Patient Safety Is More Than Avoiding Pressure Ulcers

One of the issues with the electronic systems in health care for MU is the ability to retrieve laboratory results during a patient’s visit. In 2013, Hinrichs and Zarcone reveal that over 70% of medical decisions are determined by laboratory results. In 2007, AU Health implemented Cerner Millennium PowerChart that displays clinical data to improve the point of care for patients. With the PowerChart solution, the patient’s information can be easily verified, vital signs can be entered, and family history can be updated. The Affordable Care Act (ACA) signed by President Obama in 2013 places emphasis on expanding insurance coverage of medical care for everyone. As part of the ACA, the improvements in the way these results are exchanged and transmitted will add value to quality, safety, efficiency of health information (Hinrichs & Zarcone, 2013). The transmission and availability of EHR affect how other health professionals send and receive information at the local, state, and national levels.

Quality improvement issues in healthcare focus on the care that patients receive and the outcomes that patients experience. Nurses play a major advocacy role for ensuring safe and quality care to all patients. Also, nurses share the responsibility in leading the efforts in improving patient care in all settings (Berwick, 2002). One of the ongoing problems plaguing hospitals and nursing homes is the development of new pressure ulcers in patients after admission. A pressure ulcer can be defined as a localized area of necrotic tissue that is likely to occur after soft tissue is compressed between a bony prominence and a surface for prolonged periods of time (Andrychuk, 1998). According to the Centers for Medicare and Medicaid,

Traditionally, nursing shift-to-shift reports were organized methods of communication between only the oncoming and leaving nurse, designated to a location such as the central nursing station or nook of a hallway. Shift reports can be considered the foundation of how the day is going to plan out because it introduces the patient, diagnoses, complications, medications, consults, upcoming test and the entire plan of care. These reports are full of complicated and vital information and while set in certain locations that are vulnerable to interruptions, such as the nursing station, medical errors and miscommunication are more likely to be made. The Joint Commission’s 2009 and 2010 National Patient Safety Goals (Joint Commission, 2015) included two patient safety standards, first to encourage patients to be involved in their health care plan and second, to implement a standardized communication process for handoff reports between providers. Soon after in 2013, The Agency for Healthcare Research and Quality under the United States Department of Health and Human Services introduced a set of strategies to improve patient engagement along with safety and quality in patient care. Within these strategies the new method of nurse bedside shift report was developed, which suggests nurses to conduct shift-to-shift reports at bedside in the room of each patient, rather than out of the room. The benefits of this new method were

Communication in shift change plays a major role in the nursing practice and role. Appropriate and effective communication is a tool assisting nurses in providing safe, thorough and quality cares about their patients and ensuring there is continued service delivery. Realizing the critical role of their patients and patients’ families in promoting patient safety, nurses need to engage their patients and family members in the whole communication process of exchanging information and planning the care. Nurses need to give their patients chances to participate in the discussion their health conditions, upcoming procedures, medical information, or treatment options. Bedside reporting give nurses opportunities to visualize the physical and psychological needs of their patients. Change of shift reporting is also a situation where the nurses exchange their clinical knowledge, and patients’ condition changes and allow their patients to express their understandings, concerns, and questions. This paper seeks to analyze bedside report and explain its relevance to the nursing practice.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Safety is a small measure that can make a big impact on a patient in the clinical setting. In some cases, it can even cost patients their lives. According to the Online Journal of Issues in Nursing, safety is defined as a tool to minimize risk of harm to patients and providers through both system effectiveness and individual performance (Barnsteiner, 2011). Safety problems can range from the nurse not knowing how to work certain equipment, or the nurse recording values wrong because he or she is distracted. Either way, these safety issues impact the clinical setting in a negative way. In order to have a functional, safe clinical environment, time and money must be spent to keep the hospital in working order and the nurses in the correct mindset.

Nurses are accountable for delivering safe pressure ulcer prevention for patients who are at risk. Pressure ulcers can cause considerable amount of pain and distress in patients with nutritional deficiencies and can also cause high healthcare expenses due to extended hospital stay. Marlene Varga defines a pressure ulcer as “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (Varga, 2015, p. 26). Significant to nursing practice, evidence-based pressure ulcer protocols are incorporated through research and clinical capability with the intention of aiding practitioners to make evaluations in accordance with current practices and studies (Chaves, Grypdonck, & Defloor, 2010). In hospitalized patients with nutritional imbalances, how would repositioning and turning the patient compared to the use of redistribution or patient positioning system devices manage existing pressure ulcers and prevent new ones from forming?

This is causing doctors to become too reliant on the EHR’s to communicate for them. The EHR’s should not replace oral communication between doctors and nurses.

a. Lack of face-to-face communication: Poor communication among clinical and non clinical staff members at Northwell Health has increased the rates of misdiagnosis and the patient turnaround time from admission to treatment and discharge. Because of the increased usage of electronic medical records (EMRs), clinical staff do not feel the need to communicate face-to-face, thus leading to information about a patient’s care being forgotten or omitted. Additionally, EMRs still do not meed the needs of today’s rapidly changing healthcare environment. (Evans, R. S. (2016). This leads to the rise

Pressure Ulcer is localized injury to skin and underlying tissue over bony prominence due to pressure or combination of shear and friction. Pressure ulcer not only extends hospital stay but also causes serious complication for example; pain, delay in functional recovery, serious infection, sepsis and mortality. Pressure ulcer is preventable but the problem is rising in health care facilities. Thus identifying patients at risk and implementing preventive strategies is important aspect.

In 2013, the Joint Commission, in an effort to improve quality of care and patient satisfaction, implemented a handbook and tools to transition to bedside shift reporting (AHRQ, 2013). Nursing shift reports historically have occurred in many formats like verbal reports, written, or recorded, but research supports taking the report to the patient’s bedside. Matter of fact, switching to a blend of verbal reporting and bedside reporting guided by a standardized communication tool like the Situation, Background, Assessment, and Recommendation (SBAR) structure allow patients and family to participate in the information and plan of care. Both qualitative and quantitative data have revealed improvements in patient safety, patient & family quality of care, nursing satisfaction, and accountability between nurses. One pilot study on performing shift reports at the bedside found a rise from 75% to 90% in patient satisfaction with nursing communication over a three month study period (Radtke, M., 2013). Change-of-shift report at the bedside, although a challenge for nursing staff, offers an opportunity to improve the experience of care by partnering with patients and families.

Mistakes are made in the healthcare field every day and there are a few ways that this can be prevented. We are going to discuss different ways to decrease the chances of errors for the safety of our patients. Every facility has or should have, somewhere in the building, a copy of the national patient safety goals and it is important that you know what they are and where to find them. As we navigate through the goals that are to be discussed, we will touch on a few that are very important from reducing the risk of healthcare associated infections to improving the accuracy of resident identification. With all this in mind we

Upon admission to a hospital, a patient may be at risk for numerous hospital-acquired conditions. Pressure ulcers, also known as pressure sores or “bed sores”, are a type of hospital-acquired condition that may develop during a hospital admission if proper risk assessment is not performed by a registered nurse (RN). Pressure ulcers form over bony prominences, such as the back, heel, ischium, sacrum, and elbow, when circulation of these prominences is impaired (Jarvis, 2012). Pressure ulcers may develop when a person is confined to a bed or immobilized, which impedes proper delivery of oxygen and nutrients to the skin resulting in cell death (Jarvis, 2012). Pressure ulcers are divided into four stages. In stage I, a nonblanchable redness of intact skin appears that does not disappear for 24 hours after pressure is relieved. In stage II, there is partial-thickness erosion of the epidermis or the dermis layer of the skin. Full-thickness pressure ulcers are a stage III ulcer, which extend into subcutaneous tissue. Lastly, stage IV pressure ulcers involve all skin layers and may expose muscle, tendon or bone. Pressure ulcers can be prevented if risk assessment is performed and at-risk individuals are identified (DeLaune & Ladner, 2011).

Patient safety is essential and vital component quality care (Ballard, 2003). Patient safety involves medication safety, effective teamwork, procedural and surgical skills, accurate and timely communication (What is patient safety, n.d.). Nurses are the key to safety for patients. The environment in which the nurse provides care determines quality of care and patient safety.