QualityAssurance and the “Never” Event
QualityAssurance and the “Never” Event
Healthcarefacilities are expected to offer quality services to patients. Private, government and non-governmental agencies emphasize qualitymedical services since it has a direct impact on people’s lives aswell as the community. These institutions strive to ensure that safeand quality healthcare services are offered in medical facilities. Furthermore, it is manifested in their development of policies andinitiatives that revolve around quality assurance in healthcare. Several agencies have been conducting inductions, seminars, andprograms that teach and monitor the quality of healthcare inhealthcare. The Federal State developed legislations that giveMedicare and Aid the authority to push for practices that prevent theoccurrences of ‘never events.` The Center for Medicare and MedicaidServices (CMS) came up with quality Act in 2007 focusing on patientsafety. The CMS Act on quality improvement was fully implemented inOctober 2008. The Act encourages health facilities to gear towardsminimizing medical errors (Mehtsun, Ibrahim, Diener-West, Pronovost,& Makary, 2013).
Everyorganization strives to meet quality assurance standards set out toensure deliverance of efficient and quality services. Meetings andforums are conducted so as to equip employees and the management withthe right skills to cope up new developments and trends in their lineof duty. This is applicable in healthcare as well. Nurses andsurgeons are among the target group whose roles touch lives of thepeople. The research seeks to understand quality measures applied toreduce or eradicate occurrence of ‘never’ events. The study willcritique the relationship between the inadequacy of staff and ‘never’events. Furthermore, it will tie it up with Total Quality Management(TQM) measures and how best medics can apply in assuring qualityservices in hospitals.
Inresponse to nurses’ allegations that were supported by severalsurgeons, inadequate staffing of health facilities does not eitherimply or lead to occurrences of ‘never’ events (Lord, 2013). Based on A ‘Never’ Event- Devastating Falls in a Hospital video,medical errors are not caused by inadequacy of staff but majorlytriggered by six categories of events tabled by the National QualityForum. The Forum identified 27 ‘never’ events in 2002, but thelist of these developments was revised to 29 in 2011. Two additional‘never’ events were added to the list. As signified earlier,these ‘never’ events are classified into six categories surgicalevents, product or device cases, criminal, patient protectionoversight and radiological case, environment, and care managementsums up the categories (Gitlow et al., 2013). Therefore, inadequatestaffing as mentioned in the meeting isn’t the only cause of‘never’ events. These six categories are primary contributingfactors leading to `never` events.
‘Never’events
‘Never’events are medical errors with the potential to cripple health carefacilities. Ideally, these errors should not and ‘never’ happenby any chance. They are unambiguous and severe cases, which can leadto the death of patients. However, they can be prevented. Presently, the National Quality Forum came forth and cited 29 formsof ‘never’ events in medical facilities that are grouped into sixcategories (Gitlow et al., 2013). In this case, the primary cause of‘never’ events included surgical operations and care management. Some activities conducted were done on wrong body parts and a severecase, done to the wrong patient. Other painful events cited areinstances where infants were mistakenly discharged to unintendedmothers. Furthermore, Mehtsun et al., (2013) cited a case of wrongblood group transfusion that leads to a hemolytic reaction. This wasfatal, and it resulted in the uncertain loss of the patient. He alsoadded to sexual harassment as ‘never’ event that should nothappen in a health facility.
Participatingmembers acknowledged that ‘never events’ occur in place of workand there are specific causes that lead to their occurrences. Themost similar category referenced in the meeting was the caremanagement cases. It topped the list of ‘never events.` A majorityof group members are associated with care management department where‘never’ cases were highly prevalent. Nurses in the meetingsolemnly cited the inadequacy of ward nurses and consultant medics tomonitor patient’s medical progress. They also acknowledged thatsome nurses might fail to interpret dosage, thus leading to the wrongprescription. The number of patients admitted in some wards isoverwhelming and often outweighs critical services rendered bynurses. Eventually, this caused straining of available resources andcapacity (Darbyshire, Ralph, & Caudle, 2015). This isprecarious, and it may have grave consequences and increaseoccurrences of ‘never’ cases.
Theargument issued by nurses and supported by surgeons was not rational. Its validity is skewed towards their interests. As explainedearlier, ‘never’ events are not attributed to inadequatestaffing. There are other six distinct categories. It was alsodeduced from the meeting that some events that lead to seriousinjuries and deaths are connected to wrong or erroneous medicationissued. This is seen in the poor recommendation of drugs, wrongdosage, and preparation or poor administration. Thus, it is notformally the inadequacy of staff that causes occurrences of ‘never’events but the lack of substantial capacity to engage qualifiednurses. If this is redressed, these cases will be prevented, and thequality of healthcare is restored. The argument issued by nurses aslack of adequate personnel was a dishonest fact. They could haveopted to have a colluded scheme and in a bid to secure their jobs. This comportment compromises service delivery since they advancepersonal interests at the expense of ill patients. It is a commonpractice, and it significantly undermines quality medications asemphasized by CMS (Hurst, 2015).
Preventinga recurrence of `never` event is important. Nurses and surgeons haveto adopt a standardized procedure when handling patients. Theyshould be quick to apologize and indemnify clients in cases of anyunexpected failure to prevent ‘never’ cases. Improper handlingof patients risks lives. Therefore, they are expected to upholdprofessionalism, and in the event of any difficulty, they shouldconsult expertise. They will guide on particular cases that preventoccurrences of such incidents. Nurses and surgeons are alsoencouraged to uphold professional codes and ethics that guide them inhandling patients. This step instills discipline and reducesinefficiencies that are the principal causes of ‘never’ events. Though they are bound to err, just like any other human beings, theyshould not gamble up with patient’s lives. The healthcare shouldcater such particular instances. Costs of medication can be waived,and nurses and doctors are challenged to learn from their faults andcorrect appropriately.
Alsoas healthcare quality assurance expert, I would urge participants tocomply with measures that assure quality medication. These stepsshould be integrated so as to manage inherent challenges in thesector. It also reminds healthcare leadership to employ mechanismsthat decrease severe medical errors even in complicated facilities. A classic example can be done through engagement of adequate andqualified nurses and doctors (Jebb, Esegbona-Adeigbe, Justice, &Crumbie, 2014). Such rigorous steps will streamline servicesdelivery and more importantly, offer quality services. An aggressivehealthcare management can loop in project managers. Their expertisecan be harnessed in tracking service delivery, and if there aresignals of inefficiency and substandard, they are checked so thatquality service is assured. Further analysis can be adopted so as tofind practical solutions for ‘never’ event cases. Such testedand efficient solutions are best preventive strategies, whichtranslates into safe and quality medical system.
Qualityassurance technique in preventing ‘never’ event
TotalQuality Management Principle (TQM) was developed in the 1950s, andsince then, it has maintained its relevance across all borders. Every sector desires to offer best and competitive services that meetclients’ expectations. According to Schattenkirk (2012),healthcare is not exceptional. It also needs quality assuranceapproaches that transform health care by assuring quality medicationsand reduce ‘never’ events. TQM approach serves the bestprinciple as it intertwines patients’ expectations and themanagement’s objectives (Padhy, 2013). It describes operations ofa healthcare facility, structure, and the culture. It binds themwith patients who seek medications. If nurses, surgeons, and themanagement strictly adhere to TQM blueprints, there will be reduced‘never’ cases that have marred several facilities.
Moreover,successful application of TQM vis-à-vis other quality approachesassures continual growth and development in the organization. Theresultant impact is seen in enhanced trust in workstations, employeesupholding integrity, and adhering to ethical codes. Suchincorporated moves instill a culture of teamwork that just meansquality health care services are achieved. It also prepares medicsto face contemporary medical trends and dynamics. This helps themrespond to daily challenges. Communication and commitment ofindividuals define the success of healthcare facility. Thus, awell-co-ordinated communication network smoothens operations anderadicates system inefficiencies. It also prepares them to advanceto a higher level of leadership where they manage the facility andstrive towards organization goals. The TQM approach ensures thingsare done right on the first time. This is the kind of efficiencythat health service deserves. Any defects are timely detected andstamp out, thus assuring quality services to all. If this approachadheres to the letter, ‘never’ events will be eradicated (Jebb etal., 2014).
Conclusion
Inconclusion, incidences of ‘never’ events pose loss of trust inmedical facilities and more so as a threat to well-being. However,as underscored by TQM elements, sanity can be restored in healthsector if a proper implementation is followed. Also, this is boostedby other quality approaches that enhance capacities of medicalpersonnel and guarantee the quality of medications (Schattenkirk,2012). Appropriate implementations of these quality measures focuson engagement of management in ensuring achievement of definedoutcomes. Such steps assure unprejudiced and quality servicesoffered to the public. Apart from TQM, Lean, and Six Sigma, and CQIas appropriate approaches that can streamline healthcare services(Padhy, 2013). If nurses are well empowered towards qualityservices, it would be easy to integrate these elements andcoordinated so as to assure quality medication. It will also pushforward and ensure that the facility achieves its objectives andtowards world-class healthcare.
References
Darbyshire,P., Ralph, N., & Caudle, H. (2015). Editorial: Nursing’smandate to redefine the sentinel event. Journalof clinical nursing. 13(2),62.
Gitlow,H., Zuo, Q., Ullmann, S. G., Zambrana, D., Campo, R. E., Lubarsky,D., & Birnbach, D. J. (2013). The cause of never events inhospitals. InternationalJournal of Lean Six Sigma, 4(3),p. 338.
Hurst,K. (2015). Editorial, Volume 28.4: Asking health and social carestaff to go the extra QA mile. InternationalJournal of Health Care Quality Assurance, 28(4).
Jebb,P., Esegbona-Adeigbe, S., Justice, S., & Crumbie, A. (2014). Never say never event: Should unsafe staffing in hospitals be classedas a ‘never event’? NursingStandard, 28(19), p28-29.
Lord,Sue. (2013) Are staffing levels adequate in your department: if notwhat are you doing about it? TheJournal of Perioperative Practice, 23(6),122.
Mehtsun,W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., &Makary, M. (2013) Surgical never events in the United States. Surgery. 153(4)465.
Padhy,K. C. (2013). Total quality management: An overview. SrustiManagement Review 6(1) 119-124.
Schattenkirk,Dale. (2012) Building sustainable internal capacity for qualitywithin a healthcare environment. TQMJournal, 24(4)374-382.
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