Arts

One of these learns recently preformed was of a 67 year quondam(a) enduring who presented for a hysterectomy. She ended up with complications and subsequent treatment for these complications, only wish was provided by nightingale lodge hospital. Mistakes were made with this diligents c are and tonic actions impart be taken. It is cases like these we strive to correct, in place to execute the hospital of choice for patients, employees, physicians, volunteers, and the community. (Nightingale Community Hospital, p. ) In order to learn and raise from the mistakes made with our tracer bullet patient, we must identify specific mistakes made and take on a tonic action plan to address the improvements we are sp gruesome to tell on. According to the information provided by our tracer patients worksheet, it was determined the patient presented for librarianship hysterectomy that was born-again to an open procedure due to excessive bleeding approximately flipper weeks forw ard to hospitalizing. After examining our patients worksheet, or fact sheet, a few items throughout their care with us was non up to standards.First mistake found was our tracer patient did not bring on an admissions assessment thin the 24-hour window, starting with the period of admissions. The tracer patients physical was d bingle all oer 72 hours after admission. Second, the ply reported completing a functional assessment but at that place was no documentation supporting this claim in her chart. Third, the take hold evaluated the privation for an advance directive, found n bingle to be present, and requested the family process one with them. The family never meeted through and did not provide it.Fourth, the nurses did not update the tracer patients plan of care since the procedure, and this assessment was done 5 weeks after surgery upon re-admittance. Fifth, a pain assessment is supposed to be done at bottom an hour after pain medical specialtys are fathern. The ni ght before this assessment, the follow up was done over an hour after the pain practice of medicine was distributed 4 times. Sixth, the tracer patients oxygen tanks were not secured properly and her rooms air vents were dirty. S neverthelessth, the nurse was not able to explain range order or give a proper range in milliards.Eighth, stack off conversation is poor when patient take outs units and or providers. The SD, OR nurse and PACIFIC nurses active all evaluation tasks properly. As you bum see, many steps requisite for safety were either incomplete or overlooked. In order to bring this tracer patient up to the standards of the articulate commission a corrective action plan needs to be made. For this assessment I am expiration to concentrate on the issues of medication range orders and chat during the go past off process.Medication range orders are very alpha because they can oppose over fusing and under dosing. Over dosing has obvious consequences or poisoning and ev en death, under dosing can lead to the patient Ewing in unnecessary pain. The hand off process is very important and was addressed in prior assessments. This is where most mistakes within a hospital take place. A hand-off can acknowledge when a patient goes from one department from another or even when there is Just a shift change.In our previous case, the freak out or the hand off lead to one of Nightingale Community Hospitals patients Tina, to be discharged to a parent who did not permit wait of her, resulting in a sentinel event. 2. 1 . Nightingale Community Hospital needs to repeat the steps taken to evaluate the racer patient on a wider range of patients. They need to re-evaluate the care of at to the lowest degree 100 patients receiving general anesthesia and inpatient surgery within the snuff it 60 age.This is an important step to take to make sure these mistakes were not made as an isolated incident and more as an over all hospital wide issue. Assuming these mistakes are typical to Nightingale Community Hospital, it should proceed with the following steps. 2. Nightingale Community Hospital exit concentrate on two specific failures medication range orders and communication during hand off process. These areas need to be a priority because they make the greatest consequences. Poor communication leads to almost all patient issues and medication dosage can quickly lead to fatalities. . In regards to hand offs and transferring, the Joint commission requires The hospitals process for hand-off communication provides for the opportunity for discussion between the donor and receiver of patient information. Note Such information whitethorn include the patients condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. Anoint Commission, 2014, p. 1) As described in the tracer patients information, the hand-off preformed was Disjointed hand-off process, inconsistent use of handcuff form. To correct this sta ve, specifically all nurses and transport staff, go out be re-trained how to transfer patients. Executives and unit super visors allow cooperate on making a check off list, including such items as patient condition fall over, care treatment, medications and services (as recommended by the Joint Commission), which the two providers who are handing off the patient will both initial and followup. . After the executives and unit supervisors develop the check off lists for all departments, an online cooking session will be requisite for all employees.It will followed with a brief in person review of all employees by their unit super visors within 30 age of the implementation and the results will be kept in all employee files. The heap responsible for this issues are the nurses and the transport staff. A measure of success is going to be a check off list, which has specific dubietys both the aerate off person and the receiving staff will have to fill out. twain of the questionn aires will be filed in the patients chart and their will be a set for each hand off the patient encores throughout the day.The question air protocol will start in two weeks from today. This will go on for one week throughout the entire hospital. distributively of the lead super visors for each division or floor will thus compile these questionnaires, compile a report for each staff member and review the findings with the staff member within 20 days following the one week assessment. They will discuss what can be improved generally and what the employee needs to specifically irking, if anything. C. Similar actions will be taken for range order re-training.Range orders are medications in which the medication does may vary over a prescribed range, depending on the patient status. (, 2009, p. 2) The important of training for range orders is clear. If over dosed, a patient can be killed, and if under dosed, the patient is in pain. Again, the executives and department super visors will collaborate to create range order guidelines and a re-training program. Rather then having this training be an all staff and employee requirement, range order training ill only be implemented with employees who distribute medications.Training should spread further then physicians and nurses, but also to Urns aids and certified nursing staff. It is important for them to have this basic training, even through they are not changing the dissemination amounts, but they will be better able to spot a mistake if they have further training. The people responsible for this action are all staff members who distribute the medications. The measurement of success is going to be an study, done by the nursing lead for the day. The lead will audit all charts for he last two hours of each persons shift.The staff will not be informed of this audit. The lead will look over any medications passed to the patient. Calculate what the text book dosage range is, make sure what was given to the patient was within this range. The lead will have on week from tomorrow to start these audits. They will go on for one 24 hours period throughout the hospital. The leads will have one week to compile the data, and one week following to have the reviews with the staff. During the review and nurse will distribute a pamphlet overgrowing orange order dosing.