One of the most memorable quality improvement (QI) initiatives in our hospital was a creation of an interdisciplinary team to decrease the rates of hospital-acquired infections (HAIs). The importance of HAI prevention is difficult to overstate, as HAIs are associated with increased morbidity, prolonged hospital stays, and higher mortality among patients (Taylor et al., 2020). Moreover, HAIs are associated with decreased reimbursement, which is crucial for hospitals’ financial health (Cohen et al., 2018). The interdisciplinary team gathered regularly and reviewed all the cases of HAIs during the period to design interventions and implement them.
There is a standard scenario in the hospital that helps handle adverse events (AEs). First, hospital authorities identify and investigate the AE by finding the responsible people for the AE, rating the severity of the AE, and identifying the path for an adequate response. Second, the information about the AE is registered according to the hospital protocol and reported. Third, the patient, friends, and family are informed about the AE with an apology and full information about its possible consequences. Finally, the AE is analyzed to take the necessary steps for preventing it in the future.
One of the most famous recent serious errors that made the news happened at Vanderbilt University Medical Center in December 2017 when RaDonda Vaught injected 75-year-old Charlene Murphey with the paralytic vecuronium instead of the sedative Versed (Loller, 2019). The nurse was charged with homicide for this error, even though she was not penalized by the professional disciplinary community (Loller, 2019). Currently, the trial is still in progress, as it was delayed several times due to the pandemic. In our hospital, medication mistakes are not usually penalized if the consequences are not that serious. However, the state’s Board of Nursing can impose disciplinary charges and even revoke a nurse’s license in such cases.
References
Cohen, C. C., Liu, J., Cohen, B., Larson, E. L., & Glied, S. (2018). Financial incentives to reduce hospital-acquired infections under alternative payment arrangements. infection control & hospital epidemiology, 39(5), 509-515.
Loller, T. (2019, February 21). Nurse charged in fatal drug-swap error pleads not guilty. AP News. Web.
Taylor, L., Olson, S. K., Swetky, M., Douglas, P., Pergam, S. A., Sweet, A.,… & Walji, S. (2020). An Interdisciplinary Team Decreases Hospital Acquired Infections in HCT Patients. Biology of Blood and Marrow Transplantation, 26(3), S377.