NR 360
NR 360 Unit 4 Discussion Topic: Workarounds and Their Implications for Patient Safety
NR 360 Unit 4 Discussion
NR 360 Unit 4
NR 360 Unit 4
... [Show More] Discussion Topic: Workarounds and Their Implications for Patient Safety (Summer 2020)
1. What is a workaround? Identify a workaround (specific to technology … in a hospital setting) that you have … or perhaps … someone else use, and analyze why you feel this risk-taking behavior was … over behavior that conforms to a safety culture. What are the risks? Are there benefits? Why or why not?
2. Discuss the current patient safety characteristics used by your current workplace or clinical site. Identify at least three aspects of your workplace or clinical environment that need to … changed with regard to patient safety (including confidentiality), and then suggest strategies for change.
ANSWER
Workarounds are usually shortcuts in the workplace to get things done faster. I’ve always had nurses tell me, “do as I say, not as I do.” I have heard this so many times that it is scary how many nurses find loopholes to get things done in a short period of time. A lot of times when vitals are being taken on a patient that has just been transferred to the floor, the pulse oximetry sometimes fails to work. I noticed that there is a certain machine that has a rubber band around the pulse oximetry to hold it in place on a patient’s finger. Working in environments of increasingly complex clinical care and contending with the management of large volumes of information, nurses need to take advantage of the technological tools that can support a quality practice that is optimally safe, informed, and knowledge-based (McGonigle & Mastrain, 2015). I have informed the nurses of the problem and they state that a “work order” has been placed. These are patients who have just come up from surgery or are battling some sort of illness. The risks to have a faulty pulse oximetry is not determining what their level of oxygen in the blood is, which can cause numerous complications, so obviously, there is no benefit. A patient can deteriorate quickly and one not know simply because of a faulty pulse oximetry. The pulse oximeter is unable to distinguish between hemoglobin molecules saturated in oxygen and those carrying carbon monoxide (Casey, 2001). I truly hope that the pulse oximetry is fixed by the time I come back to clinical.
My clinical site is huge on patient safety. One of the main concerns that can be visibly seen and verbalized are patients on fall precaution. Patients who are on fall precaution will have a yellow bracelet that says “fall precaution”, a yellow sign on the door and yellow socks. I believe this is a good practice so that everyone is aware of the client’s situation and is attentive just in case a bed alarm or wheelchair alarm goes off.
Three ways I feel that need improvement at my clinical site are as follows:
1. I believe that when nurses are handing off report about a patient, it should be done in that specific patient’s room. By doing so, you can avoid other patients or anyone in the hallway from listening in. This can keep the patient’s information confidential and it also leaves room to introduce the upcoming nurse on duty.
2. I have seen many nurses pull all their patient's medications and place them in a zip-lock bag. I understand that it is a shortcut and that they don’t need to go back and forth into the med room. However, this can cause a mix up if the nurse doesn’t know which zip-lock bag goes with which patient. I understand it is a long process to give medication, but patient safety comes first and the nurse should also use the 6 rights of medication administration to avoid problems.
3. Going back to number one. I like the fact the nurses give a full report on their patients and that the nurses use a specific paper that the facility provides to help the nurse's pinpoint the main problem. However, this past clinical rotation my nurse ended up losing her paper with 5 patients information on it. Detailed information. God forbid this paper would have been dropped in the hallway and a family member of those 5 patients would have picked it up and read something they shouldn’t have. We ended up finding the paper in a patient room under one of the keyboards.
I feel that as a student nurse it is my responsibility to always make sure that patient safety is number one. I have had some nurses who follow protocol to the T and others that just take shortcuts. Like I stated above with the pulse oximetry, I really hope that issue is resolved soon.
Casey, G. (2001) Oxygen transport and the use of pulse oximetry. Nursing Standard 15: 47, 46-53.
McGonigle, D., & Mastrian, K. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones & Bartlett. [Show Less]