Table of Contents
- A Mother’s View of “Lessons Learned”
- Patient-centered Care and Teamwork/Collaboration
- Disclosing Error and Accountability
- Transparency and Courage
Lewis Blackman was a 15-year-old boy who died at a teaching hospital following surgery. His mother Helen Haskell spoke on his behalf explaining her emotions about what happened to her son during their hospital experience. Helen starts off her story by mentioning her son because she feels like her son’s story is another example of a patient failed because of the shortages of staff members in the hospital systems. Lewis died because of a medication error which leads to an enlarged duodenal ulcer. Lewis was taken to the hospital for a minimally invasive surgery of pectus excavatum or defect of the chest. A drug called Ketorolac was given to Lewis for pain. This drug was widely used in America but was not approved in most other countries. Ketorolac is pain medication for short-term treatment (Karch, A. M, 2018, p. 198) Some indications that the drug is used for is inflammation, relief of itching of pink eye, and relief of pain up to five days (Karch, A. M, 2018, p.198). The side effects of this drug could be edema, anaphylaxis, the risk for an increase in blood pressure, and adverse effects on the kidney (Karch, A. M, 2018). The normal dosages for a 15-year old taking Ketorolac are 1 mg/kg IM or 0.5 mg/kg IV to 15 mg being the maximum as a single dose (Karch, A. M, 2018, p.198). The benefit of this drug is to reduce pain after surgery. However, too much of this drug can result in toxicity. An adverse effect of Ketorolac is renal impairment (Burchum, J.R., & Rosenthal, L. D. 2019, p. 860). Renal impairment means there is a failure in kidney function which can show the side effect of no urine output (Jr., W. C (2018, December 21). The needs of IV fluids could have cause Lewis to urinate more but since he was not receiving the right amount of IV fluids for his age it causes him to urinate less. When the nurses checked for a blood pressure reading, they found it undetectable and assumed it was because of equipment failure. Being that Lewis was considered a healthy child and had no history of illness, health care providers could think that it was equipment failure. Lewis crises developed over a weekend which could have played a part in his situation being overlooked. In most hospitals, during the week there are more staff and health care workers. In contrast, on the weekend they are usually less health care workers and staff. If Lewis’s situation were to take place during the week, someone potentially could have identified the problems and began working to fix them more immediately than if it were to have happened over a weekend. Whereas on the weekends most staff members are off and some are on call. I think that these factors were significant in Lewis’s crises. Lewis died from septic shock because his signs were ignored. Septic shock is an infection in the body that causes a change that can be life-threatening. The symptoms of septic shock are hypothermia decreased blood pressure, cyanosis, decreased urine output and several others (“Septic Shock: Symptoms, Causes, Diagnosis, Treatment & More,” 2016).
A Mother’s View of “Lessons Learned”
Helen Haskell describes a good professional nurse or physician as being someone who can handle an emergency, knows the side effects of medications, has goal-oriented behavior in the hospital, has critical thinking abilities, and can educate patients and families. These are some of the things that can be described as a good professional nurse or physician. She also made the statement that “patients need to be empowered and nurses need to embrace it”. I agree with this statement because patients should be the number one priority to a nurse. Patients should know that they matter and that their health is just as important as anyone else’s health. Helen also made a statement about “misplaced professionalism”, or the nurse or provider not listening to the patient and the idea of the nurse failing to explain the patients’ situations to themselves and their families. In Helen’s story, other examples of “misplaced professionalism” could include the nurses not checking Lewis’s vital signs as frequently nor monitoring him because he was on a severe pain medication that could have toxic side effects. Even though Lewis seemed healthy, there could as be an error and nurses should have been more aware of the potential side effects of the drug that was given. Other examples of misplaced professionalism are when the medication dosage is not checked before being given, when the patient’s age is not confirmed, and when the necessary age dosage is not acquired. Professionalism in my view is being responsible, accountable, educating your patients, being able to think critically, making your patient your number one concern and knowing how to approach a crisis. My reaction to Helen’s view is that nurses need policy-level help to be empowered to communicate with physicians while helping nurses build that confidence to advocate for their patients. This is important because the nurse is the last line of defense for the patient. If they sense that something is not clinically correct, they should advocate for their patients and speak up.
Patient-centered Care and Teamwork/Collaboration
Patient-centered care teamwork and collaboration are important in the hospital setting because the patient is the number one priority, and health care workers have to work together to make sure this is the case. A lack of communication, a neglect of the parents’ concerns, infrequent checking of Lewis’s status, and a shortage of staff members could have been some factors in the hospital’s ‘teamwork’ culture that could have contributed to the lack of response to Lewis’s parents’ concerns. If patients and their families were to have been considered a part of the health care team, this story could have had a better result. If the nurse and the parents came together to lay out a plan of action for Lewis’s condition, his result may have been different, and the parents may have had a better feeling towards the healthcare team because they were included. Maybe if Lewis’s parents felt that the health care team acknowledged their concerns and took immediate action on their son’s condition, they would not have felt like the healthcare team had neglected them. Considering the health care team’s neglect of the parents’ concern, I agree with Helen when she said that she said almost saw no evidence of teamwork. If healthcare team members had included Helen’s concerns, Lewis’s treatment would have been done immediately. Even though there is a shortage of nurses worldwide, patients and their families still should be a priority in the healthcare setting. Helen stated in her story that there was a shortage of nurses in the hospitals, and this is similar to hospitals that I have seen. On the weekend there are usually fewer staff and primary care providers who are on-call at home or it is often suggested that they should not be called unless it is an emergency. These are not effective practices for regarding the patients’ care as a priority. Health care professionals can create a hospital culture that supports effective teamwork and patient-centered care by having the nurses communicate with the patients and their families. Apart from the usual steps of care, nurses should provide education on the plan of care including family and patient.
Disclosing Error and Accountability
Professional accountability to me means a person who takes full responsibility for their actions and mistakes and is willing to correct them in the best way possible. Health professionals can demonstrate professional accountability for the reliability of the system they work in by acknowledging when they have made an error and then correcting it. However, some health professionals lack the demonstration of professional accountability for the reliability of the system they work in because they fear acknowledging an error that can cause punishment to them or their coworkers. Lack of accountability could be due to healthcare professionals wanting to complete a task rather than make an accurate assessment. According to Helen Haskell, she describes nurses being more focused on completing their tasks such as documenting a plan of care instead of making an accurate assessment, educating, listening to patients and families, or taking action on the patient’s behalf. Her statement of nursing care is accurate to what I have observed in healthcare settings, and these problems occur due to patient overload, shortage of staff members, and staff availability. Patient overload, shortage of staff members and lack of time can contribute to the misplaced work focus. However, if someone is involved in an error, they would report it to the nurse in charge and also be provided with education on how to prevent the error from happening again. If the error was related to the equipment, the staff would contact the appropriate professionals to fix this problem immediately. Concerning Lewis story, several errors had occurred such as he was given too much Ketorolac acid, not given adequate amounts of fluids for his age, his parents’ concerns were ignored, health care staff members assumed the equipment failed when his vital signs were abnormal, and his urine output decrease were ignored. These errors can be described as “systemic” or “individually committed” errors. The difference between these two errors is that a system error is an error that occurs because of a piece of equipment that stopped working. If there was a problem with the equipment and no one reported it, that could be an example of a system error. In contrast, an individual committed error occurs when someone does not acknowledge an error taking place or ignore the error and does not try to correct it. Individual committed errors included in Helen’s situation were the health care professionals ignoring the patient’s family concerns, ignoring the patient’s side effects of Ketorolac acid, and ignoring the patient’s vital signs and not reporting it. If I were a family member in Helen’s situation, I would have wanted the nurses and residents to acknowledge my concerns about my family member’s condition. I would want them to allow me to speak with a physician, apologize if they had made an error and make an effort to correct it. I would want the nurses and residents to treat me as if it was their family members’ care in my hands. That is what I would want to hear from the ‘frontline’.
Transparency and Courage
Being a learner is essential when doing anything pertaining to health care. Being a learner can help you prevent errors and adverse effects because learners are willing to learn about why something is not functioning correctly, are willing to correct an error, and are willing to reach out for help. However, a learner who thinks that they know more than others and acts on their reasonings without confirming them with another healthcare member can increase the risk of error and adverse events for patients and their families. Errors and adverse effects can happen within the healthcare setting, and the patient and their family must be aware. There could be safeguards in place to help protect patients and families from a health care team’s inability to recognize a developing problem. For example, a chart of normal ranges for blood pressure, heart rate, and other vital signs posted where they could be seen could be helpful. Also, a list of medications with their side effects that a patient is taking should be given to the family. These safeguards can be beneficial to the patients and their families when they speak up and voice their opinions about the signs they notice. Patients sometimes enter hospitals assuming that health professionals are watching for complications so they can “rescue” patients. Factors that detract from our effectiveness in making this true for every patient is health care professionals assuming that patients and their families are just complaining about nothing instead verifying their concerns. Helen stated ‘We were in the only place in this country where Lewis’s father and I could not get help for our son … a hospital. In any other location, she could have called 911.’ Health professionals can justify this by listening to patients’ and their families concerns, notifying a physician when patients and their families request for one, and provide patients and families with resources. Policies that can eliminate these problems would be contact numbers given to patients regarding their care and organizations that are formed to help patients and their families regarding concerns being ignored in the hospital settings. My opinion about patient empowerment and nurse empowerment regarding of the overall safety of our health care system is related to communication. Nurses can help empower patients by educating them about their health, by being an advocate for them, and by listening to their concerns. Patients’ and nurses’ interests may not be in alignment when they are not on the same page regarding the patient’s health or plan of care. However, they can be in alignment when the patient is involved with their plan of care and the nurse considers their concerns. I think Helen believes that nurses, patients, their families, and other health care professionals need to have the courage to communicate within each other, the courage to trust one another, the courage to respect the patient and their family’s concerns, and the courage to act immediately when a situation occurs.