Culture of Safety
Write a 2-3 page paper in APA format summarizing:
a. Best practices for the leader in creating a culture of safety;
b. The best actions for the nurse leader to take in managing the issues presented below.
-The paper should be double-spaced in 12-point font.
-Include at least 3 in-text citations.
-Include your reference list (as a new page not counted in the 2-3 page summary)
Just Culture Case Study:
Using the information you have learned in your nursing practice, through course work and the assigned readings and through the algorithm below, evaluate the case study and determine the decisions you would make as the nurse leader.
Case Study:
You are a nurse leader overseeing the nursing staff for Pulmonary Services with both an inpatient and clinic sites. After having been off for 4 days, you return to written reports of two incidents that occurred. The organization has a culture of safety plan and leaders are to use the just culture algorithm for analyzing patient safety risks.
Incident A: A patient was admitted for pneumonia and deteriorated, eventually requiring pneumonectomy and tracheostomy. She also had a seizure during her care, although workup for the seizure has not shown a clear cause. The patient received lorazepam 4 mg IV with order for repeat q2h for seizures. She was in the ICU for 4 days but then transferred to the general pulmonary unit. All orders were continued.
During the night, the patient is cared for by a new nurse, Andy, who completed orientation 2 weeks ago. The patient was anxious and couldnt sleep. The nurse noted the lorazepam order so administered a dose. After the patient rested for an hour, she was again anxious so Andy repeated the dose an hour later. Through the night, four doses of lorazepam were given. During shift report, the patient was noted to be lethargic. The day shift nurse found the oxygen saturation 84-86% and BP low. The patient was subsequently transferred back to the ICU. Although the night shift nurse reported giving 4 doses of lorazepam, only 2 doses were documented in the E.H.R. The patients provider brought the issue to nursing administration due to the needed transfer back to the ICU.
Incident B: The nurse leader also receives a report of another incident. A veteran nurse, Joan, works in the clinic and frequently manages triage calls. One patient with chronic lung disease calls frequently with questions and complaints. A few months ago, Joan was reported by the patient as having told the patient, You call us too much. Really, you just need to chill. The nurse leader discussed this incident with Joan who planned to communicate more appropriately.
On Friday, the report states the patient called again and spoke to Joan about an issue with dyspnea and cough. The patient later called the administration stating, That nurse was rude to me again. She told me just to settle down and then hung up on me. The patient was instructed to come to the emergency department and was admitted on Friday evening with pneumonia.
