Question

Concept: Safety:

Nurse Sarah has received an admission of a 70-years-old male patient. As reported by his son the patient became confused uttering irrelevant words and suddenly became unaware of his surroundings for the past 24 hours. The patient had suffered a stroke 3 months ago leaving him with slurred speech, left-sided weakness, unsteady gait and for that, he uses a cane for walking. The nurse kept Mr. Salim in bed, checked his vital signs, and placed an identification band labeled as Hashim, 60-years-old with a hospital number 926478. Nurse Sarah left the room with side rails down and bed elevated high from the floor with dim lights on. Confident that his son will be around all the time to watch over Mr. Salim. Minutes have passed; she heard a loud bang on the floor. She ran to the room and found Mr. Salim alone on the floor with a big hematoma in his forehead. His son went to get
tea. Sarah was likewise busy assigned to another high dependency patient who has had several urgent nursing procedures. She was responding to that patient at that time of the incident.

1. Specify three factors that have caused Mr. Salim to fall, state measures that could prevent this incident
from occurring.

2. In your own words identify what has placed Mr. Salim at risk of being a victim of medical error and
describe the reasons behind.

3. Give another example of a medical error that can happen to Mr. Salim.

4. Define risk assessment and explain how it would be helpful in the above scenario.

Answer 1

Que no 1:

In this scenario some factors that caused patient to fall down.

• The first risk of fall is, the side rails of the bed is down.

Side rails always want to up if patient is on bed. It is the most common cause of fall. Nurse must do the frequent rounding.

• On admission patient relative reported that he is walk with help of cane and oneside paralysed. Here the nurse donot provide any instructions or any callbells to use during any emergency.

The nurse must give some instructions about surroundings and must give call bell to use during emergency.

• The one factor is that nurse provide dim lights on his room and bed hight kept high and not give any instruction to his relative.

The nurse must provide visibile location to the patient and do not keep bed in high position.the nurse must instruct the patient relative about the risk of fall.

Que no 2:

Here medication error occuring due to wrong identification band provided to the patient.

Before giving medication to the patient first step is to identify the patient with his id band and inpatient file.hospitals there os the chance of same name with two or more patients.if the records wrong there is the chance of medication error and patient getting wrong treatment .so provide identification band with correct name and age.before giving any medication identified the patient correctly and check physician order to avoid medication error.

Que no3:labelling of medications with wrong details.shift changing is the most common reason of this errors. It will lead to wrong administration of medication to wrong patients.

The staff should nt check the room no or bed no. Must check the id band with correct details.

Avoid leading the patient when asking the identifiers-do some open ended questions like pls tell me your name.

Have protocols in place for patient in the same unit with same names. Be sure that alternate identifiers available for in this case.

Que no 4

In this scenario assess risk for fall and medication error.

1.In case of fall risk assessment screen the patient

• Any history of fall with in the past year
• Orthostatic hypotension
• Impaired mobility or gait
• Use of assistive device

2.During admission provide an idea about new surroundings and provide call bell to the patient.

3.Side rails should be up when patient is on bed

4.Do frequent rounds

5.Check the patient footwear and clothing.

6.Provide the room with well lightening anf non slippy floors.

Medication error, most common cause is wrong identification.

1.First step before administering medication is identify the patient. Provide correct and accurate information on id band.if patient having same names follow the protocols.

2.Should nt give medication according to room no or bed no.

3.Give medications with double checking.

4.Check the physician order with correct dose, route, frequency etc.