tracking technologies like RFID to ensure patient safety. It also discusses advanced business processes like eProcurement and unique device identification. Module 3 explores the preoperative environment, emphasizing the risks patients face and the role of nurses in mitigating these risks through assessment and support. Finally, Module 4 examines intraoperative anesthesia, detailing the different types and adjuncts used, along with the importance of post-anesthesia care and patient satisfaction. The portfolio underscores the need for continuous improvement in nursing practices to enhance patient outcomes and minimize errors.

PORTFOLIO

Table of Contents
MAIN BODY..................................................................................................................................3
Module 1......................................................................................................................................3
Module 2......................................................................................................................................4
Module 3......................................................................................................................................6
Module 4......................................................................................................................................7
REFERENCES................................................................................................................................1

MAIN BODY
Module 1
John Smith and John Adams, two separate patients were confused with each other
resulting in John Smith getting treatment of John Adams. This can be categorized under Patient
Identification Errors and Medication Administration Errors conducted on behalf of the nurses.
This is a major area of concern since getting confuse with the identity of patient and giving them
treatment is grate mistake which can lead to life threatening implications (Barkhordari-
Sharifabad & Mirjalili, 2019). A registered nurse is required to formulate some preliminary rules
need to be taken care of before admitting a patient. It is mandatory for nurses to ensure that
patients with same first names are not admitted in same room and if it is done, the medical
attendants and examiners must be notified regarding the same. Further, using proper name tags,
marking the patients name etc. are some of the additional security checks that can be applied in a
patient by the registered nurse. The science of patient safety and medical error details the
provisions which the nurse should follow in order to increase the safety standards so that such
errors can be avoided (Ginter, Duncan & Swayne, 2018). As per the artefact 1 titled Error
reporting and disclosure1, it is highlighted that using web based databases and intrainstitutional
databases can assist the nurses and other operators in taking more care so that these trivial errors
can create potential harm and therefore need to be avoided along with encouraging registered
nurses to provide quality care.
In order to ensure that these practices can be avoided in future, a better framework needs
to be formulated which would minimise the frequency of such errors and also ensure that no
critical nature grievances are caused (McClain, Hasan, & Zitlaw, 2019). Formulating proper
reporting and follow-up standards is a major action that would mandate the professionals to
adopt a predetermined step of actions that will ensure that no unaccounted error creeps in.
Another such aspect is ensuring that medical attendants and registered nurses do not conceal
their faults and errors out of embarrassment. It not only an ethical wrongdoing, but it can also
lead to severe impact on the patient who has been the target of such errors. This will facilitate
trust and responsibility amongst the care takers ensuring that all the mistakes are properly
reported with adequate follow-up actions being taken. Error related to reporting mechanisms is
another category similar to this case where the radiographer did not cross check the full name
1 Error Reporting and Disclosure, 2017 (https://www.ncbi.nlm.nih.gov/books/NBK2652/)

with the patient and trusted orderly who showed extreme carelessness and negligibility on his
behalf. When there is increased usage of written documents, reports, follow-up actions, although
it becomes easier to account for different actions of the nursing staff but, the chances of error
creeping increases and chances of manipulation or misguidance also increase (Chou & et.al.,
2016). Using web based forms or electronic systems, excel sheets, electronic reporting
mechanisms are a few of those technological methods that need to be implemented in order to
ensure that number of errors decline significantly. For nursing profession patient’s safety should
be the prime concern and it is important for nurses to address the patient effectively and make a
proper identification of patient before treating any patient
Module 2
Importance of ensuring that the environment of the healthcare facility is clean and the
instruments used are sterilized cannot be emphasized enough. There have been so many critical
cases of carelessness and unhygienic practices which has ultimately led to life threatening
situations for the patients. Development of a robust healthcare assistance system which provides
correct information regarding various aspect related to the patients and the healthcare facility is
not a new thing in the medical field. The safety of the patient needs to be ensured as many time
integration of environmental factors like sanitations with human actions like carelessness can
lead to disastrous situations (Wu, Chang, & Wang, 2018). Further, traceability of the patients at
all times becomes of even more importance when the case of patient is extremely sensitive or if
the drugs involved are of high risk and is costly. This automatically indicates the critical nature
of the patient and highlights the importance of a proper drug administration system so that proper
prescriptions for the patients can be prepared. As per the artefact 2 which is an image titled
Administration Plan of Medication2 the importance of various tracking and traceability software
can be identified.
2 RFID and other traceable technologies, 2015. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017354/)

Figure 1: Tracking and Traceability Technologies
Source: RFID and other traceable technologies, 2015
RFID i.e. Radio Frequency Identification technique can be used in order to track the
location of patients at all times. This technique is one of the most effective techniques currently
since by simply attaching a tag to the intended object or patient emits a radio signal which can be
read by the reader on his system at all times thus identifying where that particular object or
patient is (Liao, & et.al., 2016). This technique is highly recommended because it does not
require formulation of any newer network and thus no additional cost in incurred. Further. A
variety of resistant material used in the construction of these tags renders them undamaged thus
improving their service providing capability and instant facility of tracking down the patient
immediately. It also includes environmental aspects and also discusses about the tracking and
traceability in relation to risk management and patient safety and why this process is important
for patient's safety
Another major aspect in ensuring patient safety in healthcare units involve advanced
business processes like eProcurement, inventory management etc. that improve the
methodologies and process that have been implemented at the workplace (Kritchanchai, 2017).
Unique Device identification technique is one such methodology under which involves providing
an identification code by the manufacturers to the instruments that are being used in the
healthcare sector. By using such identification, the potential risk regarding the safety of the
patient is minimised and the product manufacturing process also gets standardised thus
minimising the potential risk of defective instruments.

If these systems are not adopted in the healthcare institutes, it can cause serious impacts on the
safety and protection of the patients raising questions on them. Patients suffering from mental
illness like Alzheimer’s etc. can confuse themselves with the location getting lost which can
even lead to legal troubles for the healthcare unit which is an issue that all healthcare units need
to avoid at all costs because a single negative news can even have led to shutting down of the
hospital altogether (Jayaraman, Saleh, & King, 2019). in order to increase the safety of patients it
is really important to track and trace the patient effectively which is important for patient safety.
In order to trace and track the patient there are various methods involved and the methods used
can have huge impact on the patients safety
Module 3
Preoperative environment is an extremely tense environment for everyone associated
with it i.e. the patients, the nurse, the doctors etc. it is an extremely critical situation for everyone
because life of the patient is at stake. There are a hundred things that can go wrong and the risk
to which the patients expose themselves in unaccountable. Some of the major health associated
risks that patients face is the risk of getting infected. This is chosen as a major risk because its
implications are extremely serious apart from getting infected, there are many other factors like
age and gender, comorbidity etc (Tallier, & et.al., 2017) which can lead to a patient becoming
more ill than he was earlier. Apart from this, the inevitable physiological stress that the patient
faces after surgery is another aspect that needs to be taken proper care of so that the patient does
not slip into any kind of trauma.
As per the artefact number 3 titled The Role of the Nurse and the Preoperative
Assessment in Patient Transitions3, Some of the major interventions that a nurse needs to adopt
in order to mitigate or avoid the risk involves proper assessment before, during and after the
surgery of the patient followed up by regular assessments where different aspects related to the
health of patient are observed regularly (Mighten, & Uy, 2019). Giving adequate support and
adequacy to the patient and fulfilling the role of circulating nurse during the surgery further
minimizes the risk of any potential threats or errors. Immediate provision of the resources and
controlling the environment while the surgery is ongoing can help the doctors in controlling the
situation in critical conditions and work in a cool, efficient and well-practiced manner avoiding
3 The Role of the Nurse and the Preoperative Assessment in Patient Transitions
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547842/)

any chaos. Further, supervision of ancillary personnel ensuring that they are not making any
administrative mistakes, continuous monitoring of psychological status of the patient formulates
a comprehensive care plan for the patient The surgical risks which are faced by the patients and
post-operative safety is important.
Health related risk is a major risk that the patients suffer because while the surgery is
going on as well as the point at which it ends are crucial points (Deeb & et.al., 2016). In order to
ensure that the situation of patient is stable, it is necessary to careful assess the patient based on
different health related factors so that all the risks can be addressed before hand. there are
various risks associated with surgery and there could many reason which give rise to surgical
risks and it is vital to minimise this risk
Module 4
Intraoperative use of anaesthetics usually involves the time period form which the patient
is admitted in the room to the point at which anaesthetics will be administered in the patient.
There are three major categories of anaesthesia given to the patients in intraoperative period i.e.
General, Local and Regional anaesthesia. General Anaesthesia involves transferring the patient
in a sleep like state before any medical treatment or procedure using a combination of drugs or
gases. Local Anaesthesia involves administration into a limited area that will block the pain in
the limited area which will be operated and rest of the body is fully awake to the sensations
(Leon & et.al., 2016). Similarly, regional anaesthesia which is of two types Spinal and Epidural
is given to block pain in spinal areas.
Spinal is included for shorter medical treatments where the anaesthesia is injected
directly into the fluid of spinal cord and epidural anaesthesia involves injecting of the anaesthesia
just outside the area or sac which contains fluid around the spinal cord of patient. There are
various adjuncts of anaesthesia i.e. some supplementary units or things apart from the essential
anaesthesia. Muscle relaxants are usually used for those drugs that are used for skeletal muscle
relaxants which affect the nervous systems and reduce pain and soreness associated with strains
or other muscle injury. Analegics is a drug which is used for relieving the pain and there are
many types like narcotics Tylenol etc. and is usually used to achieve numbness or relief form a
particular area that is paining (Rawicki & et.al., 2015).
After getting discharged from a Postanaestheisia Care Unit (PACU), the priority is ensuring that
the patients are satisfied with the services that they have received. As per artefact number 4 titled

Standards for Postanestheisa Care4, the nurse need to conduct a full body analysis of the patient
ensuring that the effect if anaesthesia that was administered has completely weaned off and it
has no0t resulted in any side effects and has accomplished the intended purpose for which it was
administered in the first place (Pham & et.al., 2016). There are various categories of anaesthesia
in intra-operative period and its really important to take care before giving anaesthesia to a
patient.
4 Standards for Postanestheisa Care (file:///C:/Users/user/Downloads/standards-for-postanesthesia-care.pdf)

REFERENCES
Books and journals
Barkhordari-Sharifabad, M. & Mirjalili, N. S. (2019). Ethical leadership, nursing error and error
reporting from the nurses’ perspective. Nursing ethics, 0969733019858706.
Chou, T. & et.al., (2016). Technological considerations for the delivery of real-time child
telemental healthcare. Journal of child and adolescent psychopharmacology. 26(3).
192-197.
Deeb, G. M. & et.al., (2016). 3-year outcomes in high-risk patients who underwent surgical or
transcatheter aortic valve replacement. Journal of the American College of
Cardiology. 67(22). 2565-2574.
Ginter, P. M., Duncan, W. J. & Swayne, L. E. (2018). The strategic management of health care
organizations. John Wiley & Sons.
Jayaraman, R., Saleh, K. & King, N. (2019). Improving Opportunities in healthcare supply chain
processes via the Internet of Things and Blockchain Technology. International
Journal of Healthcare Information Systems and Informatics (IJHISI). 14(2). 49-65.
Kritchanchai, D. (2017, June). A Roadmap Towards Healthcare Logistics in Thailand. In 2017
International Conference on Industrial Engineering, Management Science and
Application (ICIMSA) (pp. 1-5). IEEE.
Leon, M. B. & et.al., (2016). Transcatheter or surgical aortic-valve replacement in intermediate-
risk patients. New England Journal of Medicine. 374(17). 1609-1620.
Liao, Y. T. & et.al., (2016). The application of RFID to healthcare management of nursing
house. Wireless Personal Communications. 91(3). 1237-1257.
McClain, M. A., Hasan, Q., & Zitlaw, C. A. (2019). U.S. Patent Application No. 16/160,008.
Mighten, A. L., & Uy, M. C. (2019). Reigniting the Spirit for Perioperative Nursing.
Pham, J. C. & et.al., (2016). The prevalence of long QT interval in post-operative intensive care
unit patients. Journal of clinical monitoring and computing. 30(4). 437-443.
Rawicki, N. & et.al., (2015). High incidence of post-operative infection after ‘sinus
tarsi’approach for treatment of intra-articular fractures of the calcaneus: a 5 year
experience in an academic level one trauma center. Patient safety in surgery. 9(1). 25.
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Tallier, P. C. & et.al., (2017). Perioperative registered nurses knowledge, attitudes, behaviors,
and barriers regarding pressure ulcer prevention in perioperative patients. Applied
Nursing Research. 36. 106-110.
Wu, C. C., Chang, D. S., & Wang, R. (2018). Identifying key factors of adopting an RFID
system in nursing care using DEMATEL-based ANP.
交大管理學報. 38(1). 65-100.
Online
Error Reporting and Disclosure. 2017. [Online]. Available through: <
https://www.ncbi.nlm.nih.gov/books/NBK2652/>
Safety and Traceability in Patient Healthcare through the Integration of RFID Technology for
Intravenous Mixtures in the Prescription-Validation-Elaboration-Dispensation-
Administration Circuit to Day Hospital Patients. 2018. [Online]. Available through:
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017354/>
The Role of the Nurse and the Preoperative Assessment in Patient Transitions. 2015. . [Online].
Available through: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547842/>
Standards for Postanestheisa Care. 2019. [Online]. Available through: <standards-for-
postanesthesia-care.pdf>
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