The Nursing Process and Expert Review

The Office of Inspector General describes an adverse medical event as harm to a patient or resident as a result of medical care, including the failure to provide needed care.  However, adverse events do not always involve errors, negligence, or poor quality of care and are not always preventable.

The evaluation of adverse healthcare events is comprehensive.  It must be performed consistently, systematically, and in accordance with established standards in order to provide reliable data that is meaningful for measuring and improving the quality of care for the healthcare consumer.

When providing care, healthcare professionals use specific processes to assess patient/individual’s and develop care plans that address the specific needs of each person.

The Nursing Scope and Standards of Practice describes a competent level of nursing care which is demonstrated by the critical thinking model known as the nursing process. The model consists of six standards followed by all nurses when caring for a person. These standards include:

1. Standard 1. Assessment:  The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation.
2. Standard 2. Diagnosis: The registered nurse analyzes data to determine actual or potential diagnoses, problems, and issues.
3. Standard 3. Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
4. Standard 4. Planning: The registered nurse develops a plan that prescribes strategies that attain expected, measurable outcomes.
5. Standard 5. Implementation: The registered nurse implements the identified plan.
   1. Standard 5A. Coordination of Care: The registered nurse coordinates care delivery.
   2. Standard 5B. Health Teaching and Health Promotion: The registered nurse employs strategies to promote health and a safe environment.
6. Standard 6. Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes.

The nursing process includes performing assessments, identifying and evaluating risks, implementing and monitoring interventions, and making changes to the plan of care as necessary. The process repeats throughout a patient/individual’s treatment/admission to address changing needs and conditions. During an analysis of the nursing process, if at any time during the process a part of the cycle has not been completed, the process should stop and move back to the last fully completed area. In addition, throughout the nursing process, nurses also include those that participate in the persons care, known as the interdisciplinary team.

As part of a forensic investigation, healthcare experts will frequently evaluate the totality of care, including the effectiveness to which professionals developed, implemented, and revised the plan throughout the person’s treatment.  A review of the initial assessments is critical; this review can include determining if the assessments were timely, complete, and accurate.  The next step is to determine if potential risks were identified and analyzed in such a way to identify potential obstacles and limit the risks.  In line with the nursing process, the next step is to evaluate if appropriate interventions were developed and implemented to address the individual needs of the patient/resident.  The process does not end here, as the forensic investigator must evaluate the way in which interventions were monitored and evaluated for effectiveness, and the appropriateness with which the plan of care was modified to satisfy the changing needs of the person.  Experts will look to see that each step in the care cycle was properly completed, with appropriate involvement from the interdisciplinary team.

The evaluation of adverse healthcare events is comprehensive. It must be performed consistently, systematically, and in accordance with established standards in order to provide reliable data that is meaningful for measuring and improving the quality of care. After reviewing the patient/individual medical records and the care process, a healthcare expert can better determine if breaches in the standard of care occurred.