HCM 5030 Module 2 Adverse Events and Patient Involvement Paper Example

What the Incident Reports Miss: Adverse Events and Patient Voice in a County Jail Medical Unit

Student Name

Master of Science in Healthcare Management, Thomas Edison State University

HCM-5030: Quality Improvement Strategies in Healthcare

Mentor Name

Month Day, Year

What the Incident Reports Miss: Adverse Events and Patient Voice in a County Jail Medical Unit

The composite New Jersey county jail described in this course's samples holds about 1,100 people on an average day, and its contracted medical unit filed 61 incident reports last year. The quality committee reads every one. The question this paper asks is how many harmful events never became reports at all, and whether the people who receive care in the jail could help find and prevent them. It assesses the main types of adverse events in jail health care and their effect on outcomes, explains why voluntary reporting understates them, proposes better detection and compares strategies for involving patients in improvement.

Types of Adverse Events in Jail Health Care

In this paper, an adverse event means injury that results from treatment given or withheld, as opposed to injury from the illness itself. In a jail, the most consequential types fall into five groups. Medication events include missed or delayed doses of essential drugs such as insulin, anticonvulsants, antipsychotics and opioid treatment medications, especially in the first 72 hours after booking, when the prescriber has not yet verified community prescriptions. Withdrawal events involve alcohol and opioid withdrawal that is not recognized or treated in time, sometimes progressing to seizures, delirium or dehydration. Diagnostic delays occur when symptoms reported through sick call requests wait days for evaluation. Self-harm events reflect missed or poorly communicated suicide risk. Transfer events arise when patients sent to the hospital return without their discharge plans being acted on.

These events affect outcomes well beyond the jail walls. A seizure from missed anticonvulsants can cause injury; untreated opioid use disorder leaves people at high risk of fatal overdose after release; and each serious event exposes the county and the contractor to litigation and erodes trust between custody and medical staff.

How Large Is the Problem?

National data suggest that some of these events are both deadly and undercounted. Fiscella et al. (2020) coded the text of national jail mortality records from 2000 to 2013 and identified 1,442 deaths associated with drugs and alcohol. Among 103 deaths associated with substance withdrawal, 66 involved alcohol and 21 involved drugs, mostly opioids. They also found that only 18% of deaths occurring within seven days of an arrest for alcohol intoxication had been officially coded as involving drugs or alcohol, concluding that substances contribute to more jail deaths than official coding shows.

Undercounting is not unique to jails. Classen et al. (2011) applied three detection methods to the same sample of admissions at three leading hospitals. Staff reports and indicators drawn from billing data together caught only about one event in ten of those a trigger-based chart review uncovered, and adverse events occurred in roughly a third of admissions. If hospitals with mature safety programs miss most events through reports, a jail medical unit with 61 reports a year almost certainly misses many more.

Detecting Events Better

The unit can adapt the trigger approach to its own setting. Each month, a nurse reviewer will examine 20 randomly selected records of people booked in the prior month, looking for triggers such as a missed dose of a flagged essential medication, a withdrawal assessment score above the treatment threshold without a medication order, a sick call request with no response within 48 hours, an emergency transfer, or naloxone administration. Each trigger leads to a short review to decide whether harm occurred and whether it was preventable. Results will be reported alongside incident reports, so the committee sees both the voluntary and the detected picture. Custody incident logs, such as falls in housing units and medical emergency calls, will be added as a second source.

The review will start small and grow. For the first quarter, two nurse reviewers will each examine ten records independently and compare their judgments, so that the unit learns where reviewers disagree before relying on the results. Findings will be reported as events per 100 bookings, which allows comparison over time even as the jail's population rises and falls.

Involving Patients in Improvement

Patients in a jail have little power, which makes their involvement in quality work both harder and more important. Bombard et al. (2018) reviewed 48 studies of patient engagement in quality improvement and found that the depth of engagement shaped what it achieved: consultation such as one-way feedback mostly produced discrete products like educational materials, while higher-level engagement, such as co-design and partnership, produced changes in care processes and governance. Some patients described their involvement as tokenistic, especially when their requests were denied or decisions had already been made.

The unit can compare four strategies against that evidence. The first, analyzing health-related grievances and sick call requests for patterns, is consultative and easy to start; it will show where delays and dissatisfaction concentrate but gives patients no voice in solutions. The second, a short anonymous survey at release asking about medication continuity and access to sick call, broadens consultation. The third, a reentry advisory group of five people released within the past year, recruited through the county's reentry program and paid for their time, allows co-design of changes such as the intake medication process; it requires custody approval and a facilitator independent of the contractor. The fourth, inviting family members to report concerns about a relative's medications at booking, could improve medication verification directly.

The unit should start with the first two strategies and build toward the advisory group within a year, while guarding against tokenism by reporting back to participants what was changed because of their input and what was not, and why.

Conclusion

In a county jail, the adverse events that matter most, missed medications, unrecognized withdrawal, delayed sick call and missed suicide risk, are also the ones a voluntary reporting system is most likely to miss. A trigger-based record review will reveal more of them. People in custody and those recently released are the only ones who experience the whole process, and involving them through graduated strategies that give them real influence will help the unit find and fix what its reports do not show.

References

Bombard, Y., Baker, G. R., Orlando, E., Fancott, C., Bhatia, P., Casalino, S., Onate, K., Denis, J.-L., & Pomey, M.-P. (2018). Engaging patients to improve quality of care: A systematic review. Implementation Science, 13(1), Article 98. https://doi.org/10.1186/s13012-018-0784-z

Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C., Frankel, A., Seger, A., & James, B. C. (2011). 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-589. https://doi.org/10.1377/hlthaff.2011.0190

Fiscella, K., Noonan, M., Leonard, S. H., Farah, S., Sanders, M., Wakeman, S. E., & Savolainen, J. (2020). Drug- and alcohol-associated deaths in U.S. jails. Journal of Correctional Health Care, 26(2), 183-193. https://doi.org/10.1177/1078345820917356