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Culture of Patient Safety Case Studies
create a culture of patient safety using information and communication technologies and informatic processes to deliver safe nursing care while promoting health. Part 1: Creating a Culture of Patient Safety Instructions: Please review the following scenario and answer each of the following questions in 150-200 words using one to two sources to support your ideas. Michael is a nurse working on a busy medical-surgical unit. He is responsible for the care of five patients with complex medical needs. Michael checks on his first patient, Mrs. Wallace. She is lying in bed with the call light button within her reach. The identification armband is in place. Michael verifies that the IV is working and the correct IV fluid is infusing. The monitor is on, and the limits/volumes are set appropriately. Michael proceeds to check on his second patient, Mr. Baker. As he walks in the room, he finds Mr. Baker on the floor and alert. Mr. Baker tells Michael that he fell trying to get into the bed because the bed rolled away. Michael notes that the locks for the bed were not engaged. There is no call light in the room. The monitor is turned off. Mr. Baker does not have an identification armband on. There is an identification band on the bedside table, but it does not belong to Mr. Baker. Michael checks the IV fluid infusing and discovers that the name on the IV bag is the same as the identification armband on the bedside table. National Safety and Quality Standards • Identify two sources and applications of national safety and quality standards to guide nursing practice. • Describe two factors for Mrs. Wallace's scenario that create a culture of safety. • Support your ideas using one to two sources.
Nursing Interventions • Describe three nursing interventions that are necessary for Mr. Baker to create a culture of safety. • Discuss the nurse's accountability for reporting unsafe conditions, near misses, and errors to reduce harm.
Interprofessional Team Members • Identify the interprofessional team members that will need to be notified regarding Mr. Baker's situation. • Select three team members and explain their role in the care of Mr. Baker's situation. • Explain the nurse's role within this interprofessional team in promoting safety and preventing errors and near misses.
Basic Safety Design Principles Basic safety design principles help to reduce risk of harm. Examples of these include error-proofing, safeguards, and training. • Select one of the safety design principles and explain how it applies to Mrs. Wallace and Mr. Baker. • Discuss the benefits of using reporting system processes to understand causes of error and improve patient outcomes. • Support your ideas using one to two sources.
References: Cite a minimum of two sources in APA format to complete this assignment. Sources must be: • Published within the last five years. • Appropriate for the assignment criteria. • Relevant to nursing practice.
Part 2: Delivering Safe Nursing Care Using Information and Communication Technologies Instructions: Please review the following scenario and answer each of the following questions in 150-200 words using one to two sources to support your ideas. Stephanie, a home health nurse, is visiting an elderly man, Mr. Turner, who lives with his daughter. Prior to the visit, Stephanie reviews the electronic health record (EHR) and the clinical decision support tools for Mr. Turner. He has a pacemaker to help with his congestive heart failure. There is a module in his home that sends information from his device to the cardiologist to monitor. During this visit, Stephanie will be assisting Mr. Turner and his daughter to send a report to the cardiologist via the module connected to the internet. Mr. Turner is also a type II diabetic using an insulin pump that is connected to an app on his phone. Due to the neuropathy of his feet, Mr. Turner is unstable with his gait and uses a walker to ambulate. He wears a senior medical alert button in case he should fall. Mr. Turner is also scheduled for a telehealth visit with his doctor during Stephanie's visit. Stephanie arrives at the home for the visit. As she is starting her assessment of Mr. Turner, the insulin pump is beeping and there is an error message. Mr. Turner states that it has not been working right the last couple of days and his daughter was going to try to fix it. He also tells Stephanie that he has stopped wearing the medical alert button because it kept beeping and he was unable to get it to stop beeping. Clinical Decision Support Tools • Describe two examples of clinical decision support tools (CDST) for Mr. Turner. • Evaluate how decision support tools impact clinical judgment and help provide safe patient care.
Full Answer Section
In Mrs. Wallace's scenario, two factors that contribute to a culture of safety are the presence of the identification armband and the functioning monitor with appropriate settings. The identification armband is a direct application of the NPSGs' emphasis on accurate patient identification, ensuring the right patient receives the right intervention. A properly functioning monitor with set limits and volumes provides continuous surveillance of Mrs. Wallace's physiological status, allowing for early detection of potential problems and timely intervention, thus promoting a proactive safety approach (QSEN Institute, n.d.).
Nursing Interventions
For Mr. Baker's situation, three necessary nursing interventions to create a culture of safety are: immediate assessment and treatment of Mr. Baker's injuries, thorough investigation into the cause of the fall, and implementation of preventative measures to avoid future falls. A comprehensive assessment will determine the extent of Mr. Baker's injuries and guide appropriate treatment. A detailed investigation, including interviewing Mr. Baker and reviewing the circumstances, will help identify the root causes of the fall, such as the unlocked bed and the missing call light. Subsequently, implementing preventative measures like ensuring all beds have functional locks and readily accessible call lights, along with reassessing Mr. Baker's fall risk and implementing appropriate interventions, are crucial steps in fostering a safer environment (Hughes, 2018).
Nurses have a fundamental accountability for reporting unsafe conditions, near misses, and errors to reduce harm.Reporting allows for the identification of systemic issues that may contribute to patient safety risks.By reporting a near miss, like Mr. Baker almost falling earlier, proactive measures can be taken before actual harm occurs.Reporting errors, even if no harm resulted, facilitates analysis of contributing factors and the development of strategies to prevent recurrence.This transparency and commitment to learning from both successes and failures are essential for continuous quality improvement and the creation of a safer healthcare environment (Institute for Healthcare Improvement, n.d.).
Interprofessional Team Members
Several interprofessional team members need to be notified regarding Mr. Baker's situation. These include the attending physician, the charge nurse/nurse manager, and potentially a physical therapist.
The attending physician needs to be informed of Mr. Baker's fall, the assessment findings, and any injuries sustained. They will provide medical direction for further evaluation, treatment, and any necessary changes to Mr. Baker's care plan.
The charge nurse/nurse manager needs to be notified to address the immediate safety concerns on the unit, such as the missing call light and the unlocked bed. They are also responsible for initiating the incident reporting process and ensuring that appropriate follow-up occurs to prevent similar incidents in the future.
A physical therapist may need to be consulted to assess Mr. Baker's mobility, balance, and strength following the fall. They can develop a tailored plan to improve his safety with transfers and ambulation, reducing his risk of future falls.
The nurse's role within this interprofessional team is central to promoting safety and preventing errors and near misses. The nurse is the first responder and the primary point of contact, providing crucial initial assessment and information. They facilitate communication between team members, ensuring everyone is aware of the situation and the plan of care. Furthermore, the nurse advocates for the patient's safety needs, ensuring that identified risks are addressed promptly and that preventative measures are implemented consistently (World Health Organization, 2019).
Basic Safety Design Principles
Error-proofing, a basic safety design principle, aims to prevent errors from occurring in the first place. In Mrs. Wallace's scenario, the presence of a secured IV line with the correct fluid infusing can be seen as a form of error-proofing. Standardized procedures for IV insertion and verification, along with clear labeling, reduce the likelihood of administering the wrong medication or fluid. Conversely, in Mr. Baker's situation, the lack of engaged bed locks represents a failure in a basic safeguard. Implementing a protocol where nurses routinely check and engage bed locks after any bed movement or upon patient transfer would serve as a safeguard to prevent falls. The missing call light also highlights a lack of a crucial safety feature that allows patients to easily request assistance, increasing their vulnerability to falls.
Using reporting system processes to understand causes of error and improve patient outcomes offers significant benefits. These systems allow for the collection and analysis of data related to errors, near misses, and unsafe conditions. By identifying patterns and trends, healthcare organizations can gain valuable insights into the underlying causes of these events, moving beyond individual blame to address systemic issues.This understanding can then inform the development and implementation of targeted interventions, such as changes in policies, procedures, or technology, to prevent future errors and ultimately improve patient safety and outcomes (Institute for Healthcare Improvement, n.d.).
References
Hughes, R. G. (Ed.). (2018). Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US).
Institute for Healthcare Improvement. (n.d.). PSNet: Patient Safety Network. Retrieved from https://psnet.ahrq.gov/
The Joint Commission. (n.d.). National Patient Safety
Sample Answer
Part 1: Creating a Culture of Patient Safety
National Safety and Quality Standards
Two crucial sources of national safety and quality standards that guide nursing practice are the National Patient Safety Goals (NPSGs) from The Joint Commission and the Quality and Safety Education for Nurses (QSEN) competencies. The NPSGs provide specific, evidence-based actions that accredited organizations must implement to address significant patient safety concerns (The Joint Commission, n.d.). For instance, NPSG.01.01.01 focuses on using at least two patient identifiers when administering medications, blood products, or collecting specimens.QSEN, on the other hand, outlines six core competencies for nursing graduates to ensure quality and safety in healthcare: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (QSEN Institute, n.d.). These competencies provide a framework for nursing education and practice, emphasizing the integration of safety principles into all aspects of care.