Patient Safety

On reflection I realise that the incident which happened to Mrs D could have been avoided and prevented if proper communication and multidisciplinary team work had been implemented (Mellanby, Podmore and McNarry, 2014; DOH, 2012; NMC, 2015). The outcome of an airway crisis can be influenced by the anaesthetic nurse as the anaesthetist does not work in isolation and therefore discussion of the potential alternatives should difficulty arise is vital (Mellanby, Podmore and McNarry, 2014). As with all aspects of healthcare, structured communication within the team is central to preparing for critical incidents (DOH, 2012). Furthermore, in this situation it is possible that the anaesthetic nurse was not experienced or confident enough to deal with

Clinical human factors are important in optimising patient safety, having complete understanding reduces the risk of unintentional mistakes. This scientific discipline must be followed by each individual healthcare professional. Having an understanding off these skills strengthens performance meaning safer surroundings and more comfortable experiences for patients; being the forefront of patient care. An example of poor understanding in human clinical factors be the case study of Elaine Bromiley, 2005 resulting in death. Elaine attended routine sinus surgery, during this a sequence of occurrences caused by lack of communication, teamwork and management equalled Elaine’s passing. This case emphasises in

The Institute of Medicine’s (IOM) (1999) report To Err is Human revealed the United States healthcare system to be a rather unsafe environment for patients estimating that as many as 96,000 patients died or were seriously injured due to preventable medical errors. Incidentally, studies conducted as recently as 2011 have suggested that the actual rate of preventable medical error occurrence may be three times the IOM’s initial estimation (Andel, Davidow, Hollander, & Moreno, 2012). Statistics this extreme cannot be attributed to the mistakes or substandard practices of individual healthcare providers alone and thus it is imperative that healthcare organizations begin to seek out solutions at the system’s level (Geary, 2014). Therefore, it

This article addresses “communication failures within a healthcare institution can result in substandard care and increase likelihood of adverse outcomes for patients” (p. 181). As part of The Joint Commission goal for institutions to improve safety and reduce communication failure a program was created where doctors were (team leaders) and nurses (team members). The clinical crew resource management (CCRM) was implemented in the gastrointestinal (GI) endoscopy area at Huntington VA Medical Center.

Preventable errors, including those that occur as a result of poor communication, surgical complications, accidents, etc. cost Americans millions of dollars each year (Blouin, 2013). In 1999, the Institute of Medicine published a report, “To Err is Human: Building a Safer Health System,” that described the lack of safety in the US healthcare system. The report was a ground-breaking publication, triggering research and articles that highlighted the need for safer practices and quality standards in the US health care system (Stelfox, Palmisani, Scurlock, Orav, Bates, 2006). The Patient Protection and Affordable Care Act (ACA) have attempted to address these shortcomings by instituting legislation that ensures all individuals in the US receive quality healthcare at a reasonable cost (Nash et al., 2016).

Communication is the foundation to any relationship; Complications in communications can become detrimental. Ineffective communication may lead to misunderstanding, aggravation, and lack of collaboration. The purpose of this paper is to describe the principles used in a patient, clinician communication, and how I incorporate these principles with my patients. I will continue to discuss the methods that being used to improve interdisciplinary communication and, the way my unit prefers. Lastly, ethical principles that can apply to complications in patient care communication; the significance of ethics in communication, and how patient safety is affected by team communication.

Communication is a vital process in nursing that involves the exchanging of information, thoughts, and opinions between patients and other health care providers. The physicians and the nurses, who were part of Elaine’s surgical team, lack the communication aspect and ended up, jeopardize Elaine’s life. Effective clinical practice involves patient’s critical information must be accurately communicated between staffs (Daniel & Rosenstein, 2008). Often when patient’s information is not communicated effectively, patient safety is at risk for misinterpretation of information, unclear orders, and overlooked changes in patient’s health status (Daniel & Rosenstein, 2008). Lack of communication creates situations where medicals errors occur causing

“Although nurses and physicians share a common agenda of caring for the sick the two professions fail to understand their complementary roles (Hailu, 2016, p.2).” When nurses and physicians are not communicating, it leaves space for medical error that could be avoided. James Liber “came up with a new annual range of error deaths: 210,000 to 440,000,” which leaves medical error the third leading cause of death (Liber,2015, p.80). If physicians and nurse’s communication is inefficient valuable information is bound to be left out or forgotten leaving the patient care at risk. Patient information that is transferred between nurses and physicians is patient allergies, patient history, family history, medications taken present and past, and other critical information if any of this information is miscommunicated complications or even death could arise with the patient in need of help. For information to be transferred properly and efficiently physicians and nurses need to behave professionally.

Although the patient’s son questioned persistently about why his father’s tracheostomy was being covered, the nurses never seriously addressed the sons’ concern. When announcing the verdicts during the inquest, the council chairwoman professor Lee said it is unacceptable that “the nurses were simply following how the wound had been cared by other colleagues… it is always a nurse’s responsibility to exercise his or her own independent clinical judgement” (Tsang, 2016, para. 10). Hence, if the nurses have slightly questioned why the son was so concerned, the patients’ death could be easily avoided. Unfortunately, due to staff shortages, poor nurse-doctor interaction and heavy workload, it is arduous for nurses to utilize autonomy in such stressful environment (Weiland, 2014). Studies have shown that autonomy over patient care and unit operation can be augmented through continuing education and a climate of inquiry (Weston, 2008). Moreover, there should also be an emphasis on the nurses’ freedom to make decisions upon clinical patient care that is based on the art and science of nursing.

Patient safety is an essential part of our health care system, which helps improve and sustain quality health care. Keeping our patients safe can sometimes be a challenging issue because errors and mistakes can happen. All practitioners are responsible for keeping their patients in a safe environment and making sure the patient has the safest possible outcome. This is a worldwide issue that will never be completely resolved because medical errors are always prone to happen.

The link between poor communication and patient safety is the concern of many hospitals across settings. Thus, the breakdown of communication in the delivery of care has a dramatic impact on patient’s outcomes and cost of care. In the event where a nurse must call the attending physician due to the changing status or condition of his/her patient, the use of effective communication is extremely important. These changes of patient’s conditions may be related to the signs/symptoms of confusion, urinary tract infection (UTI), or changes in breathing patterns. The ability of nurses to use a clear verbal mode of communication affects the consistency and pertinent information received by the physician. However, this consistency in providing pertinent information to the physicians is not being facilitated by the nurses at Brooks rehabilitation hospital.

Poor communication within the healthcare team has a negative impact on how nurses implement patient care. According to Schmalenberg and Kramer (2009), the manner in which nurses and physicians interact and communicate is important because this correlates directly with the quality of care given to patients (p. 74-83). Nurses are an essential component of the healthcare team because they are the patient’s advocate, constantly at the bedside, and most significantly the first ones to find any emergent crises in the patient’s medical condition. If physicians do not listen to what nurses have to say, they are not only shutting down the nurse; they are essentially shutting down the patient, whose best interests are advocated by the nurse when the patient is incapable of doing so. Second, nurses are constantly at the bedside of their patients usually for twelve hours a day. In contrast, physicians can have dozens of patients throughout the

When it comes to health care and mistakes; consequences could be as minor as a rash to as major as loss of life. Making prevention a true part of care or cure, is to the most benefit to hospitals. Identification of the factors which lead to human error and implement procedures in order reduce serious mistakes is the top priority within governmental health care settings. In the health care there are several defenses in place that must fail in order for a detrimental or life threatening events to happen. Failure of these mechanism that impedes in harmful outcomes is known as a near miss. There are several factors that result in these mistakes. Human error is the greatest risk factor.

The effectiveness of communication is well documented and is essential in obtaining better levels of patient satisfaction and expected outcome. Apart from this therapeutic communication through a patient-centred approach also reassure relatives that their loved ones are receiving the necessary treatment. Within the nursing field, these skills are considered indicative of effective practice. (McCabe and Timmins, 2006). The Joint Commission (TJC) (2008) reported that breakdown in communication was the main cause of unexpected events which resulted in death or serious injury of client between 1995 and 2005.Ineffective communication can cause negative impacts in the outcome of patient. For example if a patent had a fall in the shift and is not included in the handover the nurse in the oncoming shift may not realise the importance of having precautions to avoid fall and the patient had a fall again. This

In 2008, the World Health Organization estimated that as many as one in ten patients are harmed while receiving care’ (Armellino, Griffin, & Fitzpatrick 2010, p.796). This demonstrates the substantial potential for improvement. Finkelman (2016) mentions that a code of silence exists because in the past people are quick to blame the person who made the mistake, over-looking all the steps in the system that precipitated that error. This malignant silence disrupts a true and just safety culture from improving patient outcomes. The ideal safety culture in healthcare should focus on the big picture of healthcare as a system by empowering staff to raise concerns. With these shared experiences, a dialogue can be created among staff and management to develop plans that improve patient safety. Multiple studies correlate that harm and poor patient outcomes are a result of lacking patient safety (DiCuccio, 2015). A successful patient safety culture requires responsibility of the team to increase staff awareness focusing on education in topics of quality care and error reporting. Why the silence exists is complex and the explanations may vary between units and between hospitals.