Identifying Safety IdentRisks and Solutions

Identifying Safety IdentRisks and Solutions

The below scenario comes from the state of Minnesota Department of Health’s Root Cause Analysis Toolkit.

For the following questions, consider the following scenario:

62 year old female with history of congestive heart failure (CHF) was admitted from the Emergency Department with Left Lower Lobe Pneumonia. She has been living independently at home with no assistance needed with cares. She was complaining of pain with inspiration, vital signs were normal, oxygen saturation was 90% on room air. On hospital day 2, she was found on the floor at 2345 in severe pain. X-rays revealed a hip fracture. The next day she was taken to surgery for repair. During surgery she had an acute myocardial infarction (AMI) and expired while on the table.

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Further analysis of the timeline leading up to 2345 discovered that the nurse came on at 2300 that evening and got report which indicated the patient was pleasant and cooperative, asking for help as needed, didn’t attempt to get up on her own, used the call light. Looking at the medical record found the patient had been given a sleeping pill and pain medication at 2200, the same as the previous night. The patient doesn’t regularly take either a pain or sleeping pill at home.

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At 2330, the nurse checked the patient to do vital signs, found her dozing but easily arousable although a little confused when first awakened. The unit became busy as they just received a fresh surgical patient post operatively.

At 2345, a nurse walking by the room heard a noise and went to investigate. She found the patient on the floor and called for help. The patient had been incontinent of bed and gown, the floor was dry. They had to move furniture in the room to get at patient as there were extra chairs in the room after her family visited that evening. Her oxygen tubing was wrapped around her IV pump. The physician came immediately and assessed the patient. X-rays were ordered and the patient was taken to x-ray. The x-rays revealed a hip fracture. Orthopedics saw the patient and scheduled her for surgery the next day. She was prepared for surgery and sent the next day.

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Question 1 of 4

What are some questions that the team investigating this adverse might want to ask as they investigate?

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Responses will vary, but some potential questions include:

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• Was the call light within reach for her to push the button for the nurse?
• Were her slippers by the bedside (a must when a patient gets out of bed?
• Was some type of night light on for her to see?
• How close was her room to the nurses’ station so that if she called out she could have been heard?
• Was she taken to the bathroom before receiving the medications?
• Was she on a diuretic for the CHF that made her need to go to bathroom in a hurry?
• Had she been getting up on her own throughout the day without assistance?
• Was the O2 tubing “kinked” causing less oxygen and lead to her being confused?

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Question 2 of 4

What were the biggest patient safety risks based on the information available?

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Responses to this question will vary, but some key points to have included are:

• Extra chairs not being cleared away after family visit.
• The sleeping pill and pain medication were not a normal thing for the patient.
• Sleeping pill given with a pain medication making patient confused.
• Oxygen tubing being too long and getting tangled.

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Question 3 of 4

Choose one of the patient safety risks you identified in the previous question. How did that risk factor contribute to the adverse events in the scenario? 

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This question will depend on your previous response. However, one example could include (Note: The key point here is to be able to justify how the risk factor contributed):

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• The extra chairs not being cleared away after the family visit seems to have been a primary contributing factor to the fall by the patient. The scenario describes the chairs needing to be moved to reach the fallen patient.

Other ideas include, but are not limited to:

• Not recognizing risk of combining a sedative with a pain pill. Both are central nervous system depressants.
• No call light within reach.
• Lack of a bathroom schedule.

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Question 4 of 4

What is one evidence-based solution or strategy that could help mitigate the risk factor(s) you have identified?

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Answer will vary. An example response based on the falls risk factor(s) 

• A 2010 study conducted by Oliver and a number of colleagues found that in-depth patient education and reducing sedative medication were effective ways to reduce fall rates. Within the context of this scenario, maybe the patient could have been given a lower dosage of a sleeping pill and/or more thoroughly educated about the potential for disorientation were she to try and get up.
  Oliver, D., Healey, F., Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clinical Geriatric Medicine, 26(4), 645-692.

Other potential ideas include, but are not limited to:

• Implement a Morse Fall Risk Scale to assess the patient’s potential of falling.
• Use a bed alarm that goes off when she gets out of bed.
• Regular rounds to check on patient, O2 tubing, call light, status, etc.

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The ability to identify safety risks and potential solutions is essential to providing quality care.

Reference:
Minnesota Department of Health. (2019). Case study: Fall. Retrieved from: https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/docs/5fall_casestudyrev101513.pdf

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Enhancing Quality and Safety

The cardinal goal of nursing is the provision of safe and quality care services. It is however noteworthy that this is not always achieved due to various factors that result in incidents related to patient safety such as patient falls and medication errors.  In the US, patient falls are the most common causes of non-lethal injuries to people over 60 years. Patient falls may occur as a result of medication errors, patients attempting to move around, or some other diseases acquired | PLACE YOUR ORDER NOW AT writtask.com | factors leading to patient falls, evidence-based practice solutions to the problem with an emphasis on medication administration, and the role of nurses in coordinating care to increase patient safety with medication administration and cost reduction will be explored. Besides, stakeholders with whom nurses will coordinate to drive safety enhancements with medication administration will be identified.

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