Risk Management and Patient Safety: CLABSI Prevention Plan

Risk Management and Patient Safety Paper
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Risk Management and Patient Safety Paper
Background Information/Introduction
Health care errors leading to patient harm remain a leading mortality and morbidity cause in the United States (U.S.) despite the implementation of the Patient Safety and Quality Improvement Act (PSQIA). At the federal level, the PSQIA implementation regulations because practical since 2009. The legislation primarily provides privilege and confidentiality protections for patient safety data when the medical provider partners with new expert domains referred to as Patient Safety Organizations (PSOs). The main patient safety events reportable under the PSQIA include surgical events, patient protection events, and device or product events. Examples of adverse outcomes recorded under the device or product events category included patients contracting central line-associated bloodstream infections (CLABSIs), patient severe disability or death linked to the use of a contaminated device, biologics, or medications administered by the hospital, as well as patient serious disability or death due to intravascular air embolism that happened where being managed within the health care facility. This paper summarizes and evaluates CLABSIs as a patient safety event and the stakeholders involved, including their roles, and articulates a specific plan to prevent the specified patient safety event.
The Patient Safety Event, What Happened, Circumstances Surrounding the Event, and Positions Responsible.
Besides clinical examination, lab investigations are crucial for patient diagnosis and subsequent management. Blood culture constitutes the most critical diagnostic procedure in addition to serum electrolytes, complete blood count, as well as liver or renal physiological tests, which are important in assessing for co-morbidities or severity. In the particular patient safety event, it was necessary that the paired blood culture (once each from the peripheral vein and central line) be drawn and marked accordingly prior to being sent to the laboratory. More specifically, a pathogen was recovered from the particular blood culture, which implied positive results for CLABSI as per the Centers for Disease Control and Prevention guidelines. In this CLABSI case, the patient had had a central line within 48 hours before he had clinical manifestations such as chills and fever. The patient also reported pain, discharge, and swelling from the exit site. The CLABSI event was recorded in an intensive care unit (ICU) patient with temporary hemodialysis catheters. Research indicates that are likely to be more CLABSIs within the temporary catheter cluster than within the permanent catheter cluster; however, this is not significant statistically (Strickler et al., 2018).
A quick assessment revealed that the trained nursing staff was directly at fault for the adverse patient safety outcome. However, a thorough investigation revealed that all quality improvement team members, including the executive sponsor, the clinical and physician co-lead, quality assurance leader, content specialists, ancillary department representation, frontline staff members, a...