IndexCase of Ineffective Nursing Care and Poor Patient SafetyANA Standards of Practice and PerformanceProvisions 3 and 4 of the ANA Code of Ethics. Institute of Medicine ReportsTo Err is Human: Building a Safer Health SystemCrossing the Quality ChasmKeeping Patients SafeTransforming Nurses' Work EnvironmentBest PracticesHow to Prevent This Situation Using I-SBARConclusionNursing is all about effective communication and on the quality of patient safety. Nursing communication is the way healthcare team members communicate patient needs while maintaining accurate patient-centered decisions and patient safety while minimizing harm (Potter,2013). This essay will focus on a case of ineffective nursing communication and poor patient safety. The American Nurses Association (ANA) Standards of Practice and Performance and the ANA Code of Ethics will be used to guide the summary of this case to determine which guidelines were not followed. Institute of Medicine guidelines, recommended practices, and the I-SBAR will be used to determine guidelines that could have changed this case for the better. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original EssayCase of Ineffective Nursing Care and Poor Patient SafetyIn November 2000 a 15-year-old boy, Lewis Blackman, came to the Medical University of South Carolina (MUSC ) to fix his condition, pectus excavatum. Postoperatively, Lewis is placed on Toradol for pain which can cause stomach ulcers and requires close monitoring, but due to poor assessment and communication Lewis dies 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 that would have prevented future harm to patients. ANA Standards of Practice and Performance Lewis Blackman's case identifies standard practice assessment and reporting standard ANA performance guidelines not met. Assessment is the way in which the professional nurse collects complete patient data (ANA, 2010). In Blackman's case, an efficient assessment was not achieved because the nurses did not collect accurate data and did not communicate it to the doctor. Nurses needed to implement early assessment to improve patient care (Voepel-Lewis, 2006). Nurses failed to communicate information to healthcare 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 provides positive patient outcomes, which was not accomplished for Blackman. (Torppa, 2006). ANA Code of Ethics Provisions 3 and 4. The ANA code of ethics analyzes the nurses in the Blackman case. In provision 3 nurses promote, support and strive to protect the patient and correct ineffective nursing behaviors (Fowler, 2010). In Blackman's case, the nurses were not preventing harm because the patient was not monitored frequently. The need for frequent monitoring and evaluation can detect postoperative complications (Voepel-Lewis, 2012). In provision 4 nurses are responsible and accountable for providing optimal nursing care (Fowler, 2010). A responsible nurse knows the tasks for thewhich is responsible and accountable to a patient (Fowler, 2010). During Blackman's assessment the nurses were irresponsible in providing correct judgment and irresponsible for patient safety. Nurses are supposed to be patient advocates and not the other way around (Torppa, 2006). Institute of Medicine Reports The Institute of Medicine (IOM) Quality of Health Care in America reported that health care is causing more harm than the system should allow ( IOM, 1999 ). The IOM reports To err is Human: Building a Safer Health System, Crossing the Quality Chasm, and Keeping Patients Safe: Transforming the Work Environment of Nurses provide guidelines that help prevent future harm to patients resulting from health system errors. To Err is Human: Building a Safer Healthcare 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' case, the hospital system was flawed; the doctor-nurse relationship was poor and the nurse's relationship and trust with the mother were not maintained. The need to raise standards, implement safety and identify errors is very important for future improvements (Kohn, 2000). After Blackman's death, changes were implemented at MUSC, including the prohibited use of Toradol in pediatrics. Overcoming the quality chasm Challenges that occur in healthcare services are overuse (where the harm outweighs the benefit), underuse (absence of service) and misuse (preventable injuries). occurs) (IOM, 2001). We must aim for safe, effective, patient-centered, timely, efficient and equitable care to provide for the patient (IOM, 2001). If these goals had been pursued during Blackman's case, it would not have taken the nurses 31 hours to realize that his symptoms were fatal, the nurses would have been Blackman's advocates, and patient safety would have been the main priority. Keeping Patients Safe Transforming Nurses' Work EnvironmentMonitoring patient health status, performing correct treatments, and utilizing patient care are nursing tasks that directly maintain patient safety (Page, 2006 ). Patient safety can be ensured if nurses are trained to prevent skill gaps (Page, 2006). In Blackman's case, nurses reported that he had gas pains and a dramatic reduction in fever as signs of recovery while Blackman's health was deteriorating. Assessment training could have prevented Blackman's death. Recommended Practices Blackman's case is preventable with changes to postoperative pediatric assessment and patient-physician-nurse communication. The ANA standard of practice assessment showed that nurses were ineffective in taking Blackman's vital signs. Nurses are required to incorporate patient assessment, data collection, help, and symptom recognition to make decisions into an ongoing assessment (Voepel-Lewis, 2012). Patient-doctor-nurse communication is vital to patient safety. Blackman's case showed poor communication between nurses and doctors due to differences in data and poor handoff communication. Communication between nurses and doctors must be clear for efficient patient care (Diwakar, 2010). Communication between the nurse and the patient failed because the nurse did not gain the trust of Blackman's mother. Nurses initiate discussion, identify topics for consultation, and hire.