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A Thesis on Poor Nursing Communication and Safety of Patients

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Nursing is based on the effectiveness of communication and the quality of patient safety. Nursing communication is the way health care team members communicate the patients’ needs by maintaining accuracy of patient-centered decisions and patient safety by minimizing harm (Potter,2013). This essay will focus on a case of ineffective nursing communication and poor patient safety. To guide the summary of this case American Nurses Association (ANA) standards of practice and performance and ANA code of ethics will be used to determine what guidelines were not followed. The Institute of Medicine guidelines, recommended practices, and I-SBAR will be used to determine the guidelines that could have changed this case for the better.

Case of Ineffective Nursing and Poor Patient Safety

In November of 2000 a 15 year old boy, Lewis Blackman, came to Medical University in South Carolina(MUSC) to fix his condition, pectus excavatum. Postoperatively, Lewis is placed on Toradol for pain which can cause stomach ulcers and needs close monitoring, but due to inefficient assessment and communication Lewis dies from a perforated ulcer (Monk, 2002). The ANA standards of practice and performance and the ANA code of ethics will be used to further discuss what guidelines were not met that would have prevented future patient harm.

ANA Standards of Practice and Perfomance

Lewis Blackman’s case identifies ANA standard assessment of practice and standard of communication performance guidelines not met. Assessment is how the registered nurse collects comprehensive data of the patient (ANA, 2010). Efficient assessment was not met in Blackman’s case because the nurses did not take early accurate data and communicate data to the doctor. The nurses needed to implement early assessment to improve patient care (Voepel-Lewis, 2006). The nurses failed to communicate information to the healthcare consumers and professional team (ANA, 2010). During Blackman’s assessment the nurses documented a heart rate of 126 while the doctor documented 80, this miscommunication was fatal. Doctor-nurse communication provides patient positive outcomes, which was unaccomplished for Blackman. (Torppa, 2006).

ANA Code of Ethics Provision 3 and 4.

The ANA code of ethics analyzes the nurses in Blackman’s case. In provision 3 nurses promote, advocate, and strive to protect the patient and correct inefficient nursing behavior (Fowler, 2010). In Blackman’s case the nurses were not preventing harm because the patient was not frequently monitored. The need for frequent monitoring and assessment can detect postoperative complications (Voepel-Lewis, 2012). In provision 4 the nurses are responsible and accountable for providing optimum nursing care (Fowler, 2010). An accountable nurse knows the duties a nurse are responsible and liable to a patient for (Fowler, 2010). During Blackman’s assessment the nurses were unaccountable for providing correct judgment and irresponsible for patient safety. Nurses are supposed to be the patients’ advocates not the opposite (Torppa, 2006).

Institute of Medicine Reports

The Quality of Health Care in America of the Institute of Medicine (IOM) reported that health care is doing more harm than the system should allow (IOM, 1999). In 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 give guidelines that help prevent future patient harm from health care system mistakes.

To err is Human: Building a Safer Health System

The problem derives from faulty systems, process, and conditions that lead nurses to make mistakes or be unable to prevent them (Kohn, 2000). In the case of Lewis, the hospitals system was faulty; the doctor-nurse relationship was poor and the nurses relationship and trust to the mother was not upheld. 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 the MUSC including the prohibited use of Toradol in pediatrics.

Crossing the Quality Chasm

Challenges that occur in the health care services are overuse (where harm exceeds benefit), underuse (absence of service), and misuse (preventable injury occurs) (IOM, 2001). We need to aim for safe, effective, patient-centered, timely, efficient ,and equitable care for providing for the patient (IOM, 2001). If these goals were aimed for during Blackman’s case it wouldn’t have taken the nurses 31 hours to realize his symptoms were fatal, the nurses would have been Blackman’s advocate and patient safety would have been the main priority.

Keeping Patients Safe Transforming the Work Environment of Nurses

Monitoring patient health status, performing correct treatments, and using patient care are nursing duties that directly keep the patient safe (Page, 2006). Patient safety can be ensured if nurses are being educated to prevent skill gaps (Page, 2006). In Blackman’s case the nurses reported him of having gas pains and dramatic fever reduction as recovering signs while Blackman’s health was failing. Assessment education could have prevented Blackman’s death.

Recommended Practices

Blackman’s case is preventable with changes to the postoperative pediatric assessment and patient-doctor-nurse communication. The ANA standard of assessment practice, showed how the nurses were inefficient in taking Blackman’s vital signs. Nurses are required to incorporate patient assessment, data collection, helping, and recognizing symptoms to make decisions in an ongoing assessment (Voepel-Lewis, 2012). Patient-doctor-nurse communication is vital for patient safety. Blackman’s case showed poor communication between nurses and the doctors due to differences in data and poor handover communication. Nurse and doctor communication has to be clear for efficient patient care (Diwakar, 2010). The nurse and patient communication was unaccomplished because the nurse didn’t gain the trust of Blackman’s mother. Nurses intiate discussion, target the topics for consultation, and take an active role in caring for the patient (Torppa, 2006). Assessment and communication of the health care providers and health care recipients must be efficient for patient care to occur.

How to Prevent this Situation Using I-SBAR

As a future registered nurse I would have prevented this situation by using the communication tool I-SBAR. I-SBAR is an acronym for handovers, patient information, from nurses to doctor s that states patient’s situation and background and the nurse’s assessment and recommendations (Diwaker, 2010). If I were one of Blackman’s nurses I would have stated to the doctor, “Hi my name is Caitlin Endly on the postoperative pediatrics ward and I am calling about 15 year old Lewis Blackman. I am unable to obtain his blood pressure,heart rate is 96 beats per minute, pallor, and is having a seizure. He recently had surgery to correct his pectus excavatum and is currently on Toradol to control his pain. I am currently observing him. I think the problem is a perforated ulcer from Toradol. I need you to come see him STAT.” I would have provided efficient assessment and communication to prevent future patient harm.


Lewis’ case is one of the man y hospital system mistakes that are made each year. His case could have been prevented if the efficient use of assessment and communication guided by the ANA and IOM were achieved. The use of I-SBAR would have saved Lewis life and in the future nurses should be able to learn that the simple assessment and communication skills we learn in our first semester of nursing school can save a 15 year old boy’s life.

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