The Pros And Cons Of Patient Safety

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Recommended: Methods of communication between nurses

Working at the hospital for a little over a year now I have seen a few instances that are a "near miss", some a failure, and as of today a complete failure in patient safety but is being overlooked in some ways. Being the most recent and fresh in my mind this incident included a known drug addict, and an order that read "pt. may go outside with family". During shift report I asked the night shift RN why a known drug addict has outdoor privileges, when it is hard enough to get anyone the order to go outside. The RN giving report agreed with me, but since the ordering physician wasn 't available we could not challenge the order overnight. As my shift continued I go into the patients room to check on them and the bed was empty the wheelchair was gone and the bathroom was empty. I asked my Clinical assistant and she said that she was never told the patient was leaving (strike 1: patients need to tell staff when they leave the unit). After 30 minutes I looked in the room and the patient was still gone, after an hour the patient returned with a family member (strike 2: patients are allowed 15 minutes off the floor). I quickly went into the room and asked the patient that if they would like to leave the unit they need to notify staff before they leave and patients need to come back to …show more content…

The Supervisor stated that we don 't really do anything but call the doctor and request the order to be discontinued. If the doctor doesn 't care then the patient has free range to harm themselves with who-knows-what kind of drugs. This problem displayed in the "Swiss cheese" model shows there are holes throughout the issue.
Latent Factors:
* High risk patients should not have outdoor privileges
*The night shift did not address the issue. (Poor access to MD)
* Patients with Saline locks (IV lock) should not be allowed to leave unless it can be temporarily unusable by the

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