Group Project

In order to create a plan to resolve this conflict the Unit managers met to fully understand the cause.

ROOT CAUSE ANALYSIS:

Hand off Report between the (Sender) ED NURSE MARY and (REICEVER) Tele Nurse Jenny was incomplete and ineffective.

Patients Diagnosis were not given only admitting complaint,

Labs were not communicated, “cardiac markers negative”

Reasons for previous admissions not addressed

“Vitals stable” no baseline given

“Some aspirin and nitroglycerine given” no dose, route or times given

“Family had left” Were they told where he was going? Does he know were he was going”

OMMITED INFO:

Ambulation status and aides needed, mental status, continent or incontinent, fall risk assessment, isolation needs, belongings, time of last head to toe assessment

ULCER FOUND when did this occur? Did it happen at our Facility? Are We responsible for payment? Patient was at risk for fall? Hypoglycemia? Insulin?

Jenny was upset that Mary did not give a full report. The hospital did not have a standard for report?

RELEVENT HUMAND FACTORS

Fatigue, Hunger, rushing to complete task

Why didn’t Jenny report to her unit manager? She vented with peers not constructive.

ACTION PLAN

Rational for the Need for Change; “Smooth, efficient, and complete patient transfers be- tween units contribute to improvements in safety and patient satisfaction through reducing the possibility of error but also through reducing conflict and improving working relationships among staff” (Clark et. al, 2012)

NEW HOSPITAL PROTICAL FOR IN HOUSE PATIENT TRANSFERS

1) If possible face to face hand-off report is to be given when patient is transferred

* Telephone report must be given within 20 minutes of a patient leaving the Unit.

* Receiving nurse must document who the “Sender” was and when report was given and when the patient was received.

Rational: To ensure most current info is being handed off. Standardized reporting is recommended so that the transfer...