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Importance of patient safety in healthcare
Patient safety and risk management
Patient safety and risk management
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A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred. In the case of Mr. B’s, an investigation into the events surrounding to and leading up to his untimely death would be required. Once the problem has been identified and described, data of events are collected and formatted into a timeline. From the events, any problems in the care of the patient which may have contributed to the end result are identified and determined whether they are causative. In appendix A, the timeline of the event is outlined. After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner. There was inappropriate staffing in the Emergency Room which was a factor in the event. There was one registered nurse (RN) and one licensed practical nurse (LPN) on duty at the time of the incident. Additional staff was available and not called in. The Emergency Nurses Association holds the position there should be two registered nurses whose responsibility is to prov... ... middle of paper ... ...teractions Checker. Retrieved June 11, 2011, from Drugs.com: http://www.drugs.com/drug-interactions/dilaudid-with-valium-1294-768-862-441.html Needleman, J., Buerhaus, P., PKankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse Staffing and Inpateint Hospital Mortality. The New England Journal of Medicine , 364, 1037-1045. Nursing Spectrum Drug Handbook 2009. (2011). The Free Dictionary. Retrieved June 11, 2011, from The Free Dictionary: http://medical-dictionary.thefreedictionary.com/hydromorphone+hydrochloride Volles, D. F. (2011, April 11). University of Virginia Health System Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures. Retrieved May 12, 2011, from University of Virgina Health System: University of Virginia Health System Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures
Needleman, J., Buerhaus, P., Pankratz, S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. England Journal of Medicine, Retrieved from http://www.nejm.org/doi/full/10.1056/nejmsa1001025
In this essay the author will rationalize the relevance of professional, ethical and legal regulations in the practice of nursing. The author will discuss and analyze the chosen scenario and critically review the action taken in the expense of the patient and the care workers. In addition, the author will also evaluates the strength and limitations of the scenario in a broader issue with reasonable judgement supported by theories and principles of ethical and legal standards.
The Lewis Blackman Case: Ethics, Law, and Implications for the Future Medical errors in decision making that result in harm or death are tragic and costly to the families affected. There are also negative impacts to the medical providers and the associated institutions (Wu, 2000). Patient safety is a cornerstone of higher-quality health care and nurses serve as a communication link in all settings which is critical in surveillance and coordination to reduce adverse outcomes (Mitchell, 2008). The Lewis Blackman Case 1 of 1 point accrued
Health care organizations are focused on providing high quality and safe patient care. There are numerous organizational factors that may directly affect patient care and outcomes, but one of great importance is nurse staffing. Low nurse staffing levels are a major problem that I have encountered during both my clinical and management experiences. There is a significant relationship between inadequate staffing levels and adverse patient outcomes; however, as I observed during my experiences, there may be increased awareness about this issue, but it has not been sufficiently addressed. In order to ensure patients’ safety and positive outcomes, as well as to improve nurse satisfaction, it is imperative to effectively address low staffing levels.
Nobody is perfect. We all make mistakes. Some of the best lessons in life are learned from making a mistake. But in the healthcare world making mistakes means losing lives. This has started to happen so frequently there has been a term coined – Failure to Rescue or FTR. Failure to rescue is a situation in which a patient was starting to deteriorate and it wasn’t noticed or it wasn’t properly addressed and the patient dies. The idea is that doctors or nurses could’ve had the opportunity to save the life of the patient but because of a variety of reasons, didn’t. This paper discusses the concept of FTR, describes ways to prevent it from happening; especially in relation to strokes or cerebrovascular accidents, and discusses the nursing implications involved in all of these factors.
The facility should have written statement to refer to in case of emergency to help and protect the health care workers that are onsite. So that it would minimize the confusion. We all know that in the case of cardiac arrest time is very critical. The nurse wasted the patient greatest opportunity of survival by standing there and refusing care. It’s the policy of this facility to not make care for cardiac arrest patient difficult. I understand at 87 years of age the end result is most likely not going to be a promising, but I would help to know that there are some people who are willing to help. I hope the nurse learned her lesson and stand clear of confusion for future patient that reside the
Q.3 Nurses as part of regulated health care practitioners are responsible and accountable to abide by the standards, codes and guidelines of nursing practice (NMBA, 2016). The nurse in the case study has breached the standard 1.4 of the Registered Nurse Standards for Practice. According to standard 1.4, the registered nurse should comply with "legislation, regulation, policies, guidelines and other standards or requirements relevant to the context of practice” when making decisions because this will be the foundation of the nurse in delivering high quality services (NMBA, 2016). The nurse in the scenario did not follow the hospital policy concerning “Between the Flags” or “red zone” and a doctor should be notified of this condition. Furthermore, the nurse failed to effectively respond to a deteriorating patient.
Gibb’s model (1988) first describes the event, so my description of the event is: Mr X was admitted to the medical assessment unit (MAU) from the A+E (accident and emergency) department, with a preliminary diagnosis of a T.I.A. (transient ischemic attack) and dysphasia. Ross and Wilson (1996) describe this as, caused by small...
This article is a comprehensive look at staffing on hospital units. It used a survey to look at characteristics of how the units were staffed – not just ratio, but the experience and education level of the nurses. It evaluated several different categories of hospital facilities – public versus private, academic medical centers versus HMO-affiliated medical centers, and city versus rural. It is a good source because it shows what some of the staffing levels were before the status quo of the ratio legislation passed in California. It’s main limitation as a source is that it doesn’t supply any information about patient outcomes.
My colleague and I received an emergency call to reports of a female on the ground. Once on scene an intoxicated male stated that his wife is under investigation for “passing out episodes”. She was lying supine on the kitchen floor and did not respond to A.V.P.U. I measured and inserted a nasopharyngeal airway which was initially accepted by my patient. She then regained consciousness and stated, “Oh it’s happened again has it?” I removed the airway and asked my colleague to complete base line observations and ECG which were all within the normal range. During history taking my patient stated that she did not wish to travel to hospital. However each time my patient stood up she collapsed and we would have to intervene to protect her safety and dignity, whilst also trying to ascertain what was going on. During the unresponsive episodes we returned the patient to the stretcher where she spontaneously recovered and refused hospital treatment. I completed my patient report form to reflect the patient's decision and highlighted my concerns. The patient’s intoxicated husband then carried his wife back into the house.
A root cause analysis (RCA) is a method used when an adverse event occurs to identify what happened, causes that led to the event and how to prevent it from recurring. The RCA is not intended to lay blame on people, but to focus on the flawed system processes.
Nurse staffing is a complex issue. There are many factors which need to be considered when staffing a nursing unit. Evidence shows an association between Registered Nurses (RNs) having decreased workloads and better patient outcomes, including a decrease in patient mortality (Aiken et al., 2011; Needleman et al, 2011; How Lin, 2013; Patrician et al., 2011; Wiltse-Nicely, Sloane, Aiken, 2013). A small percentage of patients expire during their hospitalization as evidence suggests that a portion of these deaths can be attributed to RN staffing levels (Shekelle, 2013). As the reimbursement system for hospitals today emphasizes quality outcomes, this has an increase in the importance of the nurse’s role in patient care (Frith, Anderson, Tseng, & Fong, 2012). The quality of care is effected when there are higher RN-to-patient ratios. Mortality rates can be decreased by 50% or more when there is a lower RN-to-patient ratio. The morale of nursing staff and the hospital’s reputation are effected when there is a large nurse turnover and poor patient outcomes (Martin, 2015; Knudson, 2013). Having adequate nurse staffing levels saves lives (Martin, 2015). The purpose
Advocacy in action paper is to examine various issues in nursing staffing in the hospital and the impact of this issue on the patient’s care and patient satisfaction. Every nurse role and mission is to take care of a patient and advocate for a safe and healthy work environment. It is very important for all nurses to work together, successfully advocate for nurses and the profession to achieve a safer work environment. My role in this paper is to advocate for improvement, practicing safe in the hospital to improve patient satisfaction and reduction in nurse burnout.
The purpose of this paper is to address the issue of nursing staffing ratios in the healthcare industry. This has always been a primary issue, and it continues to grow as the population rate increases throughout the years. According to Shakelle (2013), in an early study of 232,432 surgical discharges from several Pennsylvania hospitals, 4,535 patients (2%) died within 30 days of hospitalization. Shakelle (2014) also noted that during the study, there was a difference between 4:1 and 8:1 patient to nurse ratios which translates to approximately 1000 deaths for a group of that size. This issue can be significantly affected in a positive manner by increasing the nurse to patient ratio, which would result in more nurses to spread the work load of the nurses more evenly to provide better coverage and in turn result in better care of patients and a decrease in the mortality rates.
Understanding how accidents occur is important to establish strategies to prevent their occurrence (Hinze, Devenport, & Giang, 2006). In an attempt to solve the factors of the occupational accident, many previous studies have tried to develop an accident causation models, which is important to work as a body of knowledge in the safety and health field which could predict and prevent the accidents. Among the famous accident causation model includes Domino theory, Management-based theories, Multiple causation model, Human error models and many others. From the accident causation models, the factors contributing to the occupational accident will be identified to form a theoretical background to this study and will be strengthened