RTT2 Organizational Systems

Inadequate nurse staffing is commonly cited as a factor in unanticipated hospital events (ANA, 2015), whereas higher staffing levels are related to lower rates of negative patient outcomes (Registered Nurse Safe Staffing Act [RNSSA] of 2015, 2015; MN study links nurse staffing to patient outcomes, 2015). For example, inappropriate nurse staffing can result in increased infections such as pneumonia, shock, cardiac arrest, and urinary tract infections (Stanton, 2004), longer hospital stays, medication errors, falls, injuries, and death (ANA, 2015; Stanton, 2004).

Lack of situation awareness by the nurse and failure to use the SBAR protocol when on the phone to the cardiologists.

Nurses work in systems that are complex, rapidly changing, and beleaguered with financial and workforce pressures. One response to these chal­lenges is to find alternative ways to make an insufficient or detrimental system work for the nurse to get the job done and to achieve the desired patient out­come. While perhaps well intention-ed to produce the desired result, workarounds

Critical information that should have been shared at sign-out should have included the patients history of different blood pressures in each of her arms. It might have made a difference if during change of shift and SBAR the nurse was verbally informed of this information. Also if the nurse would have briefly reviewed the patients chart, she might have caught the fact that this was a norm for the patient.

Suppose there is a patch call with a patient exhibiting chest pain and the ambulance is five minutes out. In this case, the room is equipped and prepared with all the essential needs for the chest pain patient upon their arrival in the ambulance. After the patient has arrived, the primary nurse on duty receives a report from the Emergency Medical Technician (EMT) that accompanied and provided initial care to the patient in the ambulance. At the same time, the secondary nurse and ERT become technical, or hands on. The patient is administered oxygen, cardiac monitors are placed, an EKG is administered, locks and labs are drawn, normal saline is administered, and a urinalysis is taken along with the patients’ blood glucose level. Each of these tasks is initiated prior to the Emergency Room Medical Doctor (MD) seeing the patient, or at the same time. Emergency

It's Rose Ann. I just want to let you know that Mr. Bogue, James in room 564, MRN 291222300018 fell yesterday around 4pm. He was Amanda's patient and she completed the voice. I notified our risk management Jodi Palmer about the incident. Apparently the patient was instructed by Amanda not to get up because he was hypotensive, but he didn't listen and grabbed the walker and fell forward. We ended up calling RRT because he was hypotensive and developed a big hematoma on his right groin surgical post angiogram from previous day. The patient was transferred in ICU12. We were short staff from 7a-7p, I called everyone with no luck. Our nurses and PCA were overwhelmed, because we kept on getting multiple admissions, including 2 cath lab patients

Nursing-sensitive indicators are important in all aspects of patient care. A great deal of bedside care is given by nurses. Nursing-sensitive indicators are factors that rely directly on the nursing care of the patient. Quality nursing care improves patient care and therefore patient outcomes. Nursing-sensitive quality indicators promote patient safety and quality patient care. Since these quality indicators are reflective primarily on bedside care provided by nursing staff it is important that all nursing staff be aware of these indicators and their role in promoting quality patient care. There are specific indicators that could have been taken into account to promote patient

This puts patients at risk. There is the lack of consistency of how the report is given and also a lack of accountability for the patient’s safety as it relates to safety equipment at the bedside According to the Joint Commission (2011), one of the factors leading to sentinel patient events is miscommunication (Sand-Jecklin & Sherman, 2014, p. 2855). Since the inception of the sentinel event program at The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in January 1995, more than 2,455 sentinel events affecting 2,570 patients have been submitted and reviewed (Beyea, 2004, p. 315). Of those occurrences, 75% resulted in death, and the remainder resulted in loss of function or other injuries (Beyea, 2004, p. 315). While Beyea does not indicate the specific areas in which these events occurred, she did state that there was a lack communication between staff which could have led to many of these events. At the end of long hours of the nursing shift, nurses are eager to transfer responsibility to the next nurse, and without a structured end-of-shift reporting tool, important information could be missed causing

There was an error that resulted in patient harm that occurred on an oncology floor. The nurse was a newer nurse who was hanging chemotherapy and was being interrupted during the chemotherapy administration. The second nurse checking in the chemotherapy with the first nurse was also interrupted. The chemotherapy administration resulted in the entire bag being given during a short period of time because the pump was not programmed properly. Once the error was realized, the patient was sent to the ICU.

This paper briefly touches on a case study by a nursing assistant student who is assisting with an anesthesiologist that she is shadowing. The student was asked to monitor vitals during a knee surgery. The patient was given Halothane and the surgery began. After two hours in surgery, the patient, who was a young athletic female named Sharon Riley, began to show signs of distress. This patient’s temperature elevated to 105 °F and pulse began to rise up to 120 bpm, and her blood pressure began to drop down to 60/56 mmHg. This triggers the monitors alarm because normal vitals for this patient were a temperature of 98.6 °F, 75 bpm pulse and blood pressure of 105/60 mmHg. This causes the doctors to react quickly and begin to assess what is wrong

Unlike physicians who spend approximately 30 to 45 minutes per day with a patient, the presence of nurses at the bedside is essential throughout the day. Apart from attending the patients, they regularly interact with families of the sick and other healthcare practitioners, such as physicians and pharmacists. Given their constant presence at the bedside, nurses play a critical role in maintaining patient safety by continuously observing patients for deterioration or improvement of health. They also help in the detection of medical errors, identification of near misses, and discovery of weaknesses that might be inherent in some systems (“Nursing and Patient Safety,” 2017). Since the role of nurses is crucial to the maintenance of patient safety, it is logical that increasing their workload is bound to adversely affect their ability to deliver quality work and safe services.

There were multiply factors that contributed to the above scenario; Larkin and Burton writes that “after this near-miss, failure to rescue incident” (p. 394) a task force consisting of management, clinical nurse specialist (CNS) and unit educator convened to discuss the event. The task force concluded that the nursing staff members were ineffectual in critically evaluating the patient’s signs and symptoms. The CNS chose a framework that utilized “Bloom’s Taxonomy of Educational Objectives”, that provided measurable outcomes to the educational activity and enabled the nursing team to optimize their critical skill levels. A workshop to assist staff to navigate through the case study in a realistic manner was implemented (Larkin & Burton, 2008, p.395).

B, more than one causative factor affected the outcome and the death of Mr. B. The core of the issue is that Mr. B was over sedated, going into cardiopulmonary arrest and subsequently died. To make systematic changes, one must look for preventable causes or errors. In the case of Mr. B, the hospital had in place a policy regarding conscious sedation. That policy included continuous BP, pulse oximetry, and ECG monitoring. The staff did not adhere to the policy in place. The patient was placed on monitors at the conclusion of the procedure. When the monitors were in place, the reading was not evaluated by the nurse. Mr. B was left alone or with family members on more than one occasion. When the low oxygen saturation alarm is acknowledged, the LPN she resets the alarm, and she does not complete an assessment or place Mr. B on supplemental oxygen. The LPN does not notify the RN or physician on duty. The policy at this facility outlines the education required to recover a patient that has been administered conscious sedation. The educational requirements include ACLS, a moderated sedation training module, including drug selection and dose ranges. Nurse J has completed the needed training, and it is unclear if the physician or LPN have the necessary training. Over the Couse of Mr. B’s care, there are four separate incidences of verbal orders being given for medication. A verbal order leaves both the doctor and nurse open to error. With no clear system of

PPE are very important tools in the medical field. The observing RN should stop the exiting RN and explain proper PPE protocol. The exiting RN could have had a temporary lapse in judgment. The observing RN can simply reiterate the importance of PPE. An in service should be held for nursing staff on the importance of PPE protocol. The exiting RN should be made aware that the patient and staff were put at risk. The observing RN should make sure that further contamination does not take place. The observing RN can also go over facility protocol for isolation with the exiting RN. Nurses can develop short cuts that can be detrimental to staff and patients. It is important for RN supervisors to constantly emphasize the details of the job. Co-workers

Every day in this country, millions of people enter the hospital for a variety of reasons with the expectation of receiving the best of care. In the vast majority of hospital admits, the patient is treated and discharged without incidence. However, this is not the case for the estimated 210,000-400,000 annual patient deaths