Discussion Post #2: Patient Safety
Pick
one of the following topics below to answer. Discuss how the concepts of patient safety applies to these topics.
Topic 1: Communication and Patient Safety
·
Visit the Canadian
Patient Safety Institute website and watch the following two short videos.
·
Inpatient Surgical
‘Opportunity to Improve’ vs ‘Successful Outcome’ Video critique **If this
linkdoes not work for you, cut and paste this address
https://www.patientsafetyinstitute.ca/en/education/TeamSTEPPS/TeamSTEPPS-Canada-Curriculum/Pages/Module-7-Summary-Putting-it-all-together.aspx
1. Compare and contrast the communication
differences between the two videos.
2. Consider the possible outcomes/implications
for the “opportunity to improve” video.
3. Discuss a clinical situation where
incomplete or unclear information was shared. Be specific about strategies
to improve communication.
Topic 2: Annie’s Story: How a Systems Approach
Can Change Safety Culture
·
Watch the following
video (5 ½ minutes) https://youtu.be/zeldVu-3DpM
·
Reference the Canadian
Patient Safety Institute (CPSI) resources related to Analysis of Harm posted on
the course Blackboard site.
1. Reflect on the actions of the nurse in the
situation. How might the situation have been prevented? Why do you
think there was a failure to rescue?
2. Compare the initial response to the situation
to the System’s Approach used to analyze it afterward. Explore the application of
the System’s Approach. What else might have been included in the analysis?
3. Apply the assessment of the analysis of harm and discuss what should be said to
the patient and family using the disclosure guidelines. Include actual
statements that would be appropriate.
Topic 3: Failure to Rescue
The
following questions are based on the article below.
·
Mushta, J., L. Rush,
K., & Andersen, E. (2018). Failure to rescue as a nurse‐sensitive indicator. Nursing Forum
(Hillsdale), 53(1), 84–92. https://doi.org/10.1111/nuf.12215 https://senecacollege.primo.exlibrisgroup.com/permalink/01SENC_INST/1g8f6u9/cdi_proquest_miscellaneous_1920393961
Pick
one of the following to address:
·
Failure to Escalate: Apply the literature to a situation you have experienced or
witnessed in the clinical setting involving a failure to escalate. Why do
you think this happened? What was the actual and potential outcome?
Describe actions that would prevent this for future practice.
·
Error of Omission: Apply the literature to a situation you have experienced or
witnessed in the clinical setting involving an error of omission. Why do you
think this happened? What was the actual and potential
outcome? Describe actions that would prevent this for future practice.
·
Failure to Recognize: Apply the literature to a situation you have experienced or
witnessed in the clinical setting involving Failure to Recognize. Why do
you think this happened? What was the actual and potential outcome? Describe
actions that would prevent this for future practice.
·
Ineffective Decision Making: Apply the literature to a situation you have
experienced or witnessed in the clinical setting involving the Failure to
Recognize. Why do you think this happened? What was the actual and
potential outcome? Describe actions that would prevent this for future
practice.
Please the write up must look like on of the sample articles
below.
Article 1
Nurses play a crucial role in
patient care as primary caregivers, often the first to observe changes in a
patient’s condition. Their ability to recognize and respond to early signs of
deterioration is vital in preventing adverse outcomes(Mushta et al.,
2018).However, failures to recognize such changes can occur, leading to serious
complications. In a clinical setting, I witnessed a failure to recognize a patient’s
deteriorating condition, leading to septic shock and prolonged ICU stay due to
inadequate monitoring, lack of training, and communication breakdown. Deficits
in clinical data analysis and cue recognition are compounded by novice skill
levels, inadequate nursing education, and lack of experiential knowledge,
further contributing to the problem of failure to recognize patient
deterioration (Mushta et al., 2018). Early recognition and prompt intervention
could have prevented the patient’s severe decline, as signs of patient
deterioration are often observable hours before a cardiac arrest but may be
subtle and overlooked by healthcare providers. According to Mushta et al.
(2018), preventing such failures requires enhanced training on early signs of
deterioration, improved monitoring protocols (including high-frequency nurse
surveillance at least 12 times daily), and effective communication strategies
to facilitate timely reporting and response to patient deterioration. Utilizing
technology for continuous monitoring and fostering a supportive environment
where nurses feel empowered to escalate concerns can significantly reduce the
risk of failure to recognize and improve patient outcomes (Astier et al.,
2020).
References
Mushta, J., Rush, K.
L., & Andersen, E. (2018). Failure to rescue as a nurse-sensitive
indicator. Nursing Forum,
53(1),
84–92. https://doi.org/10.1111/nuf.12215
Astier, A., Carlet,
J., Hoppe-Tichy, T., Jacklin, A., Jeanes, A., McManus, S., Pletz, M. W.,
Seifert, H., & Fitzpatrick, R. (2020). What is the role of technology in
improving patient safety? A French, German and UK healthcare professional
perspective. Journal of
Patient Safety and Risk Management, 25(6), 219–224. https://doi.org/10.1177/2516043520975661
Article 2
Failure to Recognize
Nurses spend more bedside time with patients than other treating
practitioners in healthcare. The ability to critically assess and develop early
recognition of symptoms that may lead to harmful complications and adverse
outcomes is vital for appropriate and timely intervention (Mushta et al, 2018).
Inexperience often leads to failure to recognize; however, it is important to
consider that vague symptoms or similar clinical presentations of less severe
differential diagnoses may also be to blame (Britt and Agarwal, 2023; Mushta et al, 2018). In a
clinical rotation in the ER, a female 41-year-old patient was triaged with
symptoms of severe headache following a workout at her gym. Additional symptoms
were photosensitivity, hypertension, and nausea. Medical directives were
related to the migraine presentation which consisted of analgesics and
antiemetics. This patient’s symptoms later escalated to continued hypertension
and vomiting. Upon physician assessment, a CT was ordered as a precaution,
which revealed multifocal and vertebral artery dissections (VAD). VADs are rare, however are the leading cause of stroke in patients
under 45, carrying contributing risk factors including hypertension, female
gender, and physical exercise (Britt and Agarwal, 2023). Acute clinical
presentation is noted to be severe headache, vomiting, and rarely neurological
symptoms in the initial stages (Britt and Agarwal, 2023). Had this patient not
received precautionary imaging by the physician, it is likely they would have
been sent home with migraine medication, not receiving appropriate treatment
and may have suffered a stroke or death (Britt and Agarwal, 2023). In this
case, failure to recognize with the potential of significant patient harm was
owed to imprecise symptoms leading to less severe differentials as opposed to
nursing assessment inefficacy.
References
Britt, T. B., & Agarwal, S. (2023, March 20). Vertebral artery dissection. National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK441827/
Mushta, J., L. Rush, K., & Andersen, E. (2018). Failure to
rescue as a nurse‐sensitive indicator. Nursing Forum (Hillsdale), 53(1), 84–92. https://doi.org/10.1111/nuf.12215
