What are the most appropriate ways that a nurse can promote safety for a patient

In a busy pediatric ER at the end of a grueling 12 hour shift, a nurse and a physician were caring for an 18 month old, severe asthma patient. The patient had failed inhalation and epinephrine treatment and required admission. Because there were no beds available on the floor, the team had planned to start his IV theophylline drip in the holding area.

When calculating the weight-based dosage, the fatigued physician missed a decimal point and made one of those proverbial ten-fold errors in the order. The nurse caught the mistake and corrected it, preventing a potentially lethal overdose.

Near-misses like this one happen in hospitals every day. Nurses play a big role in making sure patients like this one are kept safe from harm. They are the largest segment of the U.S. healthcare workforce and are vital to keeping patients of all ages safe in our hospitals, physician offices, ambulatory surgery centers, and other facilities.

Are you empowering yours with the right tools and support to do the following?

1. Identify “wrong site, wrong procedure, wrong patient” errors

High quality hospitals view nurses as the physician’s partner in avoiding errors such as these. In the wake of the Institute of Medicine’s To Err is Human report, a myriad of quality and safety initiatives were implemented in America’s hospitals, and many of could not function optimally without nurse involvement. Nurses are that “second pair of eyes” that supports physicians and the rest of the care team in these efforts.

2. Catch medication mistakes

This is especially important in the hospital environment as patients are transferred from floor to floor and discharged. The nurse’s role in medication management is so important most inpatient floors have “quiet” stations for nurses to do this work uninterrupted. And, in the physician office setting, nurses are often part of the medication reconciliation process too, during which they check for drug interactions and therapeutic class duplications and inform the physician of potential errors when he or she enters the exam room.

3. Educate patients about their medications

Improper usage and non-compliance with medication regimens are major stumbling blocks to getting patients well and keeping them safe from harm - especially for those who have chronic conditions, and the elderly who may be on ten or more medications. Nurses are often the member of the care team best equipped to explain and motivate patients to pick up, refill, and take their medications as prescribed. Often this requires multiple communications or interventions with the patient. Nurses also answer patient follow up questions about medications, and manage communication with caregivers and family members.

4. Reduce patient falls

Falls are a leading cause of death in older Americans.[1] And falling once makes people twice as likely to fall again.[2]

In the inpatient setting, nurses are trained to follow a number of precautions that reduce the risk of falls while ambulating patients. They are on hawkeye watch for unsupervised patients, tripping hazards, and managing the turning and toileting needs of patients too ill or weak to care for themselves. Nurses are also excellent educators in discharge planning and the physician office setting, providing tips and safety sheets for senior patients and their caregivers about removing throw rugs, installing handrails, and other fall reduction tactics.

5. Monitor patients for deterioration

Physicians can’t be in two places at the same time. We count on members of the care team to watch patients for signs of clinical deterioration in both inpatient and outpatient settings. Nurses in particular help us monitor suspicious post-op incision sites, a diabetic’s wound that isn’t healing, the downhill progression of an elderly patient who can’t seem to shake her pneumonia, and the child whose mild rash has worsened. 

So, three cheers for America’s nurses. They are often unsung heroes when it comes to to patient safety. But they are invaluable when it comes to delivering it.

You might find this infographic about the future of nursing useful for planning purposes. It’s based on data from the National Academies of the Sciences, Engineering and Medicine.

[1] https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html

[2] https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

Since professional nursing began in the late 1800s the mission to provide the highest quality of care, focused on patient health and safety, has remained the same. Queensland Health has a strong commitment to a safe and patient-centred health care system. Our nursing staff are a vital component in ensuring the delivery of that high quality health care. Here are three ways nurses and nurse leaders can enhance hospital patient safety to support this goal.

1. Ensure a thorough discharge procedure

During a hospital stay, nurses not only have substantially more control over a patient’s compliance to their treatment but can also more readily answer questions about their care. This helps prevent the patient (and their family) from making incorrect assumptions about the appropriate ways to treat their condition, which can slow down recovery.

However, once the patient leaves the hospital, nurses can only do so much to ensure the patient is properly following instructions. To avoid unnecessary readmissions, nurses should work with hospital administrators and other members of the care team to develop a comprehensive discharge process that includes a simple, easy-to-understand plan. The discharge plan should include the following:

• A record of upcoming appointments
• Description of medications - for example, what each looks like (in case a pill or tablet falls out of a bottle) and potential adverse reactions
• Medication schedule (including frequency, dosing, which medicines are new or discontinued and any dosing changes)
• Names and phone numbers of whom to contact should the patient or the patient’s family have questions

2. Encourage patient participation in handover

Handover is a high risk communication process, with miscommunication being the second leading cause of sentinel events in hospitals. Active patient participation in handover is increasingly advocated as a vital strategy to improve the safety and quality of health care. Patients value bedside handover, wanting the opportunity to access information and meet their nurse, but it does not always occur.

A 2017 survey (QNMU InScope, Autumn 2017) investigated patients’ and nurses’ preferences for bedside handover and the perceived barriers surrounding it. 400 patients and 200 nurses were surveyed at hospitals in Queensland and Victoria. Both nurses and patients agreed that the most important aspect of bedside handover was active patient participation, where the patient listens, asks questions and speaks up. However nurses identified three main barriers to bedside handover.

1. They were concerned about patients and third-parties hearing sensitive information. Nurses expressed a strong dislike for disclosing sensitive information quietly at the bedside. A more accepted preference for nurses was to point to written sensitive information during handover.
2. They thought patients, family members and other nurses disrupted the flow of information. For patients, however, having a family member, friend or carer present was very important, and may encourage more participation and comprehension, particularly when concerning medciated, sedated or distressed patients, or where language is a barrier.
3. Individual patient and nurse views or capabilities were thought to impact the efficacy of bedside handover.

There is no one-size-fits-all approach. Patients are unique in terms of their conditions and preferences. Both groups want patients to be invited to actively participate in bedside handover. It’s important to use clinical judgement and check with patients to see how they want bedside handover to happen.

3. Use help from support staff

Unlicensed assistive personnel (UAP) can be a blessing for overworked nurses. From recording vital signs to documenting the care administered to assisting with ambulating patients, UAPs can handle many minor tasks associated with patient care, allowing the nurse to focus on the major aspects of the patient’s treatment.

Rather than worrying about whether a specimen was collected for a particular diagnostic test or if the patient has received a sponge bath, the nurse can concentrate on how the patient has responded to the latest dose of medication, evaluate improvement or deterioration in the patient’s condition and ensure no warning signs are overlooked. While UAPs are an important resource, it is the responsibility of the RN to ensure the tasks a UAP performs are appropriate for their level of training. Whether RNs and UAPs can work together as a team is clearly a product of the relationship they share, and trust is central to effective RN and UAP relationships. Risk factors to consider before delegating an activity to a UAP include:

1. Potential for harm to the patient
2. Condition or stability of the patient
3. Complexity of the task
4. Required problem-solving or innovation skills
5. Predictability of outcome
6. Level of patient interaction required to successfully complete task

These ideas are by no means exhaustive, and there are dozens of additional ways nurses can improve patient safety, including using the resources of the Qld Health Patient Safety Unit, clinical guidelines and procedures, however, considering these concepts adds to existing practice around patient safety and can help to improve patient-centred health care.