How Poor Nursing Communication And Safety Of Patients Can Have A Negative Impact As Presented In The Case By Lewis Blackman

Nursing is primarily concerned with providing safe, efficient care to patients. This can be accomplished by skilled communication and assessment. Lewis Blackman’s example illustrates how ineffective communication can lead to poor patient care and safety. He violated the American Nurses Association Standards of Practice and Performance and ANA Code of Ethics. The Institute of Medicine has published 3 reports with guidelines and recommendations for improving patient safety. IBAR is also providing guidelines.

Lewis Blackman (age 15) underwent elective chest surgery at Medical University South Carolina. Blackman’s postoperative pain was treated with Toradol, which is known to cause stomach ulcers. It requires careful monitoring. Blackman died from a perforated stomach ulcer due to poor communication and assessment.

The ANA Standards of Practice and Performance and ANA codes of ethics will be guidelines for analyzing mistakes made by Blackman’s nurses.

Blackman’s case shows that guidelines in ANA Standard of Practice of Assessment and Standard of Performance of Communication were not followed. The registered nurse’s assessment is the process by which she collects all the data about the patient. (ANA, 2010) Blackman failed to receive an accurate assessment of vital signs early on. In order to improve the care of patients, nurses must include data collection, patient assessments, help, and recognition symptoms in their ongoing assessment.

Blackman, whose case was analyzed by ANA in 2010, showed the importance of effective nursing communication. Blackman was a case of poor communication due to misguided data, a lack of communication during handover and between nurses and doctors. Blackman had a heart-rate of 126 recorded by the nurse, but the doctor’s was 80. This miscommunication lead to Blackman dying. Collaboration and communication between doctor and nurse can result in positive outcomes for the patient (Torppa; et.al. 2006). Blackman’s mum did not gain trust in the nurse. Nurses take the initiative to initiate the discussion, choose the topics of consultation and play an active part in the care for the patient. al, 2006). Patient care requires efficient communication and assessment between health care professionals and patients.

The ANA Code examines the nurses’ actions in Blackman. In Section 3, nurses strive to protect and promote the patient as well as correct inefficient behavior. In Blackman’s situation, nurses failed to prevent harm by not regularly monitoring the patient. It is important to monitor and assess patients frequently in order to detect complications after surgery (Voepel Lewis, 2012).

In the provision 4 nurses are accountable and responsible; accountable nurses are accountable and responsible for optimal patient care. (Badzek, 2008). Blackman was assessed by nurses who were irresponsible, as they could not be held accountable for the correct communication and assessment in Blackman’s situation. Nurses should be advocates for their patients (Torppa and others, 2006).

IOM found that the health system causes more harm then it should. In three IOM report, there are guidelines that can help to prevent future harms from the health care system.

IOM’s To Err Is Human report emphasizes the fact that nurses make mistakes that are unavoidable because of faulty processes, systems and conditions (Kohn 2000). Blackman suffered from a faulty hospital system, poor doctor-nurse relations, and no nurse-patient trust. It is essential to identify mistakes, raise standards and implement safety in order to improve future outcomes (Kohn 2000). After Blackman died, changes were made at MUSC in order to improve the system. This included the prohibition of Toradol for pediatrics.

IOM (2001) outlines three major challenges to health care delivery: underuse of services (absence), misuse (unpreventable injury), and overuse. IOM (2001) says that health professionals should aim to provide patients with safe, effective and patient-centered care, as well as timely, efficient, equitable, and timely care. If these goals were achieved in Blackman’s situation, the nurses would have realized Blackman was fatal within 31 hours. Blackman would be a priority to the nurses and their safety would be their top priority.

Page (2006) explains that nurses can keep their patients safe by monitoring the patient’s health, performing the correct treatments and providing patient care. Page, 2006) argues that nurse education can help to ensure patient safety. In Blackman’s situation, nurses reported that Blackman was experiencing gas pains. They also noted a rapid drop in his fever. Blackman might have survived if assessment education had been available.

I-SBAR is an acronym for handovers, patient information from nurses to doctors that states the patient’s situation and background as well as the nurse’s assessment and recommendations (Wacogene, 2010). I-SBAR refers to the transfer of information between nurses and doctors. It includes a patient’s medical history, their current state, and the nurse s recommendations. Caitlin endedly is an RN who works on the Cancer Ward and is calling Lewis Blackman whose main complaint is abdominal discomfort. Patient is 15-year-old man who has recently had chest surgery. He is taking Toradol for pain control. I can’t get his bloodpressure. His heartbeat is ninety six beats per second. He is pallored, has ridged stomach, and appears to be having a fit. I think there may be blood in his abdominal area due to an ulcer. I need to see him ASAP.” I could have done an early and efficient assessment of Blackman’s condition, and communicated with him to prevent any future harm.

Blackman’s situation is an example of the many mistakes made by hospitals every year. It could have been avoided if the ANA’s and IOM’s guidelines on communication and assessment were followed. I-SBAR was able to communicate with the doctor, allowing him to provide better patient care. To prevent the death of an otherwise healthy 15-year-old, nurses must receive continuing education in communication and assessment.