MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP

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Interpretation

The improvement was cumulative over time, as shown above; based on the research tool, change in the parameters measured resulted in a decrease in hospital-acquired pressure injuries. As shown in both graphs, some of the causes of the high prevalence of pressure injury can be a lack of regular akin inspection, improper use of the Braden tool, and lack of evidence-based approaches in treating pressure injury (Horntvedt et al., 2018). This project has indicated the role of evidence-based practices, has provided knowledge to the nurses on the prevention of pressure injury, and has demonstrated the role and benefits of using a multidisciplinary team to prevent pressure injury. Some of the challenges encountered in this project are; a lack of understanding of the Braden risk assessment tool, lubricant unavailability, and no appreciation of the importance of medical device-induced pressure injury.

Near-Miss Events in QI

Assessment of quality improvement outcomes may encompass factoring in adverse or near-miss data. According to the World Health Organization (WHO), a near miss is an error that can cause an adverse event like patient harm but fails to do so because of chance or because it is intercepted. In this regard, there is a minimum chance of the patient getting hurt in near-miss events. Thus, the near-miss events present a limited opportunity to improve patient safety and advocate patient expectations regarding disclosure of medical errors, both factors associated with medical malpractice claims. 

The introduction of a near-miss events reporting system during a quality improvement initiative has been established to improve interprofessional care by more than 70 percent. However, in a typical health care setting, many barriers hamper reporting of near-miss events. For example, healthcare professionals are often faced with immense workloads; thus, incorporating a near-miss event into this immense workload may not be received well by healthcare professionals. Also, recording near-miss events may lead to punitive actions. 

Besides, understanding the causes of near-miss events plays a vital hand in improving health care delivery. Work-related interruptions, distractions, and patient communication have been termed to be the leading attributing factors of near misses in health care. Thus, according to Speroni et al. (2013), hospital management should consider personal and institutional factors when assessing quality improvement initiatives, especially when dealing with near-miss events. 

Conclusion 

Hospital-acquired Pressure Injury is preventable and can be avoided by utilizing a proper quality improvement tool such as the one used in this project. Approaches such as evidence-based medicine and the utilization of a well-equipped multidisciplinary team have proven to reduce pressure injury, which has helped improve outcomes for patients and reduce the cost associated with the treatment of this injury.

References

Ayello,  E.  A.,  &  Sibbald,  R.  G.  (2017).  Report on  NPUAP  session:  untangling the terminology of unavoidable pressure injuries,  terminal ulcers,  and skin failure. Innovated Skin and Wound  Care, 30 (5),  198. 

Black, J. M. (2019). Root cause analysis for hospital-acquired pressure injury. Journal of Wound Ostomy & Continence Nursing, 46(4), 298-304

Boyle, D. K., Jayawardhana, A., Burman, M. E., Dunton, N. E., Staggs, V. S., Bergquist-Beringer, S., & Gajewski, B. J. (2017). A pressure ulcer and fall rate quality composite index for acute care units: A measure development study. International Journal of Nursing Studies, 63, 73-81.