A case study on ineffective nursing communication and poor patient safety

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A case study on ineffective nursing communication and poor patient safety

Poor nursing communication causes needless hospital injuries and deaths Nurse-doctor communication is such a problem that the Joint Commission on the Accreditation of Healthcare Organizations requires all hospitals to create policies and procedures to improve nursing communication of critical lab values June 21, When a patient is admitted to a hospital one of the most important factors for achieving treatment goals is competent nursing care.

For nurses to be able to fulfill this role, hospitals must be serious about their role to hire only qualified nurses and then to use proper testing and assessment to ensure that those nurses have the skills to take care of particular types of patients.

In other words, to meet its responsibility under the law, a hospital must have policies and procedures in place to ensure that all of the nurses it hires demonstrate competency in certain basic skills before they are assigned to care for patients independently.

These skills include things like medical record documentation, and taking blood pressure and pulse. But then the hospital must also have policies and procedures to verify unit-specific competencies, in addition to the general skills demonstrated at hiring. For example, nurses hired to work on a labor and delivery unit need different skills from nurses who work on a neurosurgery unit.

And once the general and unit-specific competencies are in place, the hospitals must provide charge nurses, a nurse executive, and other experienced nurses to supervise the bedside nursing care.

Clinical competence is just one of two prongs needed, though, for nurses to fulfill their part of the nurse-physician team effort—the other is communication. Study after study has shown that poor communication leads to a shocking number of avoidable hospital injuries and deaths.

In fact, the organization that accredits hospitals, the Joint Commission on the Accreditation of Healthcare Organizations JCAHO realized that communication was a major problem that required nationwide correction.

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JCAHO conducts surveys of hospitals on a regular basis and publishes standards that hospitals must meet in order to receive accreditation.

InJCAHO used the National Patient Safety Goals to tackle communication problems head-on, specifically as they relate to communication and handling of critical lab results. Before getting into the new JCAHO standards, let me share two real-life examples of the critical lab value communication problem from two Memorial Hermann hospitals in Houston.

Hyponatremia low serum sodium level is a very serious, life-threatening condition for post-neurosurgical or head trauma patients. In one case, a patient who had undergone a craniotomy to drain a brain abscess was on a general floor.

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A serum sodium level of was returned by the lab, but the nurses did not communicate it to the physicians. Similarly, a second sodium lab value came back atand no physician was notified. As a result, there was a delay in treatment and the patient now has a permanent, severely disabling brain injury.

A case study on ineffective nursing communication and poor patient safety

In another case, a patient sustained a head injury when he fell off a horse. His serum sodium level fell to critical lab values, but the nurses did not notify a physician.

When the repeat lab came back with a critical lab serum sodium lab value, the nurses notified no one, and the patient ultimately developed a permanent brain injury.

When hospitals do not assess the competency of their nurses, and nurses do not communicate key findings to a physician, there are serious consequences that can lead to avoidable patient injury and death.

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Patient Safety and Quality Healthcare. SUBSCRIBE to the PSQH e-Newsletter: 17% of the nursing staff felt that poor reporting and communication were barriers to efficient patient care. using real patient case studies to discuss the evaluation, differential diagnosis, and plan of care from both the medical and nursing perspective.

communication will direct targets for communication-related patient safety improvement. Background The burden of harm from patient safety events pervades the health care system and is directly.

A case study on ineffective nursing communication and poor patient safety

Search and browse our historical collection to find news, notices of births, marriages and deaths, sports, comics, and much more. Report prepared for Patient-clinician communication What is the impact of ineffective/poor communication on patient outcomes and Our report brings together studies that conceive of communication in a variety ofcaltheoreti.

This Patient Safety Primer will discuss methods of improving communication between clinicians in the context of routine patient care and emergency situations. Issues involving communication between clinicians at times of transitions in care are Understanding Communication: Case Studies for Physicians.

Hannawa AF, Wu AW, Juhasz RS, eds.

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