1) What risk analysis could be used for this event?

2- Develop an action plan -

3- which theory or model used in developing this action plan?

 

Diane was an 80-year-old resident who was returning to the nursing home from the hospital following a left hip fracture on Friday evening. She has a history of congestive heart failure with frequent exacerbations. Her hospital discharge medication list was different than the prior medication list at the nursing home, specifically relating to her Lasix prescription. Diane was already taking Lasix at the nursing home before her hip fracture. All of her medication orders were transcribed by hand onto a new medication administration record (MAR). The old MAR, prior to the hospital stay, was not removed. The nurse checked Diane's new orders and wrote "repeat" next to the new Lasix order and yellowed out the line. She was interrupted and was not able to finish reviewing the orders so she asked another nurse to review it for her. The second nurse reviewed the order and saw that the old MAR was still there. She removed the old MAR and finished reviewing the new MAR.

On Sunday, the medication nurse passed meds for Diane, as she had done for the past three days. She saw the yellowed line through the Lasix order and thought that the medication had been discontinued. She sent the medication back to pharmacy. Pharmacy picked up the medication on Monday. On Monday, it was noted that Diane weighed three pounds more since being discharged from the hospital. The nurse recorded the weight and placed a call to the physician, who failed to respond. At 2:00 a.m. Tuesday morning, Diane began to have difficulty breathing. Assessment findings included +4 pitting edema, a BP of 190/110, a HR of 120, and respirations at 28. Crackles were heard through her lungs. The on-call physician was consulted and an order was placed to transfer Diane back to the hospital. She went into cardiac arrest while waiting for the ambulance and was not able to be resuscitated.

Answer:

Question one

     Risk analysis is a process that helps to identify and manage a potential problem that is likely to undermine an aspect of life. Carrying out a risk analysis is a procedural process that begins with acknowledging the existing threat and working towards the analysis of the options in the case of the problem. Then finally, estimation of the likelihood of the dangers. In the process, Dianne's situation required a site-specific risk assessment model that was to start by identifying the possible drugs to use for her situation (Marsden, 2017). The multiple diagnoses she has means more drugs, and they subsequently need to be administered in a manner that shows the experience and knowledge in the side effects that might affect one condition while treating the other. Site-specific assessment is most relevant for this process because it is a specific work that takes into account the site location, environment, and the professionals involved.  The process is a hospital discharge, and Diane is the patient who is likely to suffer if the prescriptions are not done to the best needs of the conditions she suffers from.

Question two 

     For this process, the plan would involve making a plan for whether the process is done the wrong way; first, it is the diagnosis change. The first step, therefore, is to identify the problem. Next will involve defining the process where Diane is involved and what they risk to lose if the operation of a wrong diagnosis happens (Ben et al., 2019). This process consists of defining the risks and the solutions of the same in case they happen. For the patient, risking death is the ultimate idea that may result from the wrong diagnosis. The professional medical needs to know their job description demands and work in the patient's best interest. The fourth step is the determination of the outcomes of the process; here, all of the possible results should be determined to identify the process and what it means for both the medical facilities and the patients. The fifth step involves the study of the effects of the process and comparing it with the tangible outcomes. One serves as a control experiment for the operation, and it helps in understanding the process and making conclusions based on the same. In site-specific risk assessment, the process needs to follow the steps, understand dynamics and work for the best interests of the process.

Question three

     The model used in making a site-specific assessment is known as a strategic model to help develop a sustainable process to help improve the patient's lifestyle. The strategic model demands that the process is done in the best interest of the sample. Strategy formation process in which the risk assessment process goes in the right way. Actionable plans come from the model and therefore give site-specific assessment a reliable outlook that supports the best outcomes. The evolution of goal-based initiatives in the process reverts to the best mode of treatment enhancement that the medical personnel can use over time. 

Reference

Ben, Y., Fu, C., Hu, M., Liu, L., Wong, M. H., & Zheng, C. (2019). Human health risk assessment of antibiotic resistance associated with antibiotic residues in the environment: A review. Environmental research, 169, 483-493.

Marsden, E. (2017). Heinrich's domino model of accident causation. Risk Engineering. https://risk-engineering.org/concept/Heinrich-dominos