Question

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.

Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?

2. As a team leader, how would you use this event to promote safety education with staff?

3. What recommendations for change would you make to improve a culture of safety at the LTC facility?

4. What professional safety standards, guidelines and laws should the staff know to ensure high quality care for this patient?

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.

Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?

2. As a team leader, how would you use this event to promote safety education with staff?

3. What recommendations for change would you make to improve a culture of safety at the LTC facility?

4. What professional safety standards, guidelines and laws should the staff know to ensure high quality care for this patient?

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.

Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?

2. As a team leader, how would you use this event to promote safety education with staff?

3. What recommendations for change would you make to improve a culture of safety at the LTC facility?

4. What professional safety standards, guidelines and laws should the staff know to ensure high quality care for this patient?

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.

Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?

2. As a team leader, how would you use this event to promote safety education with staff?

3. What recommendations for change would you make to improve a culture of safety at the LTC facility?

4. What professional safety standards, guidelines and laws should the staff know to ensure high quality care for this patient?

Ms. Reid is a resident from a long-term care facility who recently had a minor surgical procedure done at the hospital. Prior to surgery, Ms. Reid was ambulatory and somewhat self-sufficient. Upon return to the home, the evening nurse reads the report from the hospital which contains the following information: Vital signs, condition of surgical dressing (on left hip), and reports that the patient has been eating well. Ms. Reid is alert upon arrival.

During the night, Ms. Reid falls when walking to the bathroom. When you come in for the morning shift you are concerned that Ms. Reid is not able to walk as she was before the surgery. There are no notes about her change in status on the chart or in the shift change report.

Using course material and other relevant resources, including Best Practices and Leadership actions and standards, provide a meaningful answer to the following:

1. What was the adverse event in this case? Why did it occur?

2. As a team leader, how would you use this event to promote safety education with staff?

3. What recommendations for change would you make to improve a culture of safety at the LTC facility?

4. What professional safety standards, guidelines and laws should the staff know to ensure high quality care for this patient?

Answer 1

The adverse event in this case is Ms. Reid fell down when walking to the bathroom during the night time and she was also unable to walk as she was before the surgery. This adverse event happened as she fell down in the bathroom might caused her unable to walk.

I would advice by evidence based education , public education and healthcare advocacy by using this incident as an example.Also the way of communication with the patient should also got influenced in a way that the nurses should be friendly and also should provide necessary education to the patients so that they can be preventive in all aspects.I would educate the nurses to support and promote the establishment of trauma care systems. I would promote the injury prevention through education of the public,media and state and federal legislators.

I would improve the Long term care settings by the following ways:

Strategies to Improve Safety in LTC Settings

1. Strategies to Improve Communication.  

1) Establish best practice guidelines

for front line staff , around eff ective

communication with families. 2) Provide

education related to leadership development

for management. 3) Establish concerns

and resolutions processes involving

management and families. 4) Present the

concerns resolution process to families

upon admission, and on an ongoing basis.

5) Social marketing and health care, geared

towards our audience and customers. 6)

Develop policy and education for staff on

appropriate disclosure. Other strategies

identifi ed to address communication

include encouraging communication with

other organizations and jurisdictions to

share strategies that have worked for them;

establishing processes for communication

that ensure continuity of care, especially

in transitions; including family in

conferencing; and using technology

strategically to aid in clear and eff ective

communication. Examining whether

eliminating shift overlap impacts safety

and continuity of care was also suggested.

It was noted that communication between

residents and staff is enhanced when

staff work with the same residents for

long periods of time, therefore, consistent

staffi ng patterns where the same staff work

with the same residents could improve

communication

2. Strategies to improve staffing and human resources

Many strategies identified to

address staffi ng/human resource issues  

revolved around leadership. The importance

of leaders in the creation of a culture of

safety was stressed. One strategy is to

reduce the scale of the responsibilities

of managers by increasing the number of

managers so that they can interact with,

encourage, empower, and mentor their

staff . This would not only reduce workload,

but could also aff ect the job satisfaction

of staff and the managers themselves.

Competencies leaders should possess

were identifi ed as being supportive of

transparency and reporting, the ability

to deal with the fear of disclosure, and

understanding assessment, best practices,

continuous quality improvement, the

quality and safety agenda and the resident

assessment instrument. Mentorship programs, where leaders can receive support

in real life situations, were suggested.

Training and leadership development are

required for management so that they have

the competencies of leaders who ensure that

the safety agenda is explicit and who are

committed to facilitating a culture of safety.

Learning how leaders can best be supported

is important. Resources must be devoted to

building leadership capacity at all levels of

staff and throughout their organizations.

The staffs should know the professional safety standards, guidelines and laws as I mentioned above to ensure high quality care for this patient.