Risk Management Quality Control Infection Control

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Risk ManagementQuality Control Infection Control

• IV Therapy
• Week 1

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Risk ManagementNursing Fast Fact

• The specialty of IV therapy is a high-risk
  technical area.
• If an act of malpractice does not create harm,
  legal action cannot be initiated.
• Coercion of a rational adult patient to place an
  intravenous catheter constitutes assault and
  battery.
• The practice of using verbal orders rather than
  written orders potentially places nurses at
  higher liability risks

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Legal Terms

• CRIMINAL LAW an offense against the general
  public caused by the potential harmful effect to
  society as a whole
• CIVIL LAW effect the legal rights of private
  persons and corporations. Contract Law and Tort
  law are most applicable to nursing practice
• NEGLIGENCE Failure to do something that a
  reasonable person would do
• MALPRACTICE Subset of negligence, committed by a
  person in a professional capacity. (nonadherence
  to the accepted standard of care)

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Legal Terms

• Four components needed to prove liability for
  malpractice
• It must be established that the nurse had a duty
  to the patient
• A breach of standards of care or failure to carry
  out that duty must be proven
• The patient must suffer actual harm or injury
• There must be a causal relationship between the
  breach of duty and the injury suffered (OKeefe,
  2000)

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Legal Terms

• The rule of personal liability is every person
  is liable for his own tortuous conduct (his own
  wrong doing.)
• A physician cannot protect a nurse from an act of
  negligence
• Nurses are liable for their own wrongdoings in
  carrying out physicians orders. This is relevant
  in the areas of medication errors and
  administration of IV fluids.

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Legal Action

• Two most common causes for legal action in
  nursing
• Unprofessional practice conduct that is a
  departure from or failure to conform to the
  minimal standards of care
• Professional malpractice professional misconduct
  or unreasonable lack of skill that results in
  harm

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Legal Issues

• Breach of duty
• Failure to observe, failure to intervene, and
  verbal rather than written orders are potential
  risks for all nursing areas
• A breach of application of standards of care can
  be the basis for negligence. Always ask what a
  reasonable and prudent nurse would do.

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Legal Perils of IV Therapy

• Not enough IV experience to become comfortable or
  proficient
• Entering the blood stream with a foreign object
• Litigation for nurses can result from
• Infiltration and phlebitis
• Fractured central venous catheters
• Nerve injury, infiltration and Extravasation
• Administering the wrong drug
• Failure to document appropriately

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Ethics

• A code of ethics acknowledges the acceptance by a
  profession of the responsibilities and trust that
  society has conferred and recognizes the duties
  and obligations in that trust.

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Infusion Nursing Code of Ethics

• Autonomy (right to self determination,
  independence
• Beneficence (doing good for patients)
• Nonmaleficence (doing no harm to patients)
• Veracity (truthfulness)
• Fidelity (obligation to be faithful)
• Justice (obligation to be fair to all people)

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Risk Management

• Standards of Practice for Infusion Therapy come
  from the Infusion Nursing Society
• New standards published in 2006
• Association of Vascular Access
• Oncology Nursing Forum

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Risk Management

• The Revised Infusion Nursing Standards of
  Practice define Risk Management as
• a process that centers on identification,
  analysis, treatment, and evaluation of real and
  potential hazards
• It is the process of collecting and analyzing
  scientific data to describe the form, dimension,
  and characteristics of risk

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Risk Management

• Risk Management involves all medical and facility
  staff.
• It provides for the review and analysis of risk
  and liability sources involving patients,
  visitors, staff and facility property

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Risk Management Components

• Identification and management of clinical areas
  of actual and high risk
• Identification and management of nonclinical
  (e.g. visitor, staff areas of actual and high
  risk)
• Identification and management of probable claims
  events
• Management of property loss occurrences

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Risk Management Components (cont)

• Review and analysis of customer surveys and
  patient complaints
• Review and analysis of risk assessment surveys
• Operational linkages with hospital Quality
  management, safety, and performance improvement
  programs

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Risk Management Components (cont)

• Provision of risk management education
• Compliance with state risk management and
  applicable federal statutes, including the Safe
  Medical Devices Act

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Clinician and Patient SafetyBarriers to
Improvement

• Lack of awareness
• Between 44,000 and 98,000 deaths annually
• Approximately 2.5 million nurses and 900,000
  Physicians practicing in 7500 Hospitals across
  the United States
• Complex environment making clear communication
  even more important.

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Clinician and Patient SafetyBarriers to
Improvement

• Two types of errors as identified by James Reason
• Active errors errors at the sharp end of
  healthcare Occur at the point of interaction
  between the person (nurse) and a larger system
  (medication cart)
• Latent errors errors at the blunt end of health
  care error that gives rise to the active error
  and is not necessarily apparent when it happens.

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Clinician and Patient SafetyBarriers to
Improvement

• Culture of Blame

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Clinician and Patient SafetyPathophysiology of
error

• Reliance on weak aspects of cognition
• Interruptions
• Fatigue
• Time Pressure
• Hand-offs
• Medication terminology
• Standardization
• Knowledge Base
• Paradigm Shifts

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Risk Management Strategies

• Informed consent
• Unusual occurrence reports
• Sentinel events
• Documentation
• Professional Liability insurance
• Patient relations
• Quality Management

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Risk Management Strategies

• Informed consent
• To provide patients with enough information to
  enable them to make a rational decision regarding
  whether to undergo treatment
• Unusual occurrence reports
• Should be filed every time there is a deviation
  from the standard. Record of the event
• Unusual occurrence reports are meant to be
  nonjudgmental, factual reports of the problem and
  its consequences.

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Risk Management Strategies

• Documentation
• Accurate, timely, and complete written account of
  the care rendered to the patient.
• Professional liability insurance
• Patient relations
• Quality management

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Dimensions of Performance

• Doing the right things includes
• The efficacy of the procedure or treatment in
  relation to the clients condition
• The appropriateness of a specific test,
  procedure, or service to meet the clients need

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Dimensions of Performance

• Doing the right thing well includes
• The availability of a needed test, procedure,
  treatment, or service to the client who needs it
• The timeliness with which a needed test,
  procedure, treatment or service is provided to
  the client
• The effectiveness with which tests, procedures,
  treatments, and services are provided

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Dimensions of Performance

• The continuity of the services provided to the
  client with respect to other services,
  practitioners, and providers overtime
• The safety of the client and others to whom the
  care and services are provided
• The efficiency with which care and services are
  provided (JCAHO, 2000)
• The respect and caring with which care and
  services are provided

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Quality Patient Management

• Quality management is the systematic process to
  ensure desired patient outcomes
• Continuous quality improvement (CQI)
• Goal to create outcome monitoring and evaluation
  processes to assist organization in improving the
  quality of care.
• Is continuous outcomes are never optimized but
  may be constantly improved.

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Quality Management

• Performance Improvement
• The use of outcomes and other performance
  measures complements the application of standards
  and completes the quality equation
• Doing the right thing well
• Evidence-Based Practice
• Goal to apply valid and reliable nursing
  research to clinical practice.
• Bring the most current knowledge to clinicians.

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INFECTION CONTROL

• Infusion Therapy
• BSN 336

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Basic Principles of Epidemiology

• Colonization the presence of a microorganism in
  or on a host, with growth and multiplication of
  the microorganisms with no clinical symptoms or
  detected immune response
• Dissemination the shedding of microorganisms
  into the immediate environment from a person
  carrying them.
• Nosocomial Infections developed within a
  hospital of are produced by organisms acquired
  during hospitalization. Now call HAC

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Chain of Infection

• First Link Causative Agent
• The ability of an organism to induce disease is
  called its virulence.
• Second Link Reservoir
• The source of microorganisms.
• Other humans
• Clients own microorganisms, plants, animals, or
  the general environment
• The place where the organism maintains the
  presence, metabolizes and replicates.

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Chain of Infection

• Third Link Portal of Exit from Reservoir
• Major portals of exit respiratory tract, GI
  tract, skin, blood.
• Fourth Link Method of Transmission
• Direct transmission
• From person to person, touching, kissing,
  biting, sexual intercourse
• Indirect transmission
• Vehicle-born toys, handkerchiefs, soiled linens,
  clothes
• Vector-born animal or flying or crawling insect

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Chain of Infection

• Fifth Link Portal of Entry to the Susceptible
  Host
• Microorganisms often enter the body of the host
  by the same route they use to leave the source
• Sixth Link Susceptible Host
• Any person who is at risk for infection

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Chain of Infection
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Breaking the Chain of Infection

• New microbiologic methods
• Advancement of Epidemiologic Methods
• Continuous Quality Improvement Programs
• Risk Management
• Antibiotic Use
• Pharmacoepidemiology
• Emporiatrics (study of disease in travelers)

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Infusion-Relate Infections

• 150 million intravascular devices are purchased
  each year.
• 7-8 million central venous catheters placed each
  year
• More that 200,000 noscomial bloodstream
  infections occur each year, 90 are related to
  CVAD

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Catheter Related Blood Steam Infections CRBSI

• Microorganisms that colonize the skin of
  hospitalized patients cause the majority of CRBSI
• Biofilm Slime extracellular polysaccharide
  which helps bacteria to adhere to surfaces

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BIOFILM

• THE STUFF YOU SEE IN YOUR DOGS WATER,

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Catheter Related Blood Steam Infections CRBSI

• Primary risk factors include
• Duration of catheterization (number of catheter
  days)
• Multiple lines
• Colonization of catheter insertion site by skin
  organisms
• Location of catheter Subclavin vein, groin
• Aseptic dressing change
• Aseptic insertion technique Total Barrier
  Precautions

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CRBSI

• Secondary Risk Factors
• Secondary bacteremia
• Host defense status
• Contaminated infusate,
• Number of catheter lumens

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CRBSI

• Predisposing factors
• Duration of placement
• Multiple lumens
• Catheters made of polyvinyl chloride
• Catheters that develop fibrin sheaths
• Port systems that develop sludge in reservoir
• Compromised immune status
• Phlebitis

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Strategies for Preventing/Treating Infections

• Follow CDC Standard Precautions Guidelines
• Tier One Standard Precautions universal
  precautions and body substance isolation
• Tier Two Transmission-Based Precautions
• Airborn precautions
• Droplet precautions
• Contact precautions
• Nursing Fast Fact Implementation of standard
  precautions has implications for infusion therapy
  nurses Use of I.V. therapy carts and trays may
  be limited for patients who are on contact
  transmission precautions.

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Strategies for Prevention/Treatment

• Follow Hand Hygiene Procedure
• Nursing Fast Fact Studies have documented
  contamination of HCWs hands with potential
  healthcare-associated pathogens. Serial cultures
  revealed that 100 of HCWs carried
  gram-negative bacilli at least once, and 64
  carried S. aureus at least once.
• 60 of Infections come from the patient, 35 from
  other sources, ad 5 from our hands

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Strategies for Prevention/Treatment

• Use Appropriate Skin Antisepsis
• Use Catheter Site Dressing Regimens
• Transparent, semi permeable polyurethane dressing
• Use Catheter Securement Devices
• Use Anticoagulants
• Use Antibiotic Locks

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Sources of Infection
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SAVE THAT LINE

• Scrupulous Hand Hygiene
• Aseptic Technique
• Vigorous Friction to Hubs
• Ensure Patency
• Association of Vascular Access