NRS 450 Assignment: Benchmark-Culture of Patient Safety Case Studies

·         Identify two sources and applications of national safety and quality standards to guide nursing practice.

·         Describe two factors for Mrs. Wallace’s scenario that create a culture of safety.

·         Support your ideas using one to two sources.

Cultural safety is essential in establishing a connection with prospective patients. An organization’s activities, attitudes, and values about clinical excellence and safety at all levels are reflected in its safety culture, which prioritizes patient care. It is evident in the case study that Mrs. Wallace is in bed with the call light button accessible and wearing her identity bracelet. She also permits Michael to verify the functionality of the IV and ensure that the correct IV fluid is being infused.

·         Describe three nursing interventions for Mr. Baker to create a safety culture.

·         Discuss the nurse’s accountability for reporting unsafe conditions, near misses, and errors to reduce harm.

A robust safety culture encourages all healthcare team members to recognize and mitigate patient safety risks by reporting errors and near misses for root cause investigation and risk elimination. Personnel often hide faults out of fear or shame in a culture of safety that is inadequately established and enforced. Nurses have historically been taught to strive for clinical perfection and to assume that competent nurses do not make mistakes. Errors are often attributed to carelessness, inattention, apathy, or misinformed judgments. Expecting high-performance standards is beneficial, but it may be harmful if it leads to an expectation of perfection that affects reporting mistakes and near misses. Experiencing embarrassment upon making a mistake might lead workers to conceal or disguise mistakes. Research shows that over 75% of errors are self-detected by the individuals who make them rather than being identified by external cues or other people (Han et al., 2019). Employees must be confident that they may disclose faults without being unfairly accused.

·         Identify the interprofessional team members who must be notified regarding Mr. Baker’s situation.

·         Select three team members and explain their role in caring for Mr. Baker’s situation.

·         Explain the nurse’s role within this interprofessional team in promoting safety and preventing errors and near misses.

The physician will screen patients for fall risks and any injuries they may have suffered. The physician will provide a prescription in case the patient needs further medicine. The nurse will monitor the infusion rate on both the primary and secondary IV tubing, confirm the infusion rate in the physician’s orders or drug administration record, help the patient get into a comfortable posture, set the call bell within reach, and raise the side rails on the bed according to agency regulation. The pharmacist will ensure the patient receives all necessary prescriptions in the appropriate dosage and strength.

In terms of patient safety, a nurse’s duties include monitoring patients for signs of clinical deterioration, identifying errors and near-misses, understanding care procedures and weaknesses in particular systems, identifying and alerting patients to changes in their condition, and performing a plethora of other tasks to ensure patients receive the best care possible (Lipscomb & Zupec, 2020).

Basic safety design principles help to reduce the risk of harm. Examples of these include error-proofing, safeguards, and training.

·         Select one of the safety design principles and explain how it applies to Mrs. Wallace and Mr. Baker.

·         Discuss the benefits of using reporting system processes to understand error causes and improve patient outcomes.

·         Support your ideas using one to two sources.

Sharing accounts of mistakes and informing patients and significant others about actual errors and near misses can help mitigate the impact of mistakes and decrease the chances of future errors by alerting others to potential risks (Wolf et al., 2020). Reporting helps minimize future errors, reducing personal suffering and financial costs. On the other hand, disclosing errors is advantageous for patients and healthcare providers as it provides prompt information and helps minimize legal disputes.

Cite a minimum of two sources in APA format to complete this assignment. Sources must be:

·         Published within the last five years.

·         Appropriate for the assignment criteria.

·         Relevant to nursing practice.

Lipscomb, C. P., & Zupec, J. (2020). Use of telehealth experiences to facilitate interprofessional education. American Journal of Health-System Pharmacy, 77(10), 734–738. https://doi.org/10.1093/ajhp/zxaa033

Mihdawi, M., Al‐Amer, R., Darwish, R., Randall, S., & Afaneh, T. (2020). The influence of nursing work environment on patient safety. Workplace Health & Safety, 68(8), 384–390. https://doi.org/10.1177/2165079920901533

Wolf, L., Parker, S., & Gleason, J. L. (2020). Human factors in healthcare. In Springer eBooks (pp. 319–333). https://doi.org/10.1007/978-3-030-55829-1_20

·         Describe two examples of clinical decision support tools (CDST) for Mr. Turner.

·         Evaluate how decision support tools impact clinical judgment and help provide safe patient care.

·         Explain how CDST reports and monitors performance metrics on patient outcomes.

·         Discuss two to three examples of healthcare performance metrics.

Healthcare performance metrics are clearly defined measures used to monitor, analyze, improve, and change healthcare processes to enhance patient and provider satisfaction. One example is Average Hospital Stay, which monitors the average duration of patients’ hospital stays. Another illustration is Bed or Room Turnover, which monitors how patients transition in and out of the facility (Sutton et al., 2020). The hospital or clinic can enhance operational efficiency by optimizing these metrics, reducing operating expenses, and elevating patient satisfaction.

·         Describe how the technology used to care for Mr. Turner enhances the quality and safety of care.

·         Identify two modalities that could be used to communicate care delivery for Mr. Turner.

A provider’s primary responsibility in engaging and caring for patients is to ensure effective communication, which is critical for patient-centered care and shared decision-making. To communicate care delivery for Mr. Turner, providers and nurses may utilize secure text messaging. E-visits, which are non-face-to-face communications initiated by the patient via an online portal; Case-based teleconferencing, which facilitates the coordination of a patient’s services across multiple multidisciplinary providers; and Audio-only visits, which are patient visits conducted via telephone but without video, are additional modes of communication that apply to this patient (Mao et al., 2020).

·         Select two emerging technologies that are used to improve healthcare delivery and clinical decision-making.

·         Describe the benefit of these emerging technologies to improve the health promotion for this patient.

·         Identify the importance of reporting system processes and functional issues (error messages, misdirections, device malfunctions, etc.) according to organizational policies and procedures.

Cite a minimum of two sources in APA format to complete this assignment. Sources must be:

·         Published within the last five years.

·         Appropriate for the assignment criteria.

·         Relevant to nursing practice.

Jabin, M. S. R., Steen, M., Wepa, D., & Bergman, P. (2023). Assessing the healthcare quality issues for digital incident reporting in Sweden: Incident reports analysis. DIGITAL HEALTH, 9, 205520762311743. https://doi.org/10.1177/20552076231174307

Mao, Y., Lin, W., Wen, J., & Chen, G. (2020). Impact and efficacy of mobile health intervention in managing diabetes and hypertension: a systematic review and meta-analysis. BMJ Open Diabetes Research & Care, 8(1), e001225. https://doi.org/10.1136/bmjdrc-2020-001225

Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. Npj Digital Medicine, 3(1). https://doi.org/10.1038/s41746-020-0221-y