A Case Study6
Nurse caring for a patient at a disadvantage by not having information that may be necessary to make critical decisions for safe patient care. Patterson et al (2004) examined hand off in settings with high consequences for failure, such as, NASA, the Johnson Space Center in Texas, Nuclear Power generation plants in Canada, a railroad dispatch center in the United States and an ambulance dispatch center in Toronto. Patterson found that hand offs in these settings were interactive, verbal, face-to-face interactions between incoming and outgoing personnel. This allowed for questioning and checking for accuracy of information. Validation of information was found to be an important factor in maintaining the plan for care or daily
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Likewise in healthcare, oncoming staff generally does initiate not patient care delivery until a hand off process occurs. “Communication failures are increasingly being implicated as important latent factors influencing patient safety in hospitals.”(Sutcliffe, 2004, p. 187) Parker (1996) reports, “the nurses handing over had direct knowledge of the patient and were able to convey idiosyncratic and personal knowledge of the patient. This is a crucial element in professional nursing practice. The nurse can report on clinical judgments and can be held accountable for the judgments made” (Parker, 1996, p. 25) Critical evaluation of nursing actions can be evaluated and considered to be either continued or discontinued based on the rationales for the action and the patient outcome. In 2005, the Australian Council for Safety and Quality in Healthcare published a literature review of clinical handover and patient safety. This report was compiled in an effort to appraise the evidence available and the research completed regarding nursing handover. Healthcare hand off processes, tools and guidelines for hand off were examined (Safety Council, 2005) the council identified three major domain areas related to …show more content…
However, in smaller, regional hospitals, it may be more likely that patients are known to each other. The extent to which bedside handover is appropriate in these situations remains unknown. A previous survey showed that almost 30% of 74 patients perceived the presence of other patients in the room during bedside handover as somewhat disturbing.30 it appears that nurses need to carefully consider how sensitive information is shared during bedside handover. Nurses perceived bedside handover in a positive light, believing it improved the accuracy of the information they handed over, however no comparison was done with other handover types, so this perception may not be accurate. Our participants said that patients’ presence not only prompted outgoing nurses to remember information that should be passed on, it also prompted oncoming nurses to ask questions and seek clarification, which may account for the perceived accuracy of bedside handover. In conclusion, this case study of bedside handover used by nursing staff in six wards in two hospitals provides a description of its structures, processes and perceived outcomes. This information may be used as the basis for standard operating protocols for more widespread implementation. Importantly, to date, measurable benefits of bedside handover for nurses and patients are yet to be firmly
Thank you for your all information. Your answer is very organized and well addressed the question. I agreed with you the Joint Commission's mission and goal now is to focus on continuously improving health care for the public by evaluating health care organizations and inspiring them to excel in providing the safest and effective care of the highest quality and value. According to the Joint Commision (JC), there are no new National Patient Safety Goals in 2015, but JC continuously determines the highest priority patient safety issues and how best to address them. For exxample, for hospital setting, the goals focus on following problems: identify patients correctly, improve staff communication, use alarms safely, prevent infection, identify
Objective One During my clinical day three, I demonstrated entry-level competence in professional nursing practice in caring for patients with multiple and/or complex unmet human needs. I addressed safety needs, safety in medication administration, effective communication, and surveillance for my patients. First, I addressed safety needs my ensuring the appropriate safety measures were implemented for the patients. Some of the safety measures included, wearing non-skid socks, wearing a yellow armband which indicated fall risk, keeping the bed in lowest position, two side rails up, bed locked, and the call light within reach.
Bedside reporting has been shown to improve communication and quality of handoff between nurses. It is also credited to promote patient safety and improve patient satisfaction. Patient satisfaction, patient safety and nursing communication and quality of report from a 32 bed surgical hospital in Dallas, Texas is to be evaluated using various surveys, HCAHPS scores, incident reports, and call light logs. Data will be collected 2 months prior and 6 months following the implementation of bedside report. Scores and communication survey results will be reviewed in this time period to determine increases or decreases from pre-implementation results using traditional nurse-to-nurse report..
Although as far as human error is concerned, initially the clerk was not at the desk, and then assumed the nurse's name which resulted in delay in attending to Claudia's call and subsequent injury to her body. 2. How might Claudia’s fall have been avoided? • Her fall could have been avoided through several timely responses to her call such as: • Identification of the assigned nurse • Communication of message to the nurse could have avoided Claudia's fall. 3.
The idea of shift work is a common one, but for nurses this is not a simple changing of staff during a certain time, change of shift signifies a time of purposeful communication between nurses and patients, in order to promote patient safety and best practices (Caruso, 2007). During this time, there is the possibility for this critical opportunity to relay important information to become disorganized by extraneous information, rather than concentrating on the needs of the patient (Sullivan, 2010). Often the patient is left out of the conversation, and is not a part of the process. Patients and families can play an important role in making sure these transitions in care are safe and effective (AHRQ, 2013).
The bedside nurse manages writing and updating the whiteboard each day using a templated board, the displayed information includes day and date, the names of the patient, bedside nurse, and primary and attending physician, family member 's phone number, diet, pain management and mobile numbers for Nurse, Charge Nurse and Nurse Assistant. This simple strategies is driving our thresholds to our benchmarks at an accelerated
In order for the future of health care to change, changes must begin at the top with stakeholders, the hierarchy and nursing management, nurses as leaders within their organizations. According to Disch J. (2008), nurses as leaders within their organizations need to also step forward, CNEs have the background, perspective, and platform to help their organizations seriously tackle safety issues that jeopardize patient care and that face nurses and their colleagues daily, and are the essential building blocks of all health systems--and
Yes, I believe it is important because communication is a key to providing patient safety. A safe hand-off supports good communication and a safe transfer of care. Yes, and I think the level of education should increase more over time. The more patients are aware the better the outcomes.
Moreover, several studies have been conducted to examine the effects of low nurse staffing on patients hospitalization experiences, as well as its effect on nurse careers in the long run. A recent study by Frith, Anderson, Tseng, and Fong (2012) to explore the relationship between nurse staffing and medication errors, demonstrated that medication errors were higher in a cardiac care unit and non-cardiac care unit when staffing levels were lower. In addition, Frith et al. (2012) pointed out that medication errors increase by 18% for every 20% decrease in nurse staffing below the average due to failure to follow medication administration protocol As mentioned earlier, nurses perform the last and the most important step of medication administration. Thus, having adequate time to assess each patient efficiently and following the medication rights is critical to provide safe patient care and prevent errors.
Communication in nursing is known for its life saving success as well as its greatest flaw in poor patient outcomes. There is always room for improvement and when communication is carried out efficiently, healthcare professionals have reaped the benefits. However, there have been many instances in which nurses have had to learn the hard way of how detrimental communication can be to patient safety. Through research and reviews of literature, the topic of patient safety related to handoff communication among units is analyzed.
Nurses play an essential role in the healthcare industry. The nurse workforce is made up of licensed nurses: registered nurses (RNs), licensed vocational nurses (LVNs) and licensed practical nurses (LPNs), along with nurse aides. Registered nurses are responsible for assessments of patients’ needs, development of care plans, medication administration, and treatments, while licensed vocational nurses perform specific care under the delegation of the registered nurses and supervisions. Nursing aides perform activities of daily living (unskilled attention) to the patient. Adequate nursing staffing is essential to both patient care and outcomes, also to the retention of nurses while inadequate staffing creates problems for both the patients and
Nursing is a highly respected profession and patients will seek advice from nurses. Therefore, nurses should learn how to react to situations that may not align completely with their own personal moral or ethical beliefs. Abandonment in the practice of nursing is not only detrimental to the health of patients involved, but to the nurse responsible for their care. If a nurse abandons his or her patients he or she has now been placed in a situation open to possible litigation, board discipline of classes or fines, and loss of licensure. As stated by the Oklahoma Board of Nursing, “abandonment may occur when a licensed nurse fails to provide adequate patient care until
In the leadership in care delivery course, we were assigned to a hospital to perform clinical hours and provide care to four patients. Additionally, the purpose of this paper is to explain and provide examples on how our patient care included the concepts of Quality and Safety Education for Nursing (QSEN) competencies, delegation, handoff reporting, and a reflection of the clinical experience. Quality and Safety Education for Nursing (QSEN) Competencies QSEN consists of six competencies: patient centered care, quality improvement, teamwork and collaboration, safety, informatics, and evidence based practice. To provide patient-centered care, I had to educate the patient when administering medications on why the patient was taking the medication and side effects. Care had to be individualized with each patient and it included providing respect with his or her decisions in their care.
They need to learn the various pieces and functions of communication in diverse areas of nursing. According to Garrett (2016), to maintain patient safety communication should be consistent, comprehensive, transparent, concise, and appropriate, consequently, leading to interacting and connecting with patients who demonstrated to improve results, reduce costs, and improve the patient’s understanding. A study conducted by Daly (2017), states that they are four themes nurses should utilize in their daily practice: 1. Prioritise people, 2. Practise effectively, 3.
An example of this are several deaths due to “unsafe discharges” caused by poor communication during handover (Royal College of Nursing Great Britain, 2014). Through effective communication the disease’s effects can be reduced through a quick response to a deteriorating patient and efficiently provide co-ordinated care to provide the correct treatment