Introduction
The present review aims to analyze the case study through the lens of IHI modules, such as Triple Aim and Patient Safety. The Triple Aim module encompasses improving the treatment experience for patients, boosting public health, and lowering healthcare costs. Patient safety is instilled in all healthcare providers as one of the foundations of high-quality care. This module concentrated on tactics and approaches for driving change in treatment. The paper will assess the fundamental components of the modules and offer recommendations for implementing quality improvement measures. The case study demonstrates the death of Tyler Ireland, 19th-year old patient, from opioid-induced respiratory depression (Ireland, 2018). Tyler was found unresponsive after having two heart attacks following surgery. Victoria, the patient’s mother, claimed that her son died because of nursing errors, lack of training, and negligence.
Review of the Key Elements
Problem Analysis
The case study’s problem should be analyzed in detail to apply IHI modules. Ireland (2018) informs that Tyler’s lung collapsed for the second time that year in October 2011. When air or gas escapes into the pleural space that divides the lung from the chest wall, it can trouble respiration. The doctors recommended surgery to prevent the same condition from happening again; pleurodesis is a standard procedure that effectively eradicates the pleural gap and binds the lung to the chest wall, protecting the lung from collapsing again (Ireland, 2018). According to Ireland (2018), doctors placed Tyler on patient-controlled analgesia (PCA) pump to cope with the discomfort following the surgery; the dosage of opioids recommended by the doctor is delivered using a PCA pump. Morphine, a narcotic pain medication routinely used to relieve moderate to severe pain, was prescribed in Tyler’s case (Ireland, 2018). Tyler was feeling better the next day after surgery; he was transported to the hospital’s regular floor, where the worst catastrophe occurred. Tyler was discovered dead the next morning after suffering two heart attacks.
Tylor’s death is a consequence of inadequate healthcare and nurses’ lack of training and education. The hospital has admitted partially that the staff did not properly care for Tyler. Tyler’s nurse that night had not been fully educated to care for a patient utilizing a PCA; she had barely finished half of the one-day training necessary (Ireland, 2018). Furthermore, an internal inquiry revealed that this nurse did not check the patient since 9 AM that night; she did not check on Tylor twice as needed (Ireland, 2018). The training and education of healthcare professionals should be questioned when investigating the case study.
Tyler has never gotten opioids before, and no precautions have been taken. At a critical juncture in which preventing opioid-related mortalities is a primary concern, Heung and Reddy (2020) recommend implementing active monitoring preventive measures such as routine screening for the risk of non-medical opioid use. Training on the proper removal and discussions with patients and healthcare professionals about a plan in case of severe complications such as overdose are crucial (Heung & Reddy, 2020). National regulations in the United States recommend taking precautions and reassessing individuals who have been administered opiates (Jani et al., 2020). According to his roommate, Tyler was snoring that night (Ireland, 2018). Marshansky et al. (2018) emphasize that chronic pain and opioid medications can also make it increasingly challenging to control sleep-disordered breathing, often known as sleep apnea. Pain and sleep management measures should be tailored to the patient’s history and current symptoms (Marshansky et al., 2018). Ireland (2018) argues that there were apparent indicators that Tyler was struggling from respiratory depression, but no measures were taken. The problem includes nurse mistakes as well as patient-controlled analgesia.
The IHI Triple Aim: Discussions and Recommendations
The IHI Triple Aim is a framework created by the Institute for Healthcare Improvement that offers a method for improving healthcare quality. According to the Institute for Healthcare Improvement, new systems must be developed to coordinate and integrate three objectives, namely the ‘Triple Aim’: enhancing the patient experience of treatment (encompassing quality and customer satisfaction), promoting public health, and decreasing the healthcare cost (The IHI Triple Aim, n.d.). Nowadays, it is difficult to find all three elements of the IHI Triple Aim in most health care settings. It is vital to leverage various public health issues, motivate families and individuals, and significantly expand the importance and influence of patient healthcare and other community-based programs to employ Triple Aim effectively (The IHI Triple Aim, n.d.). To implement the Triple Aim, specialists should concentrate on the following critical elements: patients and their families, transformation of healthcare resources and institutions, population care management, budgetary control platform, and system integration and implementation (The IHI Triple Aim, n.d.). Healthcare professionals should ensure a seamless journey through the entire healthcare delivery system throughout an individual’s life.
Tylor’s death could have been prevented if continuous monitoring had been considered. Ireland (2018) mentions that pulse oximetry monitoring would have revealed that the patient’s blood oxygen saturation was decreasing. Capnography monitoring would have shown an increase in the carbon dioxide level in his blood (Ireland, 2018). Based on the first element of the Triple Aim, healthcare professionals should improve the patient experience. Shenoy (2021) states that the first component of the Triple Aim, enhancing the patient experience of care, refers to medical technological improvements that have a beneficial influence on the patient experience of care. As an illustration, Triple Aim’s second component, which lowers per capita healthcare expenses, pertains to launching telemedicine and telehealth programs (Shenoy, 2021). Telemedicine allows clinicians to provide efficient and timely treatment even when they are not physically present with the patient; one of the benefits of telemedicine is the possibility of enhanced healthcare access (Shenoy, 2021). The third component of the Triple Aim, increasing population health, refers to encouraging and facilitating a convergence of the previously mentioned two purposes.
The first recommendation is to implement constant patient monitoring via technology, such as telemedicine and specific devices that will facilitate the communication between the patient and the nurse. Poor care transitions result in increased health expenses, overuse of emergency rooms, rehospitalizations, and negative consequences. Noel et al. (2020) acknowledge that telehealth can help enhance care transitions by increasing patient participation and medication compliance. Preventing avoidable hospital readmissions is beneficial for providers and patients alike to fulfill triple goal purposes (Noel et al., 2020). As digital technology grows more significant in patients’ lives, healthcare systems face increased demand for digital medical services.
The second recommendation is to promote the training and education of healthcare professionals. Bachynsky (2019) states that healthcare errors are not the product of human negligence but of poor systems, practices, and environments that drive individuals to make mistakes or fail to prevent them. The potential impacts of interprofessional care, in which two or more persons from various disciplines collaborate, should be stressed in healthcare. Interprofessional education/training is the participation of members of two or more professions connected with health or social care in learning with, from, and about one another (Bachynshy, 2019). It is crucial to highlight the significance of incorporating interprofessional collaboration into continuing education training to implement quality improvement measures. For instance, if more healthcare professionals were monitoring Tylor’s condition, working in a team, they would be able to prevent Tyler’s respiratory depression and subsequent death.
The IHI Patient Safety: Discussions and Recommendations
One of the overall aims of patient healthcare and quality assurance is patient safety. Patient safety is ingrained in all healthcare practitioners as one of the pillars of high-quality treatment; practitioners are engaged in direct patient healthcare (Shenoy, 2021). When patients observe steps that promote a positive environment embraced and applied, patient safety may be a system-wide strategy. The following are some of the issues of patient safety that IHI is concerned with (Patient Safety, n.d.). First, it is essential to activate the safety plan; in the United States, IHI is leading a multi-organizational campaign to develop a national implementation plan to prevent healthcare accidents. Second, engaging leaders in change is critical; IHI provides strategic counsel and innovative thinking to enable leaders at all levels to embrace, design, and execute tactics and techniques that drive change. Professionals should cultivate safe environments, identify opportunities for improvement, and make system-wide reforms that affect culture.
The recommendations for ensuring quality improvements include precise patient analysis, precautions if taking opioid medications, constant check-ups on the patient’s condition, and continuous communication. Patient safety is the primary task of the healthcare professional, and it cannot be ignored. The nurse did not check Tylor’s condition during the night shift; due to the negligence and nurse’s lack of training, the patient died. Guinea et al. (2018) emphasize that nurses account for the majority of the healthcare workforce and play a crucial role in enabling patient safety. Nursing jobs require intensive and practical learning opportunities to obtain the necessary skills and experience for patient safety (Guinea et al., 2018). It is vital to conduct proper training, for instance, on the usage of PCA and foster medical ethics among nurses. The dosage of opioids should be prescribed according to the patient’s medical history; in the case of Tylor, he did not survive the dosage prescribed because it led to respiratory depression.
Conclusion
To conclude, the report examined Tylor’s case study from the perspective of IHI modules like Triple Aim and Patient Safety. Healthcare providers should enhance the patient experience under the first component of the Triple Aim. Tylor’s death might have been avoided if constant monitoring had been considered. The second component of the Triple Aim, decreasing healthcare costs, is related to implementing remote health monitoring services. The third component of the Triple Aim, boosting population health, relates to supporting and enabling the merger of the first two goals.
The first recommendation is to use technologies, such as telemedicine and special equipment, to constantly monitor patients (capnography and pulse oximetry). The second recommendation is to enhance healthcare professional education and training. In healthcare, the potential benefits of interprofessional care, where two or more people from different disciplines interact, should be emphasized. The recommendations for assuring patient safety improvement methods include accurate patient assessment, precautions if using opioid drugs, frequent observation of the patient’s health, and regular interaction. It is critical to provide extensive training, such as on PCA, and promote medical ethics among nursing staff.
References
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