Question

In acute care, a charge nurse is assigned to oversee a unit, and a nursing supervisor oversees the nursing role across a facility. All work together to control the flow of patients in and out of the unit and facility, make staffing assignments, and assist with problems and crises.

Consider this situation: A nurse is dealing with a crisis for one patient and misses a second patient crisis--a young woman who died from a postoperative hemorrhage. In this tragic situation, competing crisis events on the unit prevented a nurse from adequately monitoring other assigned patients on the unit.

The charge nurse and nursing supervisor stated in the Board of Nursing's investigation of the event that they depended on the individual nurse to alert them if help was needed.

Question: Discuss systems-based solutions that could have prevented this event.

Answer 1

Question: Discuss systems-based solutions that could have prevented this event.

Staffs Response and escalation :

• Assigned staff could have responded as the patient assignment failed to deliver proper care due to severity in patient conditions.
• Early escalation of the situation to the charge nurse on duty for reallocation,extra help or experts to manage the situation.
• staff should discuss with the charge nurse on duty for clarifications and the need of extra training or competencies based on her difficulties.

Leadership assesment and escalation:

• Charge nurse could have assesed the patient status and ward status and reassigned the patients as a proactive management.
• if charge nurse failed to finout or reallocate staff ,then could have escalated to supervisor oncall for extra help.
• Charge nurse should reassess the staffs ability of handling critical situations and decide whether she need extra inservice educations or competencies in developing the skill.

Supervisor Role :

• supervisor should asses the ward sitation and patient acuity.
• Reallocate the staffs from other units for extra help.