According to what you learned from chapter 3 critique the documentation presented by the healthcare provider and provide examples of whether the nurse follows or did not follow documentation requisites.
Write a paper between the 300-word minimum and 500-word maximum.
Use APA format
Three references. Each reference must be published within the last three years. The textbook can be one of your references.
The purpose of the National Patient Safety Goals is to improve patient safety. The Joint Commission established its National Patient Safety Goals (NPSGs) in order to help accredited organizations address specific areas of concern in regard to health care safety, and to focus on how to solve them. The Joint Commission determines the highest priority patient safety issues and also whether a goal is applicable to a specific accreditation program and subsequently tailors the goal to be program-specific.The following define and explain the 2018 National Patient Safety Goals and corresponding Elements of Performance (EPs) that apply particularly to…Hospitals
Behavioral health
Home care
Ambulatory health care
Critical access hospitals
Identify patients correctlyNPSG.01.01.01: Use at least two identifiers when providing care, treatment, or services. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.Rationale: Wrong-patient errors occur in virtually all stages of diagnosis and treatment. It is important to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual.Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital
NPSG.01.03.01: Eliminate transfusion errors related to patient misidentificationApplies to hospital, ambulatory health care, critical access hospital
Improve the effectiveness of communication among caregiversNPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basisRationale: Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. Providing the responsible licensed caregiver these results within an established timeframe will allow the patient to be promptly treated.Applies to hospital, critical access hospital
Improve the effectiveness of communication among caregivers.NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.Rationale: Develop written procedures for managing the critical results of tests and diagnostic procedures.Applies to hospital
Improve the safety of using medications.NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.Note: Medication containers include syringes, medicine cups, and basinsRationale: Medications or other solutions in unlabeled containers are unidentifiable. The labeling of all medications, medication containers, and other solutions is a risk-reduction activity consistent with safe medication management.Applies to hospital, ambulatory health care, critical access hospital
NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.Rationale: Anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance. The use of standardized practices for anticoagulation therapy that include patient involvement can reduce the risk of adverse drug events.Applies to hospital, ambulatory health care, critical access hospital
NPSG.03.06.01 Maintain and communicate accurate patient medication informationRationale: There is evidence that medication discrepancies can affect patient outcomes. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future.Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital
Reduce the harm associated with clinical alarm systemsNPSG.06.01.01: Improve the safety of clinical alarm systemsRationale: Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety.Applies to hospital, critical access hospital
Reduce the risk of health care-associated infectionsNPSG.07.01.01: Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.Rationale: According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations.Applies to hospital, behavioral health, home care, ambulatory health care, critical access hospital
NPSG.07.03.01: Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.Rationale: Patients continue to acquire health care–associated infections at an alarming rate. Risks and patient populations, however, differ between hospitals. Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment.Applies to hospital, critical access hospital
NPSG.07.04.01: Implement evidence-based practices to prevent central line–associated bloodstream infections.Applies to hospital, critical access hospital
NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infectionsApplies to hospital, ambulatory health care
NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).Prevent patients from fallingNPSG.09.02.01: Reduce the risk of falls.Rationale: Falls account for a significant portion of injuries in hospitalized patients, long term care residents, and home care.Applies to home care, critical access hospital
The hospital identifies safety risks inherent in its patient populationNPSG.15.01.01: Identify patients at risk for suicide.Rationale: Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event.Applies to hospital, behavioral health
NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires.Rationale: A critical aspect of safe patient care at home relates to the use of oxygen. Oxygen administration presents a high risk for fire due to the acceleration of flame that oxygen causes in the presence of flammable substances (such as upholstery and clothing) and open flames (such as candles, gas appliances, and smoking materials).Applies to home care
The hospital identifies safety risks inherent in its patient populationUP.01.01.01: Conduct a pre-procedure verification process.Rationale: Hospitals should always make sure that any procedure is what the patient needs and is performed on the right person. The frequency and scope of the verification process will depend on the type and complexity of the procedure.Applies to hospital, ambulatory health care, critical access hospital
UP.01.02.01: Mark the procedure site.Applies to hospital, ambulatory health care, critical access hospital
UP.01.03.01: A time-out is performed before the procedure.Rationale: The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are identified.Applies to hospital, ambulatory health care, critical access hospital
PowerPoint Week #3File
Case Study: Late and Later Documentation:The following is a case study in which documentation played a role in the practice breakdown of nursing care. The story is encapsulated for the reader with a sample of the actual documentation provided by the nurses involved. The reader is encouraged to question whether the documentation truly reflects the story presented. According to what you learned from chapter 3 critique the documentation presented by the healthcare provider and provide examples whether the nurse follow or did not follow documentation requsitesPRACTICE BREAKDOWN IN DOCUMENTATIONMs. Amy Jones was a 55-year-old woman being treated for depression at a mental health facility. She was alert, oriented, ambulating without difficulty, and interacting appropriately with staff. The patient’s family was scheduled for a meeting with her treatment team in the afternoon. During the day Ms. Jones met with her psychiatrist, Dr. Ian Smith, in Ms. Jones’s room. When her roommate came in, Dr. Smith suggested that they complete their session in his office, and Ms. Jones accompanied him to that space. On the way she complained that she felt weak but could make it. During the session she reported that she had a headache, which Dr. Smith attributed to anxiety. He went to look for a nurse to provide medication for Ms. Jones. On his return with Ms. Mary Sullivan, a registered nurse, Ms. Jones was on the floor on her knees vomiting. A physician working across the hall came and assisted Dr. Smith and Nurse Sullivan with Ms. Jones, who was now quite somnolent, into a wheelchair. Dr. Allen, the primary care physician, ordered that Ms. Jones be given Phenergan IM for the vomiting and that the nursing staff monitor her bowel sounds. Dr. Allen reported that she was not informed of Ms. Jones’ complaints of headache or loss of bowel control. Dr. Allen thought that she was dealing with gastrointestinal symptoms so she had the nurses check for bowel sounds and softness of the patient’s belly. She reports that she received a second callback and was told bowel sounds were normal, the patient’s stomach was soft, and the patient was resting comfortably. Ms. Jones was bathed and returned to her bed. She took the prescribed Phenergan after which she vomited several more times during that shift. She was incontinent of stool once. No one considered conducting neurologic checks because the staff thought Ms. Jones was suffering from a virus.When Ms. Jones’s family members arrived, the nurses advised them that their mother was sick and was sleeping, and would not be able to attend the meeting. The family members could not arouse the patient. The staff said that Ms. Jones had been administered Phenergan for vomiting and would be awake by evening. Family members returned that evening and found the patient still unresponsive with vomit in her mouth. The family checked Ms. Jones’ pupils and found them unequal. The family reported to the registered nurse at the desk, and another nurse checked Ms. Jones’ vital signs and reported them to be normal. The family telephoned Ms. Jones’ primary care physician, Dr. Allen, and the nurse gave him a report. Soon after this call, an ambulance transported Ms. Jones to the hospital for evaluation. Ms. Jones subsequently died at the hospital.Ms. Jones’ daughter stated that the registered nurse did not assess her mother; on arrival in the unit, the EMT assessed Ms. Jones. Ms. Jones’ daughter did not believe that her mother had been adequately monitored from noon to 6:30 PM. She also complained that the nurses were laughing at the family’s concerns about the condition in which they found their mother.Ms. Cherie Hoffman, a registered nurse, had been employed at the facility for 25 years. She began her career as a nursing assistant, a title she held for 7 years. She then served as a licensed practical nurse for 10 years and then as a registered nurse for the past 6 years. She was familiar with all of the policies and procedures of the facility. On the day of the event Ms. Hoffman was working as the charge nurse; she noted that it was a particularly busy day. She returned from lunch and was informed by Nurse Sullivan that Ms. Jones was ill and had vomited. She was bathed, and the staff had documented her vital signs, completed the Glucoscan, and medicated Ms. Jones with Phenergan per Dr. Allen’s order. The family was not notified of a change in Ms. Jones’ condition because they were expected for a family conference at 3 PM, and Nurse Sullivan hoped that Ms. Jones would feel better by then and could participate in the conference. Nurse Hoffman assisted Nurse Sullivan in monitoring Ms. Jones throughout the rest of the shift. Nurse Hoffman had understood that Ms. Jones had not been sleeping well and thought it would be good to let her sleep. Nurse Hoffman thought Nurse Sullivan had last assessed Ms. Jones at 7 PM.Nurse Hoffman states she was never informed that Ms. Jones had collapsed prior to vomiting or that she had a headache, or that Ms. Jones was somnolent after the episode. She reported that Ms. Jones had a history of headaches, nausea, and dizziness, all of which had been attributed to medications.Nurse Sullivan recalls reporting everything to Nurse Hoffman. Nurse Sullivan said she had checked bowel sounds as directed. Ms. Jones was incontinent of stool at 2 PM. and was bathed and repositioned. Around 6 PM. Nurse Sullivan straightened Ms. Jones in bed and said that Ms. Jones looked comfortable. Nurse Sullivan said that she did not feel anxious about the patient, as she thought Ms. Jones was sleeping. Ms. Jones was not on 15-minute checks, but Nurse Sullivan recalled checking on Ms. Jones frequently throughout the shift to assess for vomiting.Write a paper between the 300-word minimum and 500-word maximum.Use APA formatReferences must be published within the last three years. The textbook can be one of your references.
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Oct 3rd, 2022
