Organizational Use of TERCAP®:Shifting From a Quality Management to a Whole-Systems Approach

11 Organizational Use of TERCAP®


Shifting From a Quality Management to a Whole-Systems Approach




Serious quality problems continue to exist in the health care industry in spite of a highly trained workforce of skilled and motivated people who are technically proficient (Chassin & Galvin, 1998). A fundamental shift in thinking is required to create safe and reliable practice environments for technically proficient practitioners. This shift begins with the recognition that a quality management approach is not enough, and that a whole-systems management approach is required.




SENTINEL EVENTS AND THE PATIENT SAFETY MOVEMENT


Sentinel events are any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious, adverse outcome. The events are called sentinel because they signal the need for immediate investigation and response (Speelman, 2001). In 1998, The Joint Commission on the Accreditation of Healthcare Organizations implemented standards and recommendations related to identifying, reporting, analyzing, and presenting sentinel events that had become more commonly reported in health care organizations throughout the country. These recommendations, however, fell short of expectations, and these unfulfilled expectations provided a segue to the patient safety movement.


The patient safety movement, while clearly visible, is still in its infancy. Many hospitals continue to punish care providers for the errors they make, and regulatory bodies are seen as searching for villains and punishing those who get caught. Meanwhile, the focus of many health care leaders has been on acquisitions, mergers, reimbursement, and revenue, rather than on the core focus of patient care. The patient safety movement will not progress until health care leaders move away from traditional models of management that focus almost exclusively on the bottom line to a multidimensional approach that focuses on other dimensions of organizational fitness—that is, the normative, strategic, and operational aspects of the organization (Schwaninger, 2000).



ORGANIZATIONAL USE OF TERCAP®


The Practice Breakdown Advisory Panel (PBAP) developed and used the Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP) audit (introduced in Chapter 1) as one method in a study of practice breakdown in multiple health care settings. The goal of this research (Scott, 2004) was to study selected error-events and identify the multiple individual, team, system, and cultural contributors to the practice breakdown that resulted in harm to a patient. It was asserted that an enhanced analysis would result within the context of a comprehensive framework by incorporating TERCAP into the root cause analysis and investigative process. Data collection included systematic root cause analysis findings and data obtained from medical records, staffing schedules, and physician and employee interviews. TERCAP proved to be a very useful data collection instrument for organizing and analyzing the data.


The purpose of this chapter is to examine the findings from one typical error-event that occurred in a hospital setting. The failure of this event was that a postsurgical patient’s care was inadequately monitored, and this failure resulted in significant harm to the patient. Not surprisingly, findings revealed that harmful patient care errors resulted from multiple failures by many people working in complex systems while carrying out routines of daily practice.


The researcher collected specific information about an error-event that included data from the root cause analysis process and from interviews with individuals who were directly and indirectly involved. The error-event is described in detail to assist readers in gaining a comprehensive multifaceted overview of the case through a whole-systems approach that is rich with information and carries implications for professional education and training, system design, and cultural transformation.



HISTORICAL CASE STUDY #1: Failure to Adequately Monitor a Postsurgical Patient







NARRATIVE OF THE EVENT


A young man, Mr. Steve Goldberg, was admitted to a surgical unit at 6:00 pm after an elective laparoscopic gastric bypass surgical procedure. Mr. Goldberg was stable at the time of admission and was receiving a patient-controlled narcotic infusion at a “high-normal” range for pain management via a PCA pump. He was receiving oxygen via a nasal cannula at 2 liters per minute.


On admission to the surgical unit, Mr. Goldberg’s blood pressure was stable at 142/87. He stated that he was comfortable but at times appeared uncomfortable and restless. At 8:50 pm, the patient denied having pain and wanted his oxygen removed. His oxygen levels were adequate, and the respiratory therapist removed the oxygen cannula at that time but left it in the room per routine procedure. Mr. Goldberg continued to be restless throughout the evening and was observed repositioning himself in the bed for comfort.


At midnight, the nursing assistant, Ms. Veronica Martin, removed the blood pressure cuff from Mr. Goldberg’s arm for comfort after recording a blood pressure of 92/44. She did not inform the registered nurse, Ms. Margaret Bennington, of the decrease in blood pressure but recorded the blood pressure on her worksheet, a nonpermanent record on a clipboard that contained the vital signs of the patients assigned to her. The nursing assistants used the worksheet to record vital signs for the registered nurse’s review before documenting them in the permanent medical record.


At midnight, however, Nurse Bennington was busy admitting a new patient. One hour later (1:00 AM), Nursing Assistant Martin repeated the blood pressure measurement and documented a blood pressure of 76/34 on her worksheet. Again, Nursing Assistant Martin did not report the increasingly lowered blood pressure to Nurse Bennington.


Nurse Bennington stated that at 2:45 AM she checked on Mr. Goldberg and characterized him as being restless, able to hold a conversation, and complaining of being too hot. Nurse Bennington gave Mr. Goldberg a cool wet cloth and took his blanket off. Nurse Bennington did not check any additional vital signs or ask to see the recorded blood pressure readings, stating that she assumed the patient was stable.


One hour later (3:45 AM), Nursing Assistant Martin was assigned for a short time to another unit. She did not communicate any information to Nurse Bennington regarding Mr. Goldberg before leaving the unit. She returned approximately one and one-half hours later.


At 5:15 AM, Nursing Assistant Martin returned to the clinical unit and recorded Mr. Goldberg’s vital signs as 77/34, pulse 100, and respirations 20. Nursing Assistant Martin gave Nurse Bennington a brief report on a second patient and then left to take a third patient’s vital signs.


At 5:30 am, the surgeon, Dr. Steel, came in earlier than his usual time to evaluate the patient. Dr. Steel’s intentions were to quickly assess the patient and then leave for the airport where he had an early commercial flight to catch. Dr. Steel stated that he could hear Mr. Goldberg snoring as he approached the room, and when he entered Mr. Goldberg’s room, he found the patient cyanotic from the neck up and unresponsive to verbal stimuli. Dr. Steel left the room to get Nurse Bennington for help, and together they returned to Mr. Goldberg’s room.


Nurse Bennington stated that Mr. Goldberg was positioned on his side, which was unusual, and that it was obvious he wasn’t doing well. His color was poor, respirations were slow, and he was unresponsive. At this time, Nurse Bennington repositioned Mr. Goldberg on his back to open his airway and improve his breathing.


Over the next 50 minutes, the narcotic infusion was discarded and Mr. Goldberg received two doses of medication to reverse the effects of the narcotic infusion. His arterial blood gases were assessed, and his oxygen was reinstituted via nasal cannula. He remained on the surgical unit for approximately 50 minutes while, according to each of the three staff members interviewed, Dr. Steel was reclined in a chair in the corner of the patient’s room or at the nurses’ station making phone calls while they suggested interventions to him.


The three registered nurses interviewed expressed concerns about their perceived delays in treatment after Mr. Goldberg was discovered in his unstable condition, and attributed the delays to waiting for Dr. Steel to take the initiative. According to Dr. Steel, he reinstituted Mr. Goldberg’s oxygen, instructed Nurse Bennington to turn off the patient-controlled narcotic infusion, and to give the medication to reverse the effects of the narcotic.


Dr. Steel left to catch his plane before the patient was stabilized. Mr. Goldberg showed some improvement before Dr. Steel left. Dr. Steel stated that he thought the patient’s systolic blood pressure was approximately 100, and he had oxygen saturation levels of approximately 92%. Neurologically, his pupils were reacting slightly; he was posturing on his left side and flaccid on the right side, and remained unresponsive to verbal stimuli.


Mr. Goldberg was transferred to the intensive care unit at 6:20 AM where the nurses in the ICU quickly increased the oxygen support and added intravenous vasopressors per protocol after consultation with the on-call physician in internal medicine, Dr. Asvall. A gap of approximately 30 minutes occurred between the time Dr. Steel left for the airport and the time Dr. Asvall arrived to manage the case.

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Dec 3, 2016 | Posted by in NURSING | Comments Off on Organizational Use of TERCAP®:Shifting From a Quality Management to a Whole-Systems Approach

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