RISK MANAGEMENT PROCESS
Risk Factors
A risk factor is any situation, habit, social, or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident ( 2004). An understanding of risk factors, behavior, risk factor modification, and behavior modification are integral components of health promotion, wellness, and illness prevention activities. Nurses in all areas of practice often have opportunities to assist patients in adopting activities to promote health and decrease risks of illness.
The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Nurses and other health care professionals are concerned with risk factors, sometimes called health hazards, for several reasons.
Risk factors play a major role in how a nurse identifies a patient’s health status. They can also influence health beliefs and practices if a person is aware of their presence. Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle (2004).
Risk Factor Modification
Identifying risk factors is the first step in health promotion, wellness education, and illness prevention activities. Health hazards should be discussed with the patient following a comprehensive nursing assessment; then the patient can decide if he or she wants to maintain or improve his or her health status by taking risk reduction actions. Risk factor modification, health promotion, or any program that attempts to change unhealthy lifestyle behaviors can be considered as a wellness strategy.
Risk Management
Risk management is a system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs. The steps involved in the risk management include identifying possible risks, analyzing them, acting to reduce the risks, and evaluating the steps taken. One tool used in risk management is the incidence report or occurrence report (2004).
Risk management also requires good documentation. A medical staff’s documentation can be the evidence of what actually was done for a client and can serve as proof that the medical professional like the nurse acted reasonably and safely (2004). Documentation should be thorough, accurate, and performed in a timely manner.
To protect the nurse and the patient, the nurse should document the care given and the details associated with it. Charting the statement “physician notified” may be insufficient if at the time the nurse is being questioned about the lawsuit, he or she does not recall which physician and what specific facts were told to the physician.
When a lawsuit is filed, very often, the nurse’s notes are the first thing reviewed by the attorney. The nurse’s assessments and the reporting of significant changes in the assessments are very important factors in defending a lawsuit. Therefore, the nurse should identify the physician contacted, the information communicated to the physician, and the physician’s response. For nurses in practice, the underlying rationale for quality improvement and risk management programs is the highest possible quality of care.
Intravenous Medication Administration
Medication administration is a critical skill of the professional nurse, who must understand and follow various steps in the drug administration process to assure patient safety. The nurse must be proficient in medication dosage calculation to safely administer drugs. Errors related to intravenous administration of a drug often results in the most serious injuries to patients (2003).
However, many medical-surgical nurses experience difficulty when calculating drug dosages. One study revealed that 56% of nurses could not calculate medication dosages to a 90% proficiency rate. In addition, nurses made significantly more errors in calculating intravenous drug dosages as compared to oral, intramuscular, or subcutaneous drug dosages ( 2004).
When using any method of intravenous medication administration, the nurse must observe clients closely for symptoms of adverse reactions. After the medication enters the bloodstream, it begins to act immediately, and there is no way to stop its action. Thus the nurse should take special care to avoid errors in dose calculation and preparation.
The nurse should double-check the six rights of safe medication administration and know the desired action and side effects (Potter & Perry, 2004). If the medication has an antidote, it must be available during administration. When administering potent medications, the nurse must assess vital signs before, during, and after infusion.
Administering medications by the IV route has advantages. Often the nurse uses the IV route in emergencies when a fast-acting medication must be delivered quickly. The IV route is also best when it is necessary to establish constant therapeutic blood levels. Some medications are highly alkaline and irritating to muscle and subcutaneous tissue. These medications cause less discomfort when given intravenously ( 2004).
As a safety alert, because IV medications are immediately available to the bloodstream once they are administered, the nurse must therefore verify the prescribed rate of administration so that the medication is given over the appropriate amount of time. The patients may experience severe adverse reactions if the IV medications are administered too quickly.
According to a research, perioperative nurse managers should understand that errors are more likely to occur if multiple steps are required to prepare a medication before administration or if bolus administration of medication is being used. Consideration should be given to implementing a system of centralized preparation for all IV medications and affixing warning labels to all medications intended for bolus administration ( 2003).
Medication errors can be a source of significant morbidity and mortality in the health care setting. Providing intravenous (IV) therapy is a complex health care technology and patients are at risk of experiencing adverse events such as medication errors. Increasingly, human error theory is used to investigate adverse events such as these. Therefore, it is important that medication errors be monitored so that similar incidents can be prevented in the future. Problems associated with devices that lead to medication errors should also be reported to health care authorities.
Complications of Intravenous Therapy
An infiltration occurs when IV fluids enter the surrounding space around the venipuncture site. This is manifested as swelling (from increased tissue fluid) and pallor and coolness (caused by decreased circulation) around the venipuncture site. Fluid may be flowing through the IV line at a decreased rate or may have stopped flowing. Pain may also be present and usually results from edema and increases proportionately as the infiltration continues (2004).
When infiltration occurs, the infusion must be discontinued and, if IV therapy is still necessary, a new cannula is inserted into a vein in another extremity. To reduce discomfort, the nurse should raise the extremity, which would then promote venous drainage. To help decrease the edema, the nurse should wrap the extremity in a warm, moist towel for 20 minutes while keeping it elevated on a pillow. This promotes venous return, increases circulation, and reduces pain and edema (2003).
Phlebitis is an inflammation of the vein which is another complication of intravenous therapy (2004). Selected risk factors for phlebitis include the type of catheter material, chemical irritation of additives and drugs given intravenously, and the anatomical position of the catheter. Signs and symptoms may include pain, edema, erythema, and increased skin temperature over the vein, and, in some instances, redness traveling along the path of the vein. Dehydration may also be a contributing factor because of the increase in blood viscosity ( 2000).
When phlebitis occurs, the IV line must be discontinued and a new line inserted into another vein. Warm, moist heat on the site of phlebitis can offer some relief to the client. Phlebitis can be dangerous because blood clots which are called thrombophlebitis can occur and in some cases may result in an emboli. This may result in permanent damage to veins as well as resulting in extended agency care. Phlebitis may be prevented by the routine removal and rotation of IV sites (2004).
Another complication of intravenous therapy is fluid volume excess (2004). This occurs when the patient has received a too-rapid administration of IV solutions. The assessment findings of this condition include shortness of breath, crackles in the lungs, and tachycardia. To provide an intervention for this, the nurse should slow the rate of infusion, notify the physician, raise the head of the bed, and monitor vital signs.
Bleeding can occur around the venipuncture site during the infusion or through the catheter needle or tubing if these become inadvertently disconnected. This complication is common in patients who have received heparin or who have a bleeding disorder (2004). If bleeding occurs around the venipuncture site and the catheter is within the vein, a pressure dressing may be applied over the site to control the bleeding. Bleeding from a vein is usually a slow, continuous seepage and is not serious. Still it merits special attention from the nurse and other medical staff.
Nurses in critical care settings must be familiar with the variety of ways dosages are described. The nurse should understand how to convert and determine equivalent dosages with orders that contain such units as micrograms/minute, micrograms/kg/minute, milligrams/hour, or milligrams/day. For many intravenous drugs, an infusion pump may be used which requires a pump setting in any of the above units. Alternatively, without an infusion pump, a drip factor must be considered with intravenous solutions (2004).
In efforts to improve patient safety, healthcare systems need to give first priority to averting the medication errors with the greatest potential for harm. By targeting efforts to avert such errors, hospitals can achieve the most rapid and significant impact on improving medication safety (2005).
The ever-increasing complexity of the nursing environment and the current nursing shortage further increase the possibility of error in many medical routines, including intravenous administration of drugs. Demands often exceed an individual’s capacity to function without error, even for highly experienced clinicians. Unnecessary variability in drug concentrations, dosing units, and dosing limits used in different areas of a hospital further complicates infusion programming and increases the risk of harm ( 2005).
Role of Nurses in Preventing Medication Errors
The dramatic increase in the number of new medications, including biotechnology products, makes it difficult to keep current on their proper use, and can overwhelm the best intentions of all health care practitioners, including nurses.
Administration of the wrong drug is the most common error that occurs. Factors that contribute to wrong drug error include similar labeling and packaging of products, medications with very similar names and storage of these similar products together. In addition, poor communication is a common cause of administering the wrong drug.
To administer medication safely to patients, certain cognitive skills are essential. The nurse accepts full responsibility and accountability for all actions that are taken; this includes the administration of medications, whether it is intravenous, oral, or something else.
When a nurse administers an intravenous medication to a patient, the nurse accepts the responsibility that the medication or the nursing actions in administering it will not harm the patient in any way. The nurse does not assume that the medication that is ordered for the patient is the correct medication or the correct dose.
The nurse could be held accountable for administering an ordered intravenous medication that is knowingly inappropriate for the patient. Because of this, the nurse should be familiar with the therapeutic effect, usual dosage, laboratory interferences, and side effects of all medications that are administered (2004).
Demonstrating accountability and acting responsibly in professional practice means that the nurse acknowledges when errors in professional practice occur. Most of the errors that are made by nurses are medication errors (2004), and this includes intravenous medication administration.
The nurse is the essential link in the prevention of medication errors. Unfortunately, many medication errors are never identified. When an error occurs, it should be acknowledged immediately and reported to the appropriate hospital personnel. This is necessary since measures to counteract the effects of the error may be necessary.
Pressure Ulcers
Pressure ulcer is most commonly known as bedsore. Other names for it include pressure sore, decubitus ulcer and trophic ulcer. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed, wheelchair, cast or splint for example (2003). The condition results to impaired skin integrity related to unrelieved, prolonged pressure (2004).
Such a condition is seen most frequently in patients who have diminished or absent sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition can therefore be at risk for pressure ulcer development. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible but other sites may be involved, depending on the patient’s position. Pressure ulcers can affect not only superficial tissues, but also muscle and bone.
The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be relieved. Unless a full-flotation bed such as a water bed is used, providing even distribution of the patient’s weight. If the patient is using braces or plaster casts, a protective padding at bony prominences should be used under braces or plaster casts, and a window in the cast should be cut over potential pressure sites.
Skin inspection is also important. Pressure points should be checked for erythema or trauma at least once/day in an adequate light. Able patients, mobile or immobile, and their families must be taught a routine of daily visual inspection and palpation of sites for potential ulcer formation. Exquisite skin care for neurologically damaged parts is necessary to prevent maceration and secondary infection. Maintaining cleanliness and dryness helps to prevent maceration.
The prevention of pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity may not be a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients. Prompt identification of the high-risk patients and their risk factors aids in prevention of pressure ulcers.
A well-balanced diet, high in protein, is important in the treatment of pressure ulcers. Blood transfusions may be needed for anemia. Threatened pressure sores require energetic use of all the above mentioned prophylactic measures to prevent tissue necrosis. The area should be kept exposed, free from pressure, and dry.
The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small visible surface with an extensive unknown base, and there is no good method of determining the extent of tissue damage.
More advanced ulcers require surgical treatment. Surgical debridement and closure is required for fat and muscle involvement. Affected bone tissue requires surgical removal; disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and delay healing, so it should be removed. An exception may be eschar or necrotic tissue on a heel ulcer because an open heel wound can easily become infected and lead to osteomyelitis. Several debridement methods are available; the choice depends on the amount of necrotic tissue, absence or presence of infection, patient preferences, and economic considerations (2006).
Risk factors for Pressure Ulcer Development
A variety of factors can predispose a patient to pressure ulcer formation. These factors can be directly related to disease, such as decreased level of consciousness, related to the aftereffects of trauma, the presence of a cast, or secondary to an illness, such as decreased sensory input following a cerebrovascular accident. These factors are divided into intrinsic and extrinsic factors.
Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include loss of pain and pressure sensations that ordinarily prompt the patient to shift position and relieve the pressure, and the thinness of fat and muscle padding between bony weight-bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection play contributory roles. The most important of the extrinsic factors is pressure. Its force and duration directly determine the extent of the ulcer. Pressure severe enough to impair local circulation can occur within hours of an immobilized patient, causing local tissue anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.
An individual’s potential to develop pressure ulcers may be influenced by the following intrinsic risk factors which therefore should be considered when performing a risk assessment: reduced mobility or immobility; sensory impairment; acute illness; level of consciousness; extremes of age; vascular disease; severe chronic or terminal illness; previous history of pressure damage; malnutrition and dehydration.
The following extrinsic risk factors are involved in tissue damage and should be removed or diminished to prevent injury: pressure; shearing and friction.
An individual’s potential to develop pressure ulcers may be exacerbated by the following factors, which therefore should be considered when performing a risk assessment: medication and moisture to the skin.
Identifying Individuals at Risk
The assessment an individual’s risk of developing pressure ulcers should involve both informal and formal assessment procedures. Risk assessment should be carried out by personnel who have undergone appropriate training to recognize the risk factors that contribute to the development of pressure
ulcers and know how to initiate and maintain correct and suitable preventative
measures.
The timing of risk assessment should be based on each individual case. However, it should take place within six hours of the start of admission to the episode of care. If considered not at risk on initial assessment, reassessment should occur if there is a change in an individual’s condition which increases risk.
All formal assessments of risk should be documented or recorded and made accessible to all members of the inter-disciplinary team.
There are several instruments for assessing patients who are at high risk for developing a pressure ulcer. Patients with little risk for pressure ulcer development are spared the unnecessary and sometimes costly preventive treatments and the related risk of complications.
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