This quality and safety issue breakdown began from a serious safety event (SSE) occurring from the absence of monitoring while a patient was off their home unit for diagnostic testing. For this SSE, I lead an interprofessional team of content experts to determine root cause and to develop a hospital wide solution to prevent these types of events from occurring again. DNP Essential VI which involves the interprofessional collaboration for improving patient and population health outcomes applies to this quality and safety issue. The team discovered the root cause stemming from a transportation order placed for cardiac monitoring removal to prevent the delay of the diagnostic test.
Most of the literature which exists on patient transportation involves intensive care or pediatric patients. The Pennsylvania Patient Safety Reporting System published the most beneficial resource regarding safe transport of the non-ICU patient; which focused on handoff communication and transportation teams (Huber, 2010).
Huber C. (2010). Safe intrahospital transport of non-ICU patients. The American journal of
nursing, 110(11), 66–69. https://doi-org./10.1097/01.NAJ.0000390531.14314.1c
The documentary “Heard” provided a perspective of the patients we treat everyday in the hospital. This is a valuable resource for the health care providers providing care to these patients. Many times, I have seen providers pass judgement to patients wondering why they are not compliant with their meds, why do they not follow treatment plan recommendations.
This documented pointed out many things that I have taken for granted. One the stuck out to me was having a checking/savings account. When I was younger, I remember going to the bank with my dad to set up my first checking account. I remember every time he was fill up with gas, he would update his checkbook before we drove away. In the documentary, they commented on how they didn’t have a checkbook or savings account, they always used cash. I think about how I pay all my bills online, and that I rarely have cash on me. What would the the impact on me having to pay all my bills in cash? Nurses always wonder why patients come in with so much cash. Many look at it as an inconvenience, having to fill out the paperwork in order to have the cash locked away in the safe. And at discharge, how it slows down the discharge having to go down to security to pick up the patient’s belongings.
For my DNP project, I am building an experiential learning program for bedside nurses to experience the life of a patient with diabetes. Diabetes is a challenging disease due to the heavy reliance on self-management of the disease. One individual in the documentary described working doubles, six days a week. I thought if this patient had diabetes, how would they be able to build in a regular eating pattern in order to give their insulin as prescribed. When would they have a moment to pick up their medication and healthy food options; let alone pay for all the supplies and food needed. Now that I have seen this documentary, I want to build in this part of the patient experience and not just the diabetes specific tasks of managing the disease.