Patient Safety Fishbone Diagram Analysis
Sheila, a very experienced ICU nurse, has been working with an unstable patient, who is 3 days post-op. The patient’s IV drugs are being adjusted and titrated for runs of V-Tach. The patient has been very restless and somewhat confused, moving around in bed frequently and causing the monitor to alarm. Because Sheila is providing care to this patient on a 1:1 basis, she turns off the alarm while she is in the room. She closely monitors the patient’s vital signs and drips, continuously staying at the patient’s bedside.
Suddenly, the patient across the hall sits up in bed, extubates himself, while thrashing wildly, trying to remove his restraints, and get out of bed. Sheila is in the nearest room and sees what is going on. She rushes to the other room to restrain the patient, calling for help as she goes. Another nurse comes to help her, and within a few minutes, anesthesia has responded, the ET tube has been reinserted, and the patient has been sedatedPatient Safety Fishbone Diagram Analysis.
When Sheila returns to her patient’s bedside, she notes that he is in V-fib and is unresponsive.
Questions to facilitate the Fishbone diagram process:
1. What aspects of human factors could have contributed to this situation?
2. What system and/or process factors might have played a role?
3. What system changes related to mistake-proofing could help here?
4. What are the key components to include in a policy on turning off alarms?
Patient Safety Fishbone Diagram Analysis
Fishbone Analysis
Aspects of Human Factors that Could Have Contributed to the Situation
The first human factor that could have contributed to the situation is that the patient was on the third-day post-op. This means that the patient was still recovering from surgery and may have felt more pain and discomfort than usual. This could have made the patient more restless and confused than usual. Another human factor that could have contributed to the situation is that the IV drugs were being adjusted and titrated for runs of V-tach. This means that the patient’s medication was constantly changing to control their heart rate (Barbeito et al., 2022). This could have led to the patient feeling more confused and agitated. The third human factor that could have contributed to the situation is that the patient’s monitor was alarming frequently. This would have caused the patient to become more aware of their surroundings and may have caused them to become more restless. Also, Sheila was the only nurse providing care to the patient. This means she was the only person who could monitor the patient closely. This could have led to her missing some warning signs that the patient was becoming agitated Patient Safety Fishbone Diagram Analysis.
The alarm system was not properly functioning and did not alert staff to the patient’s movements. The patient was not properly restrained and could remove the ET tube. The anesthesia team did not respond promptly. Other factors were that the nurse-patient ratio was 1:1, which left little room for error. The patient was post-op and on medication that may have caused confusion and restlessness. The monitor was also turned off while the nurse was in the room, which prevented timely intervention. The patient was not closely monitored after the initial event, which allowed him to become unresponsive. The nurse was not familiar with the anesthesia protocol, which delayed intervention.
Systems and Process Factors that Might Have Played a Role
Several systems and process factors may have played a role in this event. The first is the patient’s instability. The patient was on the third-day post-op and was still very unstable. This made it difficult for the nurses to keep the patient’s vital signs and drips stable. The second factor is the patient’s restlessness and confusion. This made it difficult for the nurses to monitor the patient and keep him from moving around the bed, causing the monitor to alarm. The third factor is anesthesia. The anesthesia could not respond quickly enough to the patient’s need for sedation. This made it difficult for the nurses to keep the patient sedated and from removing the ET tube. The fourth factor is the lack of staff. There was only one nurse available to help Sheila with the patient. This made it difficult to keep the patient restrained and from extubating himself. The fifth factor is the lack of a clear plan of care Patient Safety Fishbone Diagram Analysis. There was no clear plan of care in place for the patient. This made it difficult for the nurses to know what to do and how to respond to the patient’s needs.
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One system factor that may have played a role is the fact that the patient was on the third day post-op. This means that the patient may have still been in a lot of pain and discomfort, which can lead to restlessness and confusion. Additionally, the patient’s IV drugs may have been contributing to the patient’s condition. Another system factor is that the patient was on a 1:1 basis with Sheila. This means that Sheila was the only nurse responsible for the care of this patient. This can lead to much pressure and stress, leading to mistakes. Process factors that may have played a role include that Sheila turned off the alarm while in the room. This may have prevented her from hearing the alarm when the patient across the room began to stir.
Additionally, Sheila may have been too focused on the patient’s vital signs and drips to notice the patient across the room. Another process factor is that the patient across the room could extubate himself and remove the restraint. This may have been because the restraint was not properly secured. Finally, the anesthesia may have responded too slowly to the situation, which allowed the patient to become unresponsive.
Potential Problem-Solving Measures
Some of the system changes that could help include implementing a standardized protocol for postoperative care of patients with unstable vital signs. This protocol should include close monitoring of vital signs and titration of IV medications to maintain stability. Secondly, there is need to incorporate alarms into the postoperative care protocol so that nurses are alerted when a patient’s vital signs become unstable. Training nurses on proper restraint techniques prevents patients from self-extubating or removing other medical devices and standardizing the sedation protocol for patients who become agitated or unresponsive so that nurses can quickly and effectively sedate them—also implementing a system for tracking and reporting postoperative complications so that any trends can be identified and addressed (Soni et al., 2017) Patient Safety Fishbone Diagram Analysis.
Other system changes to mistake proofing that could help here include; reviewing and updating policies and procedures related to postoperative care, specifically about IV drug administration and monitoring of unstable patients (Rodziewicz et al., 2022) Patient Safety Fishbone Diagram Analysis. Additional interventions include implementing a system of bedside alarms that nurses cannot turn off while they are in the room with a patient, increasing staffing levels on postoperative units to allow for more one-on-one care of unstable patients, educating all staff members on the signs and symptoms of postoperative complications and the importance of timely intervention.
Key Components to Include in Policy of Turning Off Alarms
Alarms should only be turned off when the nurse is providing direct care to the patient and can closely monitor the patient’s vital signs. The nurse should turn off the alarm and monitor the patient’s vital signs and drips. If the patient across the room extubates himself and tries to remove the restraint, the nurse should rush into the room and call for help. Once the anesthesia has responded and the ET tube is reinserted, the patient should be sedated (Ramlaul et al., 2021). The nurse should then return to the patient’s bedside and check for v-fib and unresponsiveness. The alarm must be turned off by the nurse providing care to the patient on a 1:1 basis. The nurse must document all actions taken in the patient’s medical record (Woo & Bacon, 2020). Once the patient is sedated, the nurse should return to the bedside and check for signs of V-fib. If the patient is unresponsive, the nurse should turn off the alarm and provide CPR if necessary Patient Safety Fishbone Diagram Analysis.
References
Barbeito, A., Dolinski, S. Y., & Lemm, J. (2022). Postoperative care after cardiac surgery.
https://www.uptodate.com/contents/postoperative-care-after-cardiac-surgery
Ramlaul, A., Chironda, G., & Brysiewicz, P. (2021). Alarms in the ICU: A study investigating how ICU nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, South Africa.
Southern African Journal Of Critical Care
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37
(2), 57.
https://doi.org/10.7196/sajcc.2021.v37i2.469
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. In
StatPearls [Internet]
. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK499956/
Soni, P., Aggarwal, N., Kumar, V., Homel, P., & Kupfer, Y. (2017). Authenticity and Reliability of the Cardiac Monitor Alarms in the ICU: A Patient Safety Concern Due to Alarm Fatigue.
Chest
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152
(4), A566.
https://doi.org/10.1016/j.chest.2017.08.596
Woo, M., & Bacon, O. (2020). Alarm Fatigue. In Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Agency for Healthcare Research and Quality (US).
https://www.ncbi.nlm.nih.gov/books/NBK555522/
Patient Safety Fishbone Diagram Analysis
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