Reply 2 two peers

Overview

This discussion integrates your experiences with client safety concerns during patient care.

Instructions

Based upon an experience in which you encountered a client safety issue in an acute care setting or outpatient setting, write 200250 words responding to the discussion prompts provided. This could be a situation in which you were the patient, a family member, or an employee. Then, respond to at least two of your peers posts substantively. Each response needs to have a minimum of 100 words.

Discussion Prompts

Describe the problem (patient safety/quality issue) you have experienced in an acute care or outpatient setting.
Identify at least three factors that contributed to the problem.
Based on the concepts that youve learned related to improving patient safety and quality, what recommendations would you make to improve this issue? Provide at least two recommendations.

Mypost:One of the patient safety concerns that I seen happened in acute care hospital when transferring a patient to a medical unit after the emergency department. The patient documented to be severely allergic to latex, which was not explicitly reported in the handoff report between nurses. As the patient came to the unit, latex-based equipment was initially utilized during care preparation. Luckily, the electronic health record later identified the allergy alert and the patient did not react. This scenario showed how failures in communication in care transitions can pose severe safety risks.

This was caused by a number of factors. One, there was a lack of time in handoff communication between departments where important information was missed. Second, employees were highly dependent on oral report rather than confirming patient alerts in the electronic health record. Third, the hectic clinical environment and large amount of patients augmented the risk of missed care. Communication issues at care transitions are generally considered an important factor in patient safety events.

Healthcare organizations are encouraged to standardize handoff communication with the application of structured tools to enhance patient safety, including SBAR (Situation, Background, Assessment, Recommendation). It is also demonstrated that structured communication tools can minimise errors and enhance information transfer among healthcare providers (Ghosh et al., 2021). Besides this, nurses should always check patient allergy alerts directly in the electronic health record before commencement of care. It is also demonstrated through research that the enhancement of communication systems and safety culture can greatly reduce the amount of harm that can be prevented and enhance the quality of care (Mistri et al., 2023).

References

Ghosh, S., Rananoorthy, L., & Pottakat, B. (2021). Impact of Structured Clinical Handover Protocol on Communication and Patient Satisfaction. Journal of Patient Experience, 8.

Mistri, I. U., Badge, A., & Shahu, S. (2023). Enhancing Patient Safety Culture in Hospitals. Cureus, 15(12).

Peer1:For this specific discussion, Ill be sharing about my late grandmothers experience. During her hospital stay for kidney failure, I noticed a safety concern which was related to fall prevention. My grandmother was considered a fall risk, yet there were no consistent or clearly implemented safety measures that were set in place that would prevent her from falling. Her bed alarm was not always activated, her personal items were out of reach, and the nursing staff, due to staff shortage, was not able to consistently go to her to assist her whenever she needed to get up. For me, as a family member, initially you could see that something was wrong, but as I gain more knowledge from this program, I can definitely see that something was wrong.

The three factors that contributed to this issue was first lack of communication when it came to her fall risk status. The second factor was that the unit was understaffed and that showed in the care that the patients received. And then lastly, lack of accountability when it came to consistently following fall prevention protocols.

Again, as my knowledge expands throughout this program, the two recommendations that I would suggest is reinforcing fall risk protocols by making sure that the bed alarms are activated and that the patients belongings are within reach. Lastly, making sure that communication is a priority and not an afterthought when it comes to report handoffs and encouraging the nurses to prioritize high risk patients such as my grandmother.

Peer2:Patient safety concern I encountered during acute care experience: failure to properly follow through with fall risk precautions with a patient.

Brief description: A patient had been placed on high fall risk, but their bed alarm was not engaged and they got out of bed on their own and fell towards the floor. Luckily, I was walking past the room and was able to catch them before they hit the ground, but they couldve been seriously injured.

Reasons for concern: Poor communication during change of shift about fall precautions that were needed. There was also high turnover and inadequate staffing that night which caused people to become overwhelmed with workload and miss certain safety precautions. Additionally, there was some disconnect with following policies.

Interventions to improve this safety issue: I would try to implement some sort of change based on patient safety/QI concepts learned to address this. Using SBAR during handoff would improve communication between nurses during change of shift to prevent missing important patient information like fall risk. I would also try to improve accountability with hourly rounding, so patients on fall precautions are safely monitored. I would also educate staff/peers on following fall precautions to try and prevent falls from happening. If implemented correctly, I believe these changes would improve patient safety by limiting patient harm as there are multiple opportunities for falls to occur that arent just based on one individuals performance.

References

CDC (2024), Older Adult Fall Prevention to an external site.

World Health Organization (2021), World Health Organization to an external site.

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