Vital improvement for patient safety has triggered an enormous amount of positive change in the healthcare system. There were “1.6 million adverse events each year that led to 180,000 deaths” (Liang & Mackey, 2011). In a review, avoidable errors led to $19.5 billion dollars in healthcare expenses (Liang & Mackey, 2011). The National Patient Safety Agency analyzed 425 deaths from acute care hospitals and found “15% of the deaths were related to unrecognized patient deterioration” (Higgins, Maries-Tillot, Quinton, & Richmond, 2008). This finding led to the Institute for Health Care Improvement’s promotion for the use of an early warning scoring system to assist with identifying deteriorating patients (Albert & Huesman, 2011). The term “failure to rescue” refers to a clinical scenario where hospital doctors, nurses, or caregivers fail to recognize symptoms. Responders do not respond adequately to clinical signs that would prevent harm (Morse, 2008, p.2). Dr. Jeffery H. Silber, Director of the Center for Health Outcomes and Policy Research, first coined the term “failure to rescue” in the 1990’s. He characterized the matrix of institutional and individual errors that contribute to patient deaths as “failure to rescue” (Aleccia, 2008). Since 1990, it has been well documented patients usually exhibit signs and symptoms of impending cardiac or respiratory arrest 6-8 hours before an arrest (Schein, Hazday, Pena, Ruben, & Spring, 1990). Buist, Bernard, Nguyen, Moore, and Anderson’s (2004) research reported similar findings. They found patients had documented clinically abnormal signs and symptom prior to arrest (Buist, et al., 2004). When certain abnormal signs and symptoms are identified early, critical bedside consultat... ... middle of paper ... ...ng informatics. The integration of an early warning scoring system with nursing practice is a means with which technology and nursing knowledge evolve to “applied wisdom” (McGonigle & Mastrian, 2012). The data is represented by the vital signs. The collection of vital signs will generate information. The information will be scored in the system and alert the nurse when there are abnormal findings. The nest steps can only be taken by the nurse. Critical thinking, interpretation and application of the findings from the patient’s medical record are the next steps. Nurses must be able to apply the information into their nursing practice in order to continue to develop and deliver the best care to patients. As technology continues to expand to many clinical areas, nurses will need to continue to understand how the world of technology translates to patients.
Noticeable indications of deterioration have been shown in numerous patients few hours prior to a critical condition (Jeroen Ludikhuize, et al.2012). Critical condition can be prevented by recognizing and responding to early indications of clinical and physiological deterioration ( kyriacosu, jelsma,&jordan (2011). According to NPSA (2007) delay in responding to deteriorating vital signs have been defined as an complication resulting in prolonged length of stay, disability or death, not attributed to the patient's underlying illness procedure along but by their health-care management ( Baba-Akbari Sari et al. 2006; Helling, Martin, Martin, & Mitchell, 2014). A number of studies demonstrate that changes or alterations in a patient’s
One of the pivotal roles of a nurse is the ability to recognise patient deterioration. The skill of identifying crucial elements of deterioration and acting appropriately is fundamental for positive patient outcome. A vital skill performed primarily by nurses is the act of respiratory rate measurement. This skill is performed in addition to five other physiological parameters, which form a basis for a scoring system. The scoring systems commonly used are known as NEWS (National Early Warning Score) and EWS (Early Warning Score). As many adverse events are preceded by a period of time where by the patient exhibits physiological dysfunction, there is often time to correct abnormalities. This has significance for nurses, as they are responsible
Hebda, T. & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals. (5th Edition). Upper Saddle River. : N.J: Pearson Education
Featherstone, P., Prytherch, D., Schmidt, P., Smith, G. (2010). ViEWS: towards a national early warning score for detecting adult inpatient deterioration. Resuscitation, 81(8), 932-937.
... middle of paper ... ... Works Cited 1. Cooper, Paul, RN, MSN, Director of Nursing Informatics.
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
Working as a professional registered nurse in the hospital, I realized how nurses struggle to find balance between devoting the time charting on the computer and spending time taking care of the patients. Moreover, I’ve seen nurses where they get discouraged trying to find this balance between patients and charting. As a bedside nurse, I would love nothing, but to tend to the needs of my patients. The length of time consume on electronic charting all day, take the very essence of bedside nursing away from nurses, which is caring. Reducing the time of nurses being occupied on charting by eliminating redundant tasks while conforming to their standard, are the changes I would like to make. These are a few of the reasons why I wanted to pursue a degree in informatics. I would advocate for nurses everywhere and to become an instrument in providing them a better electronic health system to work on. Pursuing the degree in nursing informatics will benefit me in
It’s hard to leave a loved one in a hospital bed when night falls. Family members leave with a sense of responsibility, guilt, and sadness. They leave relying on the nurse to watch and care for their sick family member. Therefore, it is heart breaking to find out the next morning your loved one has suffered great brain damage due to nurses failing to check on alarm sounds. Now, the family is put on the spot to continue life support or disconnect their family member. One can only imagine what went wrong; up to the minute that you left the hospital, your loved one was doing fine. You are relying on the health care providers to take care of your loved one, just as you would, while you are gone. Staff made an error by ignoring the alarms sounds, warning them that the patient was deteriorating, and costing the patient’s family a great deal of pain. Jenifer Garcia’s life shattered when this exact event happened to her husband in July, 2010 (Kowalczyk, 2011). She left her husband Friday night, alive, and returned the next morning to find out he was brain dead. Advancements in technology are used to decrease and catch medical errors made by health care providers that can harm or kill patients, but alarm fatigue has proven that even technology cannot fully protect a patient from nursing errors, thus taking the lives of patients.
Nurses are fundamental to the process of implementation of certain systems used in the workplace. Nurses should be allowed to have input and suggestions regarding what works and what doesn’t when it comes to those systems, whether it is the EMR, healthcare organization systems, or even the use of point of care systems (Mitchell, 2011). This allows for open collaboration between the nurses and information technology to come up with solutions and user friendly applications when needed. The technology world is ever changing and with that comes new ways to monitor and take care of our patients.
As we enter the era of technological advances in the healthcare system, nursing informatics has become an essential element in the practice of nursing, and according to the American Nursing Association (2008), the managing of date, information, knowledge and wisdom are relevant to nursing. Thanks to health information technology (HIT), which has a wide-range of tools for improving care quality, there has been a reduction in care disparities, and improvements in care outcomes, including patient and family experience. In Addition, the advances in communication and information sharing has made HIT, a critical instrument for addressing the threats to safety and quality during care transitions, since every nursing action relies on knowledge based
Each year this panel of experts put a microscope on patient safety across the board. They decide where upmost attention needs to be paid. Sometimes items leave the list because there are been strides take to improve in that area and sometimes it continues to stay on the list because they believe the relevance and importance is growing. Healthcare is evolving b...
Wen, L. (2013, 04 26). 10 medical errors that can kill you in the hospital.
Mr Adams symptoms could indicate some cardiovascular compromise (Resus UK, 2015). However, not all heart attack will result in cardiac arrest. Visual observation must accompany some compromise physiological parameter which will indicate if cardiac arrest is imminent (Steele, 2008. Ruigomez et al., 2009). Mr Adams was later found in a state of collapse by a student nurse; an initial set of observation was performed, Mr Adams was tachycardic, hypoxic, hypertensive and slightly tachypnoea. When dealing with an emergency, there is a need for collaboration between multi-disciplinary team (Standing, 2010). The critical care outreach and medical emergency team were notified and they arrived in time to perform CPR on Mr Adams. The NQN must apply situational judgment and follows a good decision-making process that complies with all relevant legislations, including laws relating to capacity in the event of CPR (Resus UK,
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
Brokel, J. (2007). Updates within the scope of informatics in nursing. Iowa Nurse Reporter, 20(4), 19.