Impact of Poor Nursing Communication on Patient Safety

One of the primary goals of nursing is safe and efficient patient care which can be achieved by skilled assessment and communication. Lewis Blackman’s case illustrates the effects of ineffective nursing communication and poor patient safety by violating American Nurses Association (ANA) Standards of Practice and Performance and ANA Code of Ethics. The Institute of Medicine (IOM) has provided guidelines in 3 reports that along with recommended practices and I-SBAR will provide guidelines to improve patient safety.

A15 year-old- boy, Lewis Blackman, came to Medical University in South Carolina (MUSC) to receive an elective surgery for a chest condition (Monk, 2002). Postoperatively, Blackman was placed on Toradol for pain which can cause stomach ulcers and needs close monitoring. Due to inefficient assessment and communication, Blackman dies from a perforated ulcer.

The ANA Standards of Practice and Performance and the ANA code of ethics will provide guidelines to analyze the mistakes made by the nurses in Blackman’s case.

Blackman’s case illustrates guidelines in ANA standard of practice of assessment and standard of performance of communication that were not met. Assessment is how the registered nurse collects comprehensive data of the patient (ANA, 2010). Efficient assessment was not achieved in Blackman’s case because early accurate vital signs were not assessed. Nurses are required to incorporate patient assessment, data collection, helping, and recognizing symptoms to make decisions in an ongoing assessment to improve patient care (Voepel-Lewis, 2006).

Nursing communication has to be efficient for patient care to be achieved, which was a downfall in Blackman’s case (ANA, 2010). Blackman’s case showed poor communication between nurses and the doctors due to differences in data and poor handover communication along with poor communication between the nurse and the patient due to misguided information. In Blackman’s assessment, the nurses documented a heart rate of 126 while the doctor documented 80, this miscommunication led to the death of Blackman. Doctor-nurse communication and collaboration provides positive patient outcomes (Torppa et al., 2006). The nurse and patient communication was unaccomplished because the nurse didn’t gain the trust of Blackman’s mother. Nurses initiate discussion, target the topics for consultation, and take an active role in caring for the patient (Torppa et. al, 2006). Assessment and communication of the health care providers and health care recipients must be efficient for patient care to occur.

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 (Towney, 2008). 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; accountable nurse are responsible and liable for optimum patient care (Badzek, 2008). During Blackman’s assessment, the nurses were irresponsible because they were unaccountable for providing correct assessment and communication in Blackman’s case. Nurses are supposed to be the patients’ advocates (Torppa et al., 2006).

The IOM has reported that health care is doing more harm than the system should allow. In the three IOM reports, guidelines are given to help prevent future patient harm from health care system mistakes.

The IOM report To err is Human emphasizes that problems derive from faulty systems, process, and conditions that lead nurses to make unpreventable mistakes (Kohn, 2000). In Blackman’s case, the hospital’s system was faulty, the doctor-nurse relationship was poor, and the nurse-patient relationship trust was never gained. The need to raise standards, implement safety, and identify errors is important for future improvements (Kohn, 2000). After Blackman’s death, changes were implemented at the MUSC to better the hospital’s system including the prohibited use of Toradol in pediatrics.

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

Keeping Patients Safe illustrates monitoring patient health status, performing correct treatments, and using patient care as 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.

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 (Wacogene, 2010). As Blackman’s nurse, I would have stated to the doctor, “Hi my name is Caitlin Endly, I’m an RN on the cancer ward calling about Lewis Blackman whose chief complaint is abdominal pain. Patient is a15-year-old male post op from recent chest surgery and is on Toradol to control his pain. I am unable to obtain his blood pressure, heart rate is ninety-six beats per minute, pallor, ridged abdomen, and is having a seizure. I think he may have blood in his abdomen due to a perforated ulcer. I need you to come see him STAT.” I would have provided an early efficient assessment and communication to prevent future harm to Blackman.

Blackman’s case is one of the man y hospital system mistakes that are made each year. His case could have been prevented if efficient use of assessment and communication guidelines were achieved which were given by the ANA and IOM. The use of I-SBAR would have saved Blackman’s life by communicating to the doctor and expediting patient care. In the future, nurses need ongoing education about assessment and communication skills along with annual review of the health care system to prevent a healthy 15 year old boy’s death.