Healthcare IMPROVING PATIENT SAFETY WITH EVIDENCE-BASED RESEARCH

My workplace is currently experiencing the need for improvement is in the area of enforcing and communicating hospital policies/procedures regarding care of patients requiring special attention. This is illustrated by a recent incident of an elderly cancer patient admitted for unexplained dizziness but then falling and sustaining injuries when left unattended in the hospital. Fortunately, we have a nursing supervisor who is the epitome of a transformational nursing leader. She immediately commenced best practices, exhibited Gardner's leadership tasks and is transforming the unfortunate incident into a valuable learning opportunity.

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The most pressing patient safety issues in work setting that need improvement

While a number of areas would benefit from improvement, a recent incident leaps to mind and underscores the need for better communication and enforcement of hospital policies/procedures. An 87-year-old female diagnosed with Stage 4 colon cancer and admitted to the hospital due to dehydration and otherwise unexplained dizziness/fainting was left unattended while toileting, fainted and fell on her face, incurring multiple facial bruises and possible brain trauma. The nurse who left her unattended is a visiting nurse from Jamaica who claimed that she left the patient on the toilet after telling the patient to "buzz" her if the patient required help. The patient was found face-down on the bathroom floor 25 minutes later by a hospital aide. Leaving an elderly patient admitted for dehydration and otherwise unexplained dizziness/fainting unattended clearly violated hospital practices/procedures. Furthermore, the morning after this incident was discovered and reported, the patient was again left unattended in the bathroom until one of her family members angrily stopped the aide who was leaving her mother unattended and firmly told him that her mother was not to be left unattended. The aide replied that no hospital staff told him the patient could not be left unattended. The patient's family was understandably livid, filed a formal complaint with hospital administration, removed their mother from our facility against medical advice and later had her transported to another hospital approximately 40 miles away, which admitted her. Clearly, there is a disconnection between hospital policies/procedures and the behaviors of at least one visiting nurse and one aide regarding careful attention to patient safety. In view of the five management practices (Institute of Medicine, 2004):

a. Balancing the tension between production efficiency and reliability (safety):

The hospital's current financial situation forces it to perform as cost-effectively as possible, with fewer nurses covering an entire floor of patients. As a result, the harried visiting nurse cut corners by skimping on reliability, leaving the patient unattended. Furthermore either the nursing supervisor failed to inform or the next day's hospital aide failed to follow reliable hospital procedures to safeguard the patient while she was toileting. Here, we failed to adequately balance production efficiency and reliability.

b. Creating and sustaining trust throughout the organization:

The organization's level of trust throughout the organization (Institute of Medicine, 2004) certainly suffered from this incident. The incident and subsequent blaming, first of the visiting nurse blaming the patient, then of the hospital aide blaming the nursing supervisor for failing to inform him that the patient should not be left unattended, created a distrustful situation. The distrust affected not only the staff on that hospital floor and the hospital but also affected the patient's family, who so deeply distrusted the hospital's care of their mother that they removed her against medical advice and essentially decided to try another hospital for adequate care.

c. Actively managing the process of change:

The organization failed in at least one of the five practices important for successful change implementation: ongoing communication; training; use of mechanisms for measurement, feedback, and redesign; sustained attention; and worker involvement (Institute of Medicine, 2004). We failed at ongoing communication, as either the nursing supervisor failed to sufficiently communicate or the visiting nurse and hospital aide both failed to adequately "hear" the policies/procedures regarding attending this type of patient. However, we are making some progress in the aftermath. The nursing supervisor encouraged a formal complaint from the patient's family, the nursing supervisor met with them, obtained a written report and photographs of the patient's injuries and is implementing special instructions emphasizing the importance of careful attendance to this type of patient, illustrating the consequences of failing to follow this hospital practice/procedure, and stressing the importance of communication about each patient's special needs.

d. Involving workers in decision making about work design and work flow:

I strongly believe the organization failed to adequately involve nursing staff in making decisions about work design and flow (Institute...

While it is true that the particular nurse involved was a visiting nurse, nurses regularly employed by the organization would stress the need for a larger staff to adequately attend to all the patients on this floor. The visiting nurse did not leave the described patient to take a coffee break; rather, she had other nursing duties to attend to and was compensating for inadequate staff.
e. Using knowledge management practices to establish the organization as a "learning organization":

We are attempting to create, acquire and transfer knowledge and modify behavior to reflect new knowledge and insight (Institute of Medicine, 2004) in the aftermath of this incident. As mentioned above, the nursing supervisor invited a formal complaint and meeting with the patient's family, gathered written and graphic information about the incident and is drawing up teaching materials to stress the policies/practices, both regarding patient care and to improve communication about particular needed of each patient.

2. Rationale using evidence-based research on patient safety issue that speaks to how patient safety could be improved in work setting

a. What are the best practices?

Several best practices are involved in this situation. For example, the nursing supervisor actively sought the knowledge and strategies to empower the patient's family in all aspects of the health care process (QSEN Institute, 2014) by engaging the patient's family in active partnership to promote health, safety and well-being. Furthermore, the nursing supervisor focused on future effective communication, consensus building and conflict resolution and examined nursing roles in patient care (QSEN Institute, 2014). Regarding teamwork, the nursing supervisor is actively analyzing differences in communication style among health team members, analyzing other barriers to effective teamwork and discussing effective strategies to resolve the communication dilemma in this patient care conflict (QSEN Institute, 2014).

Ultimately and ideally, the best practices involve careful attention to hospital policy/procedures regarding attention paid to patients with special conditions. In addition, communication of both the policies/procedures and each patient's special needs is vital for visiting nurses, regularly employed nurses and hospital aides alike (with special emphasis on nurse communication, of course). Finally, we have to create an environment in which staff is far more interested in resolving a problem than in blaming. All that blaming was a waste of time/energy that could be better spent solving the problem and it undercut every kind of needed trust. Fortunately, our nursing supervisor and regular nursing staff are striving to remedy the shortcomings that resulted in this patient's incident and attempting to create a trusting, communicative environment in which that type of incident never happens again.

b. How are they being implemented?

The nursing supervisor, in particular, is in the initial stages of implementing the best practices. She acknowledge the importance of the family's thoughts, feelings and input (Yoder-Wise, 2015, p. 7), invited formal and informal criticism by the patient's family in the forms of a formal complaint, written and verbal explanations and photographic evidence. Furthermore, she met with the hospital administrators to explain the situation and underscore all the shortcomings, from lack of attention, to lack of communication, to a "blaming" subculture that undercuts our primary goal of excellent patient care. Finally, she is brainstorming with regular nursing staff and administration to hone communications and create/build a trusting relationship across the organization in which staff requiring assistance will ask for assistance rather than cutting corners by leaving patients unattended when they require special attention.

c. What could your work setting improve upon based on the best practices presented in the literature?

Based on the best practices presented in the literature, in addition to seeking and implementing patient/family involvement and focusing on future effective communication, consensus building and conflict resolution and examined nursing roles in patient care, we need to identify system barriers and facilitators of effective team functioning (such as the factors creating the distrustful subculture) in order to improve teamwork, possibly even by redesigning the team's supporting systems (QSEN Institute, 2014).

d. One (1) out of the five (5) essential management practices that could best be utilized: using knowledge management practices to establish the organization as a "learning organization"

At this juncture, we can no longer help that particular patient, as she was removed from the facility. However, we can certainly improve future outcomes by using knowledge management practices to establish the organization as a "learning organization." The nurse supervisor initiated that management practice as soon as she learned of the incident. As mentioned above, she immediately focused on learning about the incident, though it meant facing very angry family members, encouraged their formal complaint, gathered all information…