Introduction
The recent research by IBM® Watson Health® (2021) transparently demonstrates the need to implement quality-oriented changes at most healthcare facilities in the United States. According to the analysis, if all hospitals adhered to the highest standards of quality of 100 Top Hospitals, it would have been possible to save almost 80,000 additional lives in 2021 (Watson Health, 2021). Moreover, ineffective service organization and outdated treatment methods led to nearly $10 billion in losses due to inpatient costs. This data clearly shows that most hospitals must implement quality-oriented changes in the workplace.
Root Cause Analysis
The current case study is a tragic example of an organizational failure that led to the patient’s demise. During the night shift, a patient experienced a near-death situation and required CPR. However, the supervision nurse and the LNA needed to check the code status first, which determines the personnel’s actions. The nurses could not get this information immediately in the rehab unit, and the supervision nurse sent the LNA to check the code status at a different location. Consequently, the LNA reported the DNR code (“do not resuscitate”), while the patient was assigned the Full Code (full authority to perform CPR). As a result, the nurses did not perform CPR, resulting in the patient’s death.
The primary causes of the problem frequently concern organizational problems, which determine human errors (Okes, 2019). In the current case, the inability to retrieve the code status immediately in the rehab unit was the crucial flaw that led to the patient’s demise. Sub-causes also include ineffective communication, human error, misunderstanding of codes’ importance, and inadequate personnel training. The general Root Cause Analysis is presented by a Fishbone Diagram.
Data Integration Implementation
Data integration is a process of connecting data from various sources into one unified database. This approach allows for establishing a functional system in the facility that improves information accessibility, speed of response to problems, resource management, and decision-making (Wang et al., 2018). Extensive academic research highlights data integration as an effective method for resolving organizational problems and information clustering. In the current case, improved information accessibility would allow the supervision nurse to retrieve the patient’s code status immediately in the rehab unit. In turn, it would mitigate the chances of human errors since the LNA has relatively little experience and might misinterpret the code information. Ultimately, healthcare data integration is a practical solution to the occurred problem.
Consequently, it might be beneficial to collect additional data before implementing a data integrity program. Namely, managers can utilize hospital internal data, direct observation, and surveys with employees and patients to improve the overall quality of the plan. For instance, evaluating the percentage of medical errors before the implementation and after installing data integration tools might reveal informative insights about the effectiveness of the approach. As a result, this data might be beneficial to track the progress of the quality-oriented change.
Plan Implementation
The four primary steps of the program implementation are:
- Identify the existing infrastructure;
- Select the appropriate data integration instrument;
- Assign a competent specialist to implement the system;
- Collect feedback.
The four consequent steps are essential to the healthcare data integration program and would allow for an objectively assess the results of the implementation. There are some barriers to the plan, such as the nurses’ reluctance to learn new skill sets. However, improved information accessibility might save the patient’s life, making it a necessary investment.
Conclusion
Summing up, the current case study describes a tragic accident; however, it could have been mitigated by organizational changes in the facility. Healthcare data integration is an effective method to improve information accessibility which would allow the supervision nurse to immediately obtain information about the patient’s code status and perform CPR. This approach also significantly reduces the risks of human errors and increases the quality of resource management. Ultimately, Healthcare Data Integration is an effective response to organizational failure.
References
Okes, D. (2019). Root cause analysis: The core of problem solving and corrective action. ASQ Quality Press.
Wang, Y., Kung, L. A., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting & Social Change, 126, 3-13.
Watson Health. (2021). 100 top hospitals (28th edition). Web.