Table of Contents Cases of Ineffective Breastfeeding and Poor Patient SafetyANA Standards of Practice and Performance, Provisions 3 and 4 of the Code of Ethics the ANA. Institute of Medicine ReportsTo Err is Human: Building a Safer Health SystemCrossing the Quality ChasmEnsuring Patient SafetyTransforming the Nurse Work EnvironmentRecommended PracticesHow to Prevent This Situation Using I-SBARCConclusionNursing is based on effectiveness of communication and quality of patient safety. Nursing communication is how health care team members communicate patient needs by maintaining the accuracy of patient-centered decisions and patient safety by minimizing harm (Potter, 2013). This essay will focus on a case of ineffective nursing communication and poor patient safety. To guide the summary of this case, the American Nurses Association (ANA) Standards of Practice and Performance and the ANA Code of Ethics will be used to determine which guidelines were not followed. The Institute of Medicine guidelines, recommended practices, and I-SBAR will be used to determine which guidelines could have improved this case. Say no to plagiarism. Get a tailor-made essay on "Why violent video games should not be banned"? Get the original essay Case of ineffective breastfeeding and poor patient safety In November 2000, a 15-year-old boy, Lewis Blackman, arrived at the Medical University of South Carolina (MUSC) to address his condition, pectus excavatum. Postoperatively, Lewis was placed on Toradol for pain that could cause stomach ulcers and required close monitoring, but due to ineffective assessment and communication, Lewis died of a perforated ulcer (Monk, 2002) . The ANA Standards of Practice and Performance and the ANA Code of Ethics will be used to further discuss which guidelines were not followed and which would have prevented future harm to patients. ANA Standards of Practice and PerformanceLewis Blackman's case identifies the ANA's standard assessment of practice and communication standards. performance guidelines are not met. Assessment is how the registered nurse collects comprehensive data about the patient (ANA, 2010). An effective assessment was not performed in Blackman's case because the nurses did not collect accurate data at the beginning and did not report this data to the doctor. Nurses were expected to implement early assessment to improve patient care (Voepel-Lewis, 2006). Nurses failed to communicate information to health care consumers and the professional team (ANA, 2010). During Blackman's evaluation, the nurses documented a heart rate of 126 while the doctor documented 80, this miscommunication was fatal. Doctor-nurse communication produces positive outcomes for patients, which was not the case for Blackman. (Torppa, 2006). Provisions 3 and 4 of the ANA Code of Ethics. The ANA Code of Ethics analyzes nurses in Blackman's case. In Disposition 3, nurses promote, advocate, and strive to protect the patient and correct ineffective nursing behaviors (Fowler, 2010). In Blackman's case, nurses failed to prevent harm because the patient was not frequently monitored. The need for frequent monitoring and evaluation can detect postoperative complications(Voepel-Lewis, 2012). In provision 4, nurses are responsible for providing optimal nursing care (Fowler, 2010). A charge nurse knows the tasks for which she or he is responsible for a patient (Fowler, 2010). In Blackman's evaluation, nurses were not responsible for their correct judgment and irresponsible for patient safety. Nurses are supposed to be patient advocates and not the other way around (Torppa, 2006). IOM, 1999). In IOM reports To Err is Human: Building a Safer Health System, Crossing the Quality Gap and Keeping Patients Safe: Transforming the Work Environment for Nurses provides guidelines that help prevent harm future losses to patients due to errors in the health system. To Err is Human: Building a Safer Health System The problem arises from faulty systems, processes, and conditions that lead nurses to make errors or be unable to prevent them (Kohn, 2000). In Lewis's case, the hospital system was flawed; the doctor-nurse relationship was poor and the relationship between nurse and mother was not respected. The need to raise standards, implement security and identify errors is very important for future improvements (Kohn, 2000). After Blackman's death, changes were implemented at MUSC, including the banned use of Toradol in pediatrics. Crossing the quality chasm The challenges that arise in health services are overutilization (where harm outweighs benefits), underutilization (lack of service), and misutilization (preventable injury). occurs) (IOM, 2001). We must aim for safe, effective, patient-centered, timely, efficient, and equitable care in providing patient care (IOM, 2001). If these goals had been pursued in Blackman's case, it would not have taken 31 hours for nurses to realize that his symptoms were life-threatening, nurses would have been Blackman's advocates, and patient safety would have been the top priority. . Ensuring Patient Safety Transforming Nurses' Work EnvironmentMonitoring the patient's health status, performing correct treatments, and using patient care are nursing tasks that directly ensure patient safety (Page, 2006). Patient safety can be ensured if nurses are trained to avoid skill deficits (Page, 2006). In Blackman's case, nurses reported gas pain and a dramatic reduction in fever as signs of recovery as Blackman's health deteriorated. Assessment education could have prevented Blackman's death. Recommended Practices Blackman's case is preventable with changes to postoperative pediatric assessment and patient-doctor-nurse communication. The ANA assessment standard of practice showed how ineffective nurses were in taking Blackman's vital signs. Nurses must integrate patient assessment, data collection, assistance, and symptom recognition to make decisions in continuous assessment (Voepel-Lewis, 2012). Patient-doctor-nurse communication is vital for patient safety. Blackman's case showed poor communication between nurses and doctors due to differences in data and poor communication between handoffs. Communication between nurse and doctor should be clear for effective patient care (Diwakar, 2010). Communication between nurse and patient was unsuccessful because the nurse did not gain the trust of the mother.