This week readings bring us overview of the issues we face in today’s healthcare such as “safe, effective, patient-centered, timely, efficient, and equitable” care (IOM, 2001, p 3). Safety and quality of care are the major factors which I think must be address to assure the best possible patients’ outcomes and to build culture of safety.
I remember we had a patient who was neurologically and hemodynamically unstable. He underwent craniotomy upon admission and had external ventricular drain placed to monitor his ICP. First day post op, the nurse noted elevated ICP. It has happened for 2 consecutive hours. Each time, the nurse assessed patient for possible reasons for elevated ICP such as vital signs, LOC, body alignment, elevation of HOB, checked the drainage system etc. Resident on call was notified each time but as there was no neurological
…show more content…
changes in patient, resident did not come to assess patient himself nor situation itself; CT head was not ordered as well. Patient was given additional pain medication and nurse continued him to be monitored. Within 3 hours from the first elevation in ICP, patient became obtunded, hypertensive, bradycardic. Patient was immediately intubated, CT head was ordered and done. It revealed massive hemorrhagic stroke with midline shift. Patient had to be taken to OR for another craniotomy and unfortunately passed away few hours later. The Institute for Healthcare Improvement (IHI, 2015) emphasize that errors should be recognized as early as possible.
The individuals involved in error should not be punishing but we all must learn from those mistakes by improving the system. In the case above, a root cause analysis was conducted as part of the learning and improvement process. There were a few breakdowns in the system noted that led to this sentinel event. A large part of the issue was related to the utilization of the chain of command by the nurse. Another problem was attributed to the comfort level of the nurse in reaching out to the next person in the chain of command. A final concern was noted regarding why the resident did not come to assess patient after the first time when he received the call from the nurse. Rizzo (2013) writes that we must remain open to anyone who questions the safety of care being provided and we must foster open, honest communication among the multidisciplinary team members. Furthermore, the healthcare systems cannot build a fear of retribution for these mistakes in their employees if they want to build a culture of
safety. There are many plans and project implemented and researched every single day. These take to consideration patients’ needs, patients’ safety, and quality of care. We want our patients to be free of harm and injury that is why “Safety is a critical first step in improving quality of care” (IOM, 1999, p. 5). Change is difficult in many organizations and is especially challenging at the healthcare environment. Financial obstacles, staffing requirements, pressure from the public, and government regulations make some organizational policy changes difficult. Putting patients’ safety first as well as consistency and accountability are essential throughout the organizations to provide uniformity in development of new policies and guidelines and creating safe and just patient-centered care.
The dose that was used for the patient was so high that it acted as a vasoconstrictive agent to reduce the blood flow and facilitate hemostatic plug formation in the bleeding vessel thus causing the MI (complication of high dose vasopresson infusion) (Cagir, B. & Katz, J.). Furthermore, the nurse caring for this patient administered the incorrect dose of vasopressin as a result of the domino effect. In fact, the incorrect dose was given for more than 16 hours, which means that more than one nurse was involved in the error. It was not until a nurse was discussing the medication dosing with nursing students that the incorrect ... ...
Planning included reaching out to other health organizations, objectives, and goals of health fair were established. The implementation includes getting volunteers, set up for the health fair. The evaluation of the process occurred throughout the implementation and changes were made as needed. The evaluation will be completed by gathering information from health booth to determine the number of participants. Review vendor and participant evaluations about the health fair including how they heard about the health fair, ratings of booths and suggestions for improvements. Record everything to determine changes. Reflection on past experiences and what worked and did not work.
The term “safety comes first” or more simply put, “safety first,” is a message that patients not only want to hear, but also want to know is the focus of the professionals that are caring for them; in particular, when they are under anesthesia and have limited or no ability to speak up or lookout for themselves. The National Patient Safety Agency (NPSA) has implemented two initiatives; Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) and How to Guide: Five Steps to Safer Surgery (NPSA, 2010). Understanding that human beings make up the healthcare professional workforce, it is evident that tools and checklist can and will only be as good as the how people utilize and follow them. Thus, these initiatives “have been developed with consideration of human factors” (Beaumont & Russell, 2012). I know firsthand, that if my healthcare team would have followed these standards, I would have avoided torture, fear, and long term side effects from a routine hysterectomy procedure.
Since you examined the number of moral issues you will face in this profession, look through the code of ethics that you chose for this assignment and explain
Define a critical thinking task that your staff does frequently (Examples: treat high blood sugar, address low blood pressure, pain management, treating fever etc.). Create a concept map or flow chart of the critical thinking process nurses should take to determining the correct intervention. Include how much autonomy a nurse should have to apply personal wisdom to the process. If the critical thinking process was automated list two instances where a nurse may use “wisdom” to override the automated outcome suggested. Note the risks and benefits of using clinical decision making systems.
I chose to go into nursing because I had taken a sports medicine class in high school I enjoyed, and I thought I would be guaranteed a job graduating that had something to do with medicine. I can remember being so excited to learn how about illnesses and medications, and all the difference procedures done in the hospital. At the time I thought a nurse’s job was to do what the physicians said, and I expected set guidelines that would tell me what I was and wasn’t allowed to do. I had no idea that I was entering onto a career path involving so much complexity, and that the skills I had dreamed of learning were such a small part of nursing in comparison to the emotional, decision making, and critical thinking skills that a nursing career requires. Ethics in nursing was not something that had ever crossed my mind when I chose to take this path, however now ethics is something that I think about every day I am practicing, whether in clinical or theory courses. Ethical theories often come from the idea that because we are human we have the obligation to care about other’s best interests (Kozier et al., 2010), however in nursing ethical practice is not just a personal choice but a professional responsibility.
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
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.
Deontology is an ethical theory concerned with duties and rights. The founder of deontological ethics was a German philosopher named Immanuel Kant. Kant’s deontological perspective implies people are sensitive to moral duties that require or prohibit certain behaviors, irrespective of the consequences (Tanner, Medin, & Iliev, 2008). The main focus of deontology is duty: deontology is derived from the Greek word deon, meaning duty. A duty is morally mandated action, for instance, the duty never to lie and always to keep your word. Based on Kant, even when individuals do not want to act on duty they are ethically obligated to do so (Rich, 2008).
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...
The overall goal for the Quality and Safety Education for Nurses (QSEN) plan is to meet the challenge of educating and preparing future nurses to have the knowledge, skills and attitudes that are essential to frequently progress the quality and safety of the healthcare systems in the continuous improvement of safe practice (QSEN, 2014).Safety reduces the possibility of injury to patients and nurses. It is achieved through system efficiency and individual work performance. Organizations determine which technologies have an effective protocol with efficient practices to support quality and safety care. Guidelines are followed to reduce potential risks of harm to nurses or others. Appropriate policies
Patients Safety is the most crucial about healthcare sector around the world. It is defined as ‘the prevention of patients harm’ (Kohn et al. 2000). Even thou patient safety is shared among organization members, Nurses play a key role, as they are liable for direct and continuous patients care. Nurses should be capable of recognizing the risk of patients and address it to the other multi disciplinary on time.
The combination of professionalism and ethics can be equated with an extraordinary nurse because they are core components in the nursing profession and crucial to patient trust, confidence and wellbeing. Having a degree in nursing is not what makes one a professional. Professionalism is
This assignment addresses the implications relating to an ethical dilemma encountered in practice using an appropriate model of reflection. The assignment will highlight ethical theories and four guiding ethical principles, such as autonomy, beneficence, paternalism and non-malificence. The two main principles that will be discussed in depth will be autonomy and beneficence and how they impact on practice. I will use Bortons (1970) reflective model, which was taken from Jasper (2003).
It is right of a patient to be safe at health care organization. Patient comes to the hospital for the treatment not to get another disease. Patient safety is the most important issue for health care organizations. Patient safety events cost of thousands of deaths and millions of dollars an-nually. Even though the awareness of patient safety is spreading worldwide but still we have to accomplish many things to achieve safe environment for patients in the hospitals. Proper admin-istrative changes are required to keep health care organization safe. We need organizational changes, effective leadership, strong health care policies and effective health care laws to make patients safer.