Unit 5 Health And Social Care Case Study

the inability for local, state, and federal actors to coordinate effectively. The first step for

To do so, I am going to use the fishbone diagram to categorize the causative factors (Potter & Perry, 2008).   For patient characteristics, Mr. B was a 67 year old patient with routine use of oxycodone to treat chronic pain.  Because of his routine use of oxycodone, he may need a different dose to get to a sedated level than other people who are not on any medication.  Next is the task factors, the hospital had a policy which requires that anyone who are treated with moderate sedation or analgesia have to be put on continuous blood pressure, ECG, and pulse oximeter monitoring until the procedure is done and patient is in stable condition.  Mr. B was not being monitored accordingly during the sedation process.  Another task factors is that all staffs must first complete a training module on sedation before performing the task.  Individual staff is a factor too, Nurse J had completed the training module on sedation, he had an ACLS certification as well as experience working as a critical care nurse.  Team factors include communication between staffs; an example would be the LPN not informing Nurse J or Dr. T when the alarm went off the first time, it showed that Mr. B had low oxygen saturation.  Work environment factors included the staffing in the ER, the equipments they had, and the level of experience of the staffs.  According to the scenario, additional staffs were available for back up support and all the equipment needed

Communication between nurses at report change is essential. The next nurse needs the most important information whether it is as Situation-Background-Assessment-Recommendation (SBAR) that the Institute for Healthcare Improvement (n.d.) outlines to use or in another form. The case of Rio Grande Regional Hospital Inc v. Villarreal discusses how one nurse breached the standard of care because the record reflects that from the time Hermes was given the double-edged razor until he died neither Nurse Bergado nor any other nurse checked to see how Hermes was doing in the bathroom” (Find Law for Legal Professionals, 2016). At Baylor Scott & White at All Saints, we have a policy that each patient is rounded on physically every hour.

Accurate exchange of information among nurses is important, but shift to shift report even more important among hospital staffs. Hospital staffs include a health care provider, nurses, dietitian, therapists, laboratory technicians and etc. to prevent possible errors, ensure patient safety, and

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

Conducting nurse change-of-shift report at the bedside with the patient and family should be viewed as a core safety strategy in hospitals today. (Gooch, 2015). Bedside nursing increases the accuracy of the information on the patient and reassures patients that they are being taken care of properly. Families and patients reported that they liked meeting staff prior to being taken care of by them. After an initial learning curve, nursing staff acknowledged that report was precise, and feedback from the patient and family was helpful. Also nurses realize that standardizing bedside reporting is one step toward improving communication between nurses, patients, and their families.

In our first negative solution, the nurse has breached her ethical duties to her patient. Our 35-year-old patient, Chris Morrow, who is on a medical floor

first step in conducting a root cause analysis is to form a committee of individuals that are from

What were the existing mindsets and biases that could have clouded analysts’ ability to diagnose the situation?

I think this needs more exploration of the charting system and sufficient nursing knowledge in order to make the correct judgments. Reporting findings from my shift orally was not a good idea. I might forget the findings and the primary nurse needed a written report rather than an oral report. Overall, I did worst on my care plan.

The shift report between the off-going and oncoming nurses must include all of the critical information about a patient’s plan of care. This information must be communicated. The change of shift report that is done incorrectly can be a result of missed information and poor communication between nurses, affecting their ability to deliver safe and efficient care for the patients. This problem occurs not just at one but at most hospitals, where inter-shift report still continues to take place at the nursing station without inclusion or a visual of the patient until the report is done. As I witnessed shift report in the hallways or at the nursing stations of SCVMC of the 33 bed mother and baby unit, I noticed that at times unnecessary information is received and critical information may not be communicated. On the other hand, at Redwood City Kaiser neuroscience unit bedside inter-shift nursing report works well and I have witnessed better nurse-patient relationship, lower incidents of falls, strong teamwork, as well as improved nurse accountability and prioritization at the beginning of the shift. As evidence shows in the article “Improving Client and Nurse Satisfaction Through the Utilization of Bedside Report”, there is a direct correlation between the bedside report and both client and nurse satisfaction in care settings, validating the importance of changing to bedside report (Vines, Dupler, Guido, 2014). I

Communication in a health care setting is vital for the continuation of care. The change-of-shift report is the approach nurses from one shift communicate and transfer information, liability and accountability to nurses on the next shift. Potter and Perry (2013) define the change-of-shift report also known as nursing hand-off as a method used by incoming and off going nurses to transfer information about the patients they will be caring for and or cared for. During this change of shift report, the off going nurse reviews information about the patients such as the patient’s condition, their medical history, their course of treatment to the incoming nurse and if they met their daily goals. This vital information helps the incoming nurse to continue with the plan of care for the patients and patient safety by avoiding setbacks and errors.

Obviously there were many faulty decisions made, or important and critical decisions, not made, which contributed to the Deepwater Horizon/BP disaster. Decision making entails identifying and choosing alternative solutions that lead to a desired state of affairs (Kreitner & Kinicki, 2013, p.330). Herbert Simon’s normative model is represented in this case. In the end decision makers were not able to evaluate all potential alternatives, thus choosing a solution that did not meet all qualifications (Kreitner & Kinicki, 2013, p.333). Decision makers made decisions without possessing complete information, thus not making optimal decisions. Unpredicted pressure caused the increase of disagreements between the workers from the two different firms.

There are several different in nature factors that joined together and contributed to a disastrous beginning of operations. Most of them were management mistakes and others, although external factors, if

We have reviewed the different drivers that led to the decision making that brought to the extreme situation in which the company finally was involved: