Question

Write an outline with your design for a performance improvement project based on these near miss/great saves:

Below are examples of three near misses or great saves, where harm to the patient was averted due to quick action by a member of the team, by a team member speaking out to advocate for the patient or just by sheer luck.

-A critical care nurse responds to a Code Blue (Patient is in cardiac arrest) on another unit. When she arrives, she notes that the patient has a yellow DNR arm band so she instructs all to stand down. The nurse caring for the patient returns to the room with the patient's Medical Record and notices that nothing is happening. When told the reason, she states that this patient is a full code and the Code Blue is resumed. The patient makes a full recovery.

-The nurse on the telemetry unit has admitted a patient who has been made a DNR by the physician based on the patient's request and advance directive. The nurse heads to the patient's bedside to place the yellow arm band and is interrupted. She places the armband in her pocket and addresses several other patient care needs. She suddenly remembers the arm band when she hears a rapid response called for the patient's room. As care is provided for the patient, the nurse follows the hospital policy for placing the arm band and making the patient a DNR. The interventions of the Rapid Response Team were not effective and the patient stops breathing and becomes pulseless. The patient's self-determination wishes were respected and the patient was not resuscitated.

-During the admission registration process, the code status for the patient is never address nor is an advance directive requested per policy. The admission nurse also does not address. The patient is later found in the bed unresponsive, a Code Blue is called and the patient is successfully resuscitated. No one in the room is sure of the patient's code status since it was never addressed but the team decides to fully resuscitate in the absence of the needed information. After the incident, it was discovered that the patient's wishes were to be resuscitated.

Answer 1

*Outline design for a performance improvement project based on the near miss/great saves.

-Hospital admission registration must include the details of the code status and details of it.

-option must be given for the willingness of the patient regarding the selecting code status.

-Based on the patient selection only the code status must be implemented related to DNR.

-Admission registration process must mention the benefit/harm to the patient with this code status.

-When patient do not aware of the code status and taking the previlage of accept/do not accept DNR just based on code status is not correct procedure.

-Necessary information guidelines to be given by the staff/team members while collecting the data and proceeding with the treatment even in emergency admission process related to code status.