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Nursing Leadership and Patient Safety 

Table of Contents

Introduction.

What problems or an issue is being addressed?.

Why is it (or is it likely to be) a problem?.

What is the extent/prevalence of the problem?.

What are the known contributing factors?.

What are the strategies for preventing or minimizing the occurrence of problem or the consequences of the problem?

Conclusion.

References.

Introduction to Clinical Quality, Safety or Governance Issue

Clinical Quality refers to extra services provided to the patient in hospital for improvement in health more than the services essential for life. Also the term ethics are combined with clinical quality services because it is very essential for the patients and service providers to work with ethical practices in health care organizations. The term governance means the process and the structures used for ensuring the stability, empowerment, transparency, rule of law, equity and accountability. For managing the country’s administrative, political and economic affairs it is essential to follow the rules and norms ("Concept of Governance", n.d.). Australian Commission on Safety and Quality in Health Care develop and regulate the part of standards of The National Safety and Quality Health Service Standards with the name of Australian Health Service Safety and Quality Accreditation (AHSSQA) for protecting and improving the quality of health of patients in hospitals and health care organizations. The aims for providing these schemes are consistency in safety and health care norms in health care institutes in Australia. The standards focus on protecting public and enhance the quality of health services. Also they provide a mechanism for quality assurance for regular checking over the safety and quality standards. The aim of this literature review is one such issue that is Failure to Rescue. The issue means the failure of treatment of the patient due to increase in complications which may harm the patient (Pucher & Aggarwal, 2014). Here the problem or issue addressed is Failure of Rescue, why is it a problem or issue, what is the prevalence of problem, what are the factors contributing in this issue and what are the strategies for preventing and minimizing the occurrence of problem are discussed with the help of literature review.

What Problems or An Issue Is Being Addressed?

The issue addressed here is Failure to Rescue. The Failure to Rescue refers to the problems of harming the patients due to various reasons. The reasons for failure to rescue may be the incapability of the health care staff, lack of knowledge about the signals of deteriorating health, less practice before appointment in health care institutes, poor communication system and may be the centralization of decision making in hospitals or health care organizations. Holzer (2019) said that for improving the health of patient, it is necessary to measure and check the outcomes of patient regularly so that at initial stage the nursing staff will identify the deteriorating symptoms within the patient and take immediate actions or communicate to the superiors for protecting the life of patient. According toAustralian Commission on Safety and Quality in Health Care: Transforming the safety and quality of health care" (2013) the problem of failure of rescue is aligned with the 9th standard of National Safety and Quality Health Service Standards that is Recognizing and Responding to Clinical Deterioration in Acute Health Care. This standard describes about the implementation of systems and processes by the health care institutes for effective response of patients in case of deteriorating clinical conditions. Patients of deteriorating conditions must be identified at early stage and necessary action should be taken for improvement. Also the timely performance and outcome report must be shown to patients, family and carers for contributing in process of improving their health. It was observed that the chances of changes in patient’s condition were more after the surgery due to difference in the quality care provided to the patient by health care institutes. If quality care is provided to the patients and regularly monitor them by measuring and evaluating their outcomes will helps the patient to recover from the problem as soon. Taenzer, Pyke, McGrath, & Warner (2011) explained that failure of rescue is the reason for increase in the death rates in hospital or health care institutes because of the adverse steps taken by clinical staff. The unsuitable or incapable actions taken by the clinical staff will harm the life of patient. In support of above statement Walsh, & Prinsloo (2019) said that timely recognition of the abnormal significant signs by clinical staff helps in improving the deteriorating situation of the patients timely because only then they can start the remedial actions as early as possible. The Australian Health Service Safety and Quality Accreditation (AHSSQA) Standards works as a part of National Safety and Quality Health Services (NSQHS) Standards for improving the working and services of the health care institutions and provide safety to public across the country. This transformational effort taken by both standards is because of their hardwork, innovation and commitment shown by the quality and safety managers, board members, clinicians and executives. They want to focus on providing the safety and quality care to the patients consistently. Lafonte, Cai & Lissauer (2019) postulated that failure to rescue is more important metric than mortality rate in case of surgery and it is improvable also. After surgery patients needs extra care by the clinical staff so it is mandatory to regularly check up the outcomes of that patients and and note down each and every aspect so that if any serious problem occur with patients they can treat them at initial stage. According to DeVita et al. (2010) patient monitoring system alerts the clinicians after scanning the patient data if criteria of warning are matched with patient. They focus on using monitoring system which will evaluate the outcomes of patients properly.

Why Is It (or Is It Likely to Be) a Problem?

The failure to rescue is a serious problem because the outcomes may improve in case of early identification of deterioration of the patients. Due to the failure of rescue, case of death increased and it will reduce the clinical effectiveness because the postoperative complications occurs more fastly and leads to death of the patient. According to Mushta, L. Rush & Andersen (2017) if nurses don’t have proper knowledge about the early warning signals then it leads to decade, because due to such inappropriate knowledge or attitude of nurse the patient who may be survive with best medical care may die. Brown, Terrence, Vasquez, Bates & Zimlichman (2014) also supports this statement that due to lack of consistently checking and monitoring the reports of an average risk patients is just like unexpected contributes factor in- hospital mortality. As the health care provisions are getting so complex for the clinical staff because it is difficult for them to study and evaluate the outcomes of different patients. The patients of different characteristics and behaviors have different warning signals of deteriorating health which was very difficult to identify by nursing staff. Therefore it is very important to start observing the factors at very initial stage so that remedial action must be taken before the situation gets their worst state. Ghaferi, Birkmeyer & Dimick (2009) supports and said that in surgical hospital mortality failure to rescue is considered as the principle driver. Failure to rescue affects the motive of providing safety and quality care to the patients of the health care institutes. The death case is more due to the complications or incapability by clinical staff than the death by illness is more painful and shameful for the health care institutes. Such type of behavior by the clinical staff will destroy the image and trust of the general public and patients over their doctors and nursing staff. Failure to rescue is a serious problem because the lack of trust by patients over their clinical staff will reduces the effectiveness of treatment over the patients. A happy and positive patient can recover easily and fastly from their disease but due to some incapability of managers and nursing staff, the patient were in threat of losing their life. Lafonte, Cai & Lissauer (2019) state that there are some variables which are difficult to measure but affect the failure to rescue rate like hospital culture and the teamwork. The culture of any organization is not measured in quantitative terms but it impacts the patients to a greater extent and faculties of health care institutes. The delay in identification will leads to mortality and ICU transfers said by "Rapid Response Systems" (2020). The failure to rescue is a major problem for the society and health care institutes because the aim of hospitals and health care organizations is to provide safety and quality care to the patient and failure of rescue were not follow any safety norms and also does not provide any quality care to the patients in hospitals. According to Ghaferi, Osborne, Birkmeyer & Dimick (2010) there are many macro system characteristics associate with failure to rescue which are not easily modifiable and are not favourable for improving failure to rescue rate by the clinicians or hospital administrators. The failure to rescue will disprove the commitment of health care organizations which is not good for patients and as well as clinicians, administrative members and nursing staff. Failure to rescue harms the health of patients and image of the health care institutes as well

What Is the Extent/Prevalence of The Problem?

According to the statistics provided in research article by Ahmad et al. (2017) out of 35 patients who experienced complications 1 will experience death before leaving hospital due to failure to rescue and the failure to rescue rate is 2.8%. Also with their statistics they said that the hospitals having high complications rates will have low case of failure to death which shows the difference in capability of nursing of various health care institutes in treating the patients and provide quality care to them. The promptly identification of problem and start treatment at initial stage for prevention of death from failure to rescue shows the effectiveness level of a health care institute. Joseph et al. (2015) performed regression analysis for finding the independent factors related with failure to rescue after adjustment of various factors like mechanism of injury, volume of crystalloids, blood products, initial vital signs and demographics. They observed 1029 patients, out of which 21% (n=217) were developed from major complications. 82% of male and 61% had blunt trauma. 15.7% (n=34/217) was the failure to rescue rate. They conclude their report by stating that severity of head injury, age, prolonged resuscitation ad uninsured status are the independently associated with failure to rescue. Lafonte, Cai & Lissauer (2019) explained that failure to rescue rate changes from less than 1% to 40%. SCHREIBER (2018) said that estimation of 5 Million deaths of people out of 8.6 million deaths is due to poor quality health in low and middle income countries. The estimation of deaths due to poor care is five times more than the annual deaths occurring due to HIV/ AIDS. On average basis, only 50 percent of patients are properly diagnosed by clinical staff in sub- Saharan Africa. On basis of an International Research Busweiler et al. (2017) postulated that after esophageal surgery hospital mortality depends upon the management skills means the capability of clinicians of treating the patients appropriately and softly. The complications related to vascular, respiratory, infections and cardiac have higher chances of failure to rescue said by Trinh et al. (2013). Also according to research it is observed that the problem of failure to rescue is identified in case of old citizens because of mixture of health disease signals with the aging signals of patients. The clinicians will take some symptoms very seriously which are normal and some symptoms which are taken to be serious are ignored by considering the aging symptoms. Dr. Martin Makary, professor of Surgery and Health policy at Johns Hopkins University School of Medicine said that people die because of poor coordinated care; not only die because of heart attacks and bacteria. Team of Hopkins used four studies for evidence and calculate the mean death in U.S. hospitals due to medical errors are 2,51,454 deaths take place out of 35 million in 2013. All the studies conclude that the failure or poor care by the clinicians results in deteriorating health of patient or may lead to death of the patient.

What Are the Known Contributing Factors?

Mushta, L. Rush & Andersen (2017) state that nurses have a significant role in failing to rescue because it includes four key attributes that are: Failure to recognize changes in patient condition, errors of omission in care, failure to communicate changes and failure in clinical decision making. Failure in recognition of the changes in patient at early stage will leads to the patient in deteriorating stage or the patient may die. Error of omission in care refers to the error takes place due to non action of the nursing staff or clinicians when required or they forget to perform an important action or test with the patient to check their outcomes. Failure to communicate changes refers to when the nursing staff observed the changes in patient’s body but not communicate the changes to superiors. There are various reasons for failure in communication like there may be poor communication structure between nursing staff and superiors or the nursing staff was not comfortable in communicating their superiors because of reluctant and harsh nature of superiors etc. Failure in clinical decision making means the action not occurred timely for the patient due to various reasons like, lack of knowledge among the nursing staff, lack of power distribution among nursing staff or may be due to centralization structure of power in health care institutes, etc. Kremsdor ( 2005) also supports that error of omission s one of the factor contributes failure to rescue. Error of omission takes place when inappropriate information about the patient is available with nursing staff or when the patient’s body shows some vital sign but the nursing staff will not consider them as warning signals. Blotsky, Mardini & Jayaraman (2016) explained that failure to rescue have two approaches: failure to monitor identify properly; failure in responding timely to the patients of high risk. The nursing staff will not able to identify the deteriorating signals at early stage due to various reasons like lack of knowledge and training among nursing staff. They don’t know the technique of measuring and evaluating the outcomes of patients due to which no timely actions taken by them. Whereas sometimes the nursing staff identify the signals but will not respond to patients timely because of lack of knowledge about how to respond or they may be feel uncomfortable while communicating their superiors. Gupta et al. (2018) also stated that most of the patients with OIRD are not properly monitored by the nursing staff of health care institutes. Whereas it is very important to regularly update outcomes of such patients. Varley, Geller & Tsung (2017) also support the statement by stating that the patients who are gone with pancreaticoduodenectomy are required to regular update their outcomes because several factors affects them and failure to rescue is one of the important factor to harm the patients. Therefore many programs and strategies are developed for preventing patients from high risk after Pancreatic surgery. Earl-Royal et al. (2016) postulated that age factor and preexisting condition of the patients will also influence the trauma patients. It is difficult to identify difference between the warning signals and aged signals in the patient of more age. There are some diseases or problems in the patient due to their age and some symptoms are related with their health problem. The age factor are concerned with the increased failure to rescue.

What Are the Strategies for Preventing or Minimizing the Occurrence of Problem or The Consequences of The Problem?

The Health systems are developed for improving the health and providing quality care to the patients. The term equity is used for providing equal treatment to different section and no biasness on basis of gender, age and caste but the medical care faculties have to focus the poor people. Therefore the term equity is replaced by the term quality which means provide the quality care to the patients required. According to SCHREIBER (2018) the term quality care refers to improve the health of patient, earn the trust of patient and their family and to adopt the adjusting services according to the patients. Mushta, L. Rush & Andersen, (2017) state that there are various strategies which helps in reducing the problem of failure to success such as use the sign for early warning situation, maintain a proper structure for communication, work in team, shifts the course from failure to rescue, provide training to the medical and nursing staff, availbality of operating rooms and practice sessions for nurses for catching the symptoms at early stage. Brown, Terrence, Vasquez, Bates & Zimlichman, (2014) suggested to have a monitor with the patients for monitoring their outcomes. Technical devices will give actual outcomes of the patients and no chance of carelessness or incapability. QIP | NSQHS (2019) explained that for identification and responding to the small deterioration, there is a need to review and strengthen the governance arrangements and consistency in the system and with the patients regular interaction is also must. Smith, Wells, Friese, Krein & Ghaferi (2018) stated that for improvement in failure to rescue, two targets are focused that are reduces the time for identification in complications and need to improve the communication between professionals in health care institutes and also reduces the inability of expressing the clinical concerns. According to Ghaferi & Dimick (2015) there are three broad categories which are associated with failure of rescue: attitudes, hospital resources and behaviours. Good behavior and attitude of clinical staff will improve the safety and quality care with the help of hospital resources. There are different actions which are suggested by Australian Commission on Safety and Quality in Health Care: Transforming the safety and quality of health care" (2013) like, by the clinicians must provide safety and quality care according to the governance standards. Identify and respond to the minor changes occurring in patient. The health care institutes must use the monitoring system. Monitor and evaluate outcomes on regular basis with the help of technology. Clinicians must partner with the consumers for active participation of patients in their treatment. Monitor the patients personally who required separate attention. Prepare graph and track report of change in the performance of the patients. The patients of mental state are to be observed carefully by the monitoring devices and note every small change in the health of patients. Examine the reports of outcomes and causes for the changes. Provide call no for emergence assistance to the clinicians and nursing staff. Atleast one clinician must be appointed with one patient for providing quality care to them. Take decisions quickly for meeting the needs of patient in case of mental health problem. Discuss the vital signs and parameters with nursing staff for different situations of the patients. Make the communication system good so that everyone can comfortable with their superiors and subordinates. Tell about the parameters and indicators to clinicians for emergency situation. . The main focus of the standard is to integrate whole governing system for improving the quality and reliability of patient care. For managing the patient safety and protecting their health from risk, the governance system must be integrated. They develop a quality framework for implementation of health care and safety policies in the hospitals. The health care institutes implement an open disclosure system for quality care and safety on basis of national open disclosure standard and trained workers accordingly. The top authority also implements complaints management system for analyse mistakes and improve in response of complaints. Patient complaints and feedback are important source of governance system for healthcare institutes.

Conclusion on Clinical Quality, Safety or Governance Issue

This literature review conclude that regular monitoring and evaluating the patient outcomes will decrease the time period of patient to stay in hospital. The concern and efforts taken by clinical staff for optimizing the culture, hospital factors, communication, patient and early identification of deteriorating position of patient will help in improving the failure to rescue rate. The standards address various areas like: Governance for Safety and Quality in Health Service Organisations, partnership between the health care employees and consumers, controlling and preventing the infections associated with healthcare; focus on medication safety, blood and blood products, managing and reducing the pressure injuries which is very important for providing safety and quality care to patients. After considering the data given by different researchers about death of patients due to failure to rescue will generate a huge need for focusing over the standards established by National Safety and Health Quality Service Standards. Health care institutes require providing training and practice to the clinicians so that they will identify the signals at initial stage and reduces the risk of patient. For achieving the aim of the health care institutes of providing safety and quality care to patients some other measures and steps are given by various authors. The regular communication between clinical staff, non clinical staff, patients and carers is very necessary for reducing the problem of failure to rescue in hospitals and health care institutes. So that they will communicate each other comfortable and no barrier will create any hurdle between them.

References for Clinical Quality, Safety or Governance Issue

Ahmad, T., Bouwman, R., Grigoras, I., Aldecoa, C., Hofer, C., & Hoeft, A. et al. (2017). Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery. British Journal Of Anaesthesia119(2), 258-266. doi: 10.1093/bja/aex185

Australian Commission on Safety and Quality in Health Care. NSQHS Standards in 2013: Transforming the safety and quality of health care. Sydney: ACSQHC, 2014

Blotsky, A., Mardini, L., & Jayaraman, D. (2016). Impact of a Local Low-Cost Ward-Based Response System in a Canadian Tertiary Care Hospital. Critical Care Research And Practice2016, 1-8. doi: 10.1155/2016/1518760

Brown, H., Terrence, J., Vasquez, P., Bates, D., & Zimlichman, E. (2014). Continuous Monitoring in an Inpatient Medical-Surgical Unit: A Controlled Clinical Trial. The American Journal Of Medicine127(3), 226-232. doi: 10.1016/j.amjmed.2013.12.004

Busweiler, L., Henneman, D., Dikken, J., Fiocco, M., van Berge Henegouwen, M., & Wijnhoven, B. et al. (2017). Failure-to-rescue in patients undergoing surgery for esophageal or gastric cancer. European Journal Of Surgical Oncology (EJSO)43(10), 1962-1969. doi: 10.1016/j.ejso.2017.07.005

CHREIBER, M. (2018). NPR Choice page. Retrieved from https://www.npr.org/sections/goatsandsoda/2018/09/05/644928153/what-kills-5-million-people-a-year-its-not-just-disease.

Concept of Governance. (n.d). Retrieved from http://www.ibe.unesco.org/en/geqaf/technical-notes/concept-governance.

DeVita, M., Smith, G., Adam, S., Adams-Pizarro, I., Buist, M., & Bellomo, R. et al. (2010). “Identifying the hospitalised patient in crisis”—A consensus conference on the afferent limb of Rapid Response Systems. Resuscitation81(4), 375-382. doi: 10.1016/j.resuscitation.2009.12.008

Earl-Royal, E., Kaufman, E., Hsu, J., Wiebe, D., Reilly, P., & Holena, D. (2016). Age and preexisting conditions as risk factors for severe adverse events and failure to rescue after injury. Journal Of Surgical Research205(2), 368-377. doi: 10.1016/j.jss.2016.06.082

Ghaferi, A., & Dimick, J. (2015). Importance of teamwork, communication and culture on failure-to-rescue in the elderly. British Journal Of Surgery103(2), e47-e51. doi: 10.1002/bjs.10031

Ghaferi, A., Birkmeyer, J., & Dimick, J. (2009). Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients. Annals Of Surgery250(6), 1029-1034. doi: 10.1097/sla.0b013e3181bef697

Ghaferi, A., Osborne, N., Birkmeyer, J., & Dimick, J. (2010). Hospital Characteristics Associated with Failure to Rescue from Complications after Pancreatectomy. Journal Of The American College Of Surgeons211(3), 325-330. doi: 10.1016/j.jamcollsurg.2010.04.025

Gupta, K., Prasad, A., Nagappa, M., Wong, J., Abrahamyan, L., & Chung, F. (2018). Risk factors for opioid-induced respiratory depression and failure to rescue. Current Opinion In Anaesthesiology31(1), 110-119. doi: 10.1097/aco.0000000000000541

Holzer, R. (2019). “Failure to Rescue”: An Imperfect Measure Well Suited to Complement an Imperfect World. Journal Of The American Heart Association8(21). doi: 10.1161/jaha.119.014356

Joseph, B., Zangbar, B., Khalil, M., Kulvatunyou, N., Haider, A., & O'Keeffe, T. et al. (2015). Factors associated with failure-to-rescue in patients undergoing trauma laparotomy. Surgery158(2), 393-398. doi: 10.1016/j.surg.2015.03.047

Kremsdorf, R. (2005). Tackling the Underlying Problems of Failure to Rescue. Retrieved 22 September 2020, from https://www.the-hospitalist.org/hospitalist/article/122945/tackling-underlying-problems-failure-rescue

Lafonte, M., Cai, J., & Lissauer, M. (2019). Failure to rescue in the surgical patient. Current Opinion In Critical Care25(6), 706-711. doi: 10.1097/mcc.0000000000000667

Mushta, J., L. Rush, K., & Andersen, E. (2017). Failure to rescue as a nurse-sensitive indicator. Nursing Forum53(1), 84-92. doi: 10.1111/nuf.12215

Patient Safety Network. Rapid Response Systems. https://psnet.ahrq.gov/primers/primer/4/rapid-response-systems.

Pucher, P., & Aggarwal, R. (2014). Failure to Rescue. JAMA Surgery149(7), 747. doi: 10.1001/jamasurg.2014.586

QIP | NSQHS, (2019).Standard 8: Recognising and Responding to Acute Deterioration | Second Edition. YouTube. https://youtu.be/lItwhdYanR8.

Rapid Response Systems. (2015). Retrieved from https://psnet.ahrq.gov/primers/primer/4/rapid-response-systems.

Smith, M., Wells, E., Friese, C., Krein, S., & Ghaferi, A. (2018). Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Affairs37(11), 1870-1876. doi: 10.1377/hlthaff.2018.0704

Taenzer, A. H., Pyke, J. B., McGrath, S. P., & Warner, D. S. (2011). A review of current and emerging approaches to address failure-to-rescue. The Journal of the American Society of Anesthesiologists115(2), 421-431.

Trinh, Q. D., Bianchi, M., Hansen, J., Tian, Z., Abdollah, F., Shariat, S. F., ... & Sun, M. (2013). In-hospital mortality and failure to rescue after cytoreductive nephrectomy. European urology63(6), 1107-1114.

Varley, P. R., Geller, D. A., & Tsung, A. (2017). Factors influencing failure to rescue after pancreaticoduodenectomy: a National Surgical Quality Improvement Project Perspective. Journal of Surgical Research214, 131-139.

Walsh, Y., & Prinsloo, A. (2019). Recognise and rescue deteriorating patients: A large-scale quality improvement project to address failure to rescue. Southern African Journal of Critical Care35(1), 32-33.

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