One of the primary goals of nursing is safe and efficient patient care which may be achieved by competent assessment and communication. Lewis Blackman’s circumstance illustrates the consequence of ineffective nursing communication and poor sufferer safety by violating American Nurses Connection (ANA) Specifications of Practice and Performance and ANA Code of Values. The Commence of Medicine (IOM) has presented guidelines in 3 studies that along with suggested practices and I-SBAR provides guidelines to boost patient safety.
A15 year-old- boy, Lewis Blackman, came to Medical University or college in South Carolina (MUSC) to get an optional surgery to get a chest condition (Monk, 2002). Postoperatively, Blackman was put on Toradol for pain which can cause belly ulcers and needs close monitoring. Due to ineffective assessment and communication, Blackman dies from a punched ulcer.
The ANA Standards of Practice and Performance plus the ANA code of ethics will provide recommendations to analyze the mistakes made by the healthcare professionals in Blackman’s case.
Blackman’s case shows guidelines in ANA normal of practice of assessment and normal of overall performance of communication that were not really met. Evaluation is how the registered nurse collects comprehensive info of the affected person (ANA, 2010). Efficient assessment was not obtained in Blackman’s case because early correct vital signs were not examined. Nurses are required to incorporate individual assessment, data collection, supporting, and spotting symptoms to make decisions in an regular assessment to improve patient attention (Voepel-Lewis, 2006).
Nursing communication has to be successful for individual care to get achieved, that was a downfall in Blackman’s case (ANA, 2010). Blackman’s case demonstrated poor connection between nurses and the doctors due to variations in data and poor handover communication along with poor communication involving the nurse plus the patient as a result of misguided details. In Blackman’s assessment, the nurses recorded a heartrate of 126 while the doctor documented 70, this misunderstanding led to the death of Blackman. Doctor-nurse communication and collaboration gives positive individual outcomes (Torppa et approach., 2006). The nurse and patient connection was unaccomplished because the doctor didn’t gain the trust of Blackman’s mother. Nursing staff initiate dialogue, target the topics intended for consultation, and take the role in caring for the patient (Torppa ainsi que. al, 2006). Assessment and communication from the health care providers and health care people must be efficient for individual care to happen.
The CHOIX Code of Ethics evaluates the healthcare professionals in Blackman’s case. In Provision three or more nurses promote, advocate, and strive to protect the patient and correct ineffective nursing patterns (Towney, 2008). In Blackman’s case, the nurses weren’t preventing harm because the affected person was not frequently monitored. The advantages of frequent monitoring and assessment can identify postoperative complications (Voepel-Lewis, 2012).
In Provision 4 the nurses are in charge of and dependable, accountable nurse are responsible and liable for optimum patient care (Badzek, 2008). During Blackman’s assessment, the nurses were irresponsible mainly because they were unaccountable for rendering correct assessment and interaction in Blackman’s case. Rns are supposed to always be the patients’ advocates (Torppa et al., 2006).
The IOM has reported that health care is doing more harm than the system will need to allow. Inside the three IOM reports, recommendations are given to assist prevent foreseeable future patient damage from medical system mistakes.
The IOM report To err is Human emphasizes that problems get from defective systems, procedure, and circumstances that business lead nurses to generate unpreventable mistakes (Kohn, 2000). In Blackman’s case, the hospital’s system was flawed, the doctor-nurse relationship was poor, as well as the nurse-patient relationship trust was never received. The need to raise standards, implement safety, and identify mistakes is important for future advancements (Kohn, 2000). After Blackman’s death, adjustments were executed at the MUSC to better the hospital’s program including the prohibited use of Toradol in pediatrics.
Crossing the coffee quality Chasm determines challenges that occur in health care: overuse (where harm exceeds benefit), underuse (absence of service), and misuse (preventable injury occurs) (IOM, 2001). Health care professionals need to strive for safe, powerful, patient-centered, well-timed, efficient, and equitable look after providing to get the patient (IOM, 2001). In the event that these desired goals were gained during Blackman’s case, that wouldn’t have taken the nursing staff 31 several hours to realize Blackman’s symptoms had been fatal. The nurses would have been able to advocate pertaining to Blackman fantastic safety may have been the nurses key priority.
Keeping Patients Secure illustrates monitoring patient wellness status, performing correct treatment options, and applying patient care as nursing duties that directly keep the patient safe (Page, 2006). Patient protection can be ascertained if nurses are becoming educated to avoid skill spaces (Page, 2006). In Blackman’s case the nurses reported him of obtaining gas discomfort and dramatic fever decrease as recovering signs whilst Blackman’s health was declining. Assessment education could have prevented Blackman’s death.
As a upcoming registered nurse I would personally have prevented this situation utilizing the communication application I-SBAR. I-SBAR is an acronym to get handovers, patient information, by nurses to doctor s i9000 that states patient’s situation and background the nurse’s assessment and recommendations (Wacogene, 2010). While Blackman’s nurse, I would have got stated to the doctor, “Hi my name is Caitlin Endly, Now i am an REGISTERED NURSE on the malignancy ward phoning about Lewis Blackman whose chief complaint is stomach pain. Patient is a15-year-old male post op from recent torso surgery and is on Toradol to control his pain. I am struggling to obtain his blood pressure, heartrate is ninety-six beats per minute, pallor, ridged abdomen, and it is having a seizure. I think he may have blood in his stomach due to a perforated ulcer. I need you to come see him STAT. ” I might have supplied an early efficient assessment and communication to stop future harm to Blackman.
Blackman’s case is one of the man y hospital program mistakes that are performed each year. His case could have been prevented if efficient utilization of assessment and communication suggestions were obtained which were provided by the SPICILÈGE and IOM. The use of I-SBAR would have preserved Blackman’s existence by communicating to the doctor and expediting patient treatment. In the future, rns need constant education regarding assessment and communication skills along with annual review of the health treatment system to stop a healthy 15 year old son’s death.
