I-C Quality and Safety

1. Quality and Safety:

      Quality and safety are essential components of patient care. Patients are at risk for a
myriad of harms, which increase morbidity, mortality, length of hospital stay, and costs
for care

1. Nursing Process:

 
The American Nurses Association (ANA) describes six core standards of practice

1. a. Assessment:  Collection of Data

                   - conducting interview, review past medical history and records, completing
physical
                      examination current patient status

1. Diagnosis:    Analysis of data to determine nursing diagnosis

                   -    this is where the nursing care plan is based. This is the clinical judgement
                        regarding the   patient’s response to actual or possible medical problems.

1. Outcome Identification: Identification of expected outcomes specific to the

patient

                        and/or situation

 Setting short- and long-term goals that are patientoriented and measurable,
Including assessment and diagnosis details. utilizing a standardized care plan
or clinical pathway as a guideline

1. Planning: Development of a plan detailing interventions aimed to achieve

expected

                                     outcomes.

1. e. Implementation:   Performance of the interventions noted in the plan of care.

                 -    Documenting the care provided to the patient properly. performing
treatment in a      
                      way that minimizes complications and life-threatening issues. involving
patients,
                      families, caregivers, and other members of the health care team

1. Evaluation:    Evaluation of the patient’s progress toward achievement of

expected

                      outcomes
                 -  evaluating the status of the patient and the effectiveness of the treatment

2. Communication:

 Effective communication is essential for delivering safe patient care.

Communication breakdowns occur during handoff situations when patient
information is being transferred or exchanged of care.
 Common handoff situations include nursing shift reports, transcription of
verbal orders, and interfacility patient transfers.

1. Report or Handoffs
2. Importance:

     Report or handoff involves providing information to the nurse who will be taking over
the care of your patients. It should be given anytime patient care is transferred to
another nurse. This may include at the end of your shift or if a patient is being
transferred to another unit in the hospital.
     The report is necessary to educate the incoming nurse about the patients he or she
would be caring for. If critical information is left out of the report, it might have a
negative impact on patient care and safety. The transfer of information from one nurse
to the next should include a chance for the receiving nurse to ask questions and explain
any points that are unclear.
 

2. Purpose:

      The purpose of report is to provide information about the patients you cared for.
Although the information should be in the patient’s chart, it is often more practical to
present a brief synopsis of what is going on with the patient. 
        It is beneficial to have your notes in front of you when giving a report. When you
first got your report at the start of your shift, you should have taken some notes. In
addition, you will almost certainly have jotted down notes during your workday.
 

3. Barriers to Effective Handoff Communication:

4. Physical setting – background noise, lack of privacy, interruptions
5. Social setting – organizational hierarchy and status issues
6. Language – differences between people of varying racial and ethnic
backgrounds or

        geographical areas

1. Communication medium – limitations of communications via telephone, email,

or

                    computerized records versus face to face

1. SBAR Approach:

 
    The SBAR (Situation-Background-Assessment-Recommendation) technique provides a
framework for communication between members of the health care team about a
patient's condition.
 

 S = Situation(a concise statement of the problem)

 B = Background(pertinent and brief information related to the situation)
 A = Assessment(analysis and considerations of options — what you
found/think)
 R = Recommendation(action requested/recommended — what you want)

 
     SBAR is an easy-to-remember strategy for framing any interaction, particularly those
that require a clinician's immediate attention and action. It provides a simple and focused
way to establish expectations for what will be communicated and how between team
members, which is critical for creating teamwork and fostering a patient safety culture.
           
 
SAMPLE SBAR Approach Teamwork and Collaboration
Situation: My name is (caregiver): Mary Smith, RN from
the (unit) emergency department. I will be transferring (patient name) John Jones, a (age)
34-year-old (gender) male
admitted (time/date) 3 hours ago with (diagnosis) diabetic
ketoacidosis, to (receiving department) medical ICU. Attending physician is Dr. Michael
Miller.
Background: Pertinent history – type 1 diabetes for 20 years.
on insulin pump; managed pump failure 24 hours ago inappropriately; renal insufficiency.
Summary of episode of care:

 Admitting glucose 648 mg/dL; positive ketones; pH 7.27.

PaO2 90 mm Hg; PaCO2 20 mm Hg; HCO3

2 12 mEq/L; K1
3.4 mEq/L; BUN 40 mg/dL; creatinine 1.8 mg/dL; admitting
weight 65 kg; lethargic

 Received 1 L normal saline in field. Normal saline now infusing at 200 mL/hr.
 Received IV bolus of 6.5 units regular insulin at 1300. Insulin infusion of 100
units regular in 100 mL normal saline

infusing at 7.5 units per hour (7.5 mL/hr). 1500 repeat glucose 502 mg/dL.

 20 mEq potassium chloride infused in emergency department

 200 mL urine output last hour – hourly intake and output
 Hemoglobin A1c level 6 weeks ago was 9.2% (patient

report)
Assessment:

 Vital signs: B/P 102/60 mm Hg; Pulse 106 beats/min; Respirations 30

breaths/min; Temperature 37.5° C
 Intake: 1400 mL Output: 450 mL
 Pain level: 0/10
 Neurological: Lethargic; but responsive to stimuli
 Respirations: Deep with acetone odor noted. Lungs clear.
 Cardiac: S1/S2; no murmurs
 Cardiac rhythm: Sinus tachycardia
 Code Status: Full
  GI: Abdomen soft/slightly distended, hypoactive bowel

sounds

 GU: Voiding frequently. Urine concentrated.

 Skin: Skin dry with poor turgor; intact
 IV: (location) right forearm (catheter size) 18 g (condition)

no redness/edema

 Assessment: Diabetic ketoacidosis secondary to poorly

managed insulin pump failure with gradual improvement of

glucose over past 2 hours
Recommendation:

 Hourly vital signs

 Repeat glucose, K1, arterial blood gas due at 1600 today.
 Continue normal saline at 200 mL/hour for 4 hours
 IV insulin infusion at 6.5 units (6.5 mL) per hour – bedside

glucose monitoring hourly and adjust per protocol

 Monitor urine output hourly

 Contact Dr. Miller with 1600 lab work for further orders
 Refer to diabetes educator and clinical dietitian
 Repeat renal profile in am

  Example: Nurse/Doctor interaction

Situation:
     S
This is Nurse Jones on the Hematology Ward. I’m calling about Mr John
  Smith, a day case patient, because he is breathless, and his heart rate is 120.
I am concerned that might be having a transfusion reaction.

  B Background:
  Mr Smith came in this morning for a transfusion of 2 units of red cells. His
hemoglobin dropped to 80g/L following his last round of chemotherapy and
 he was symptomatic during light activity.
His first unit of blood was given over 90 minutes and the second one started
half an hour ago and is over halfway through.
He developed dyspnea within the last 15 minutes, his heart rate has
increased from the baseline observations of 90 and his blood pressure is also
elevated.

Assessment:
His current observations are:
Temp: 37.1oC, Pulse: 120, BP: 150/96, Resps: 28, SPO2: 92%
 
He also looks a little flushed.
 
I think he is showing signs of circulatory overload, so I have stopped the
transfusion for now and administered oxygen.
I note that he wasn’t prescribed a diuretic on this admission.

Recommendation:
  A I would like you to come and see the patient immediately.
  Is there anything I should do in the meanwhile, or anything you will need as
part of your assessment?

Recommendation:
  R I would like you to come and see the patient immediately.
  Is there anything I should do in the meanwhile, or anything you will need
as part of your assessment?