When teams communicate poorly in health care, consequences can sometimes include Quizlet

Terms in this set (19)

A healthy 45-year-old athlete is scheduled for a knee arthroscopy to clean up her knee so that she can ski better in the coming winter. This is a low-risk, straightforward procedure. The chief of orthopedics will perform the procedure. After two complex and time-consuming procedures, this is his final surgery of the day. Because of a staffing issue, two nurses are pulled from another operating room (OR) to help. They are experienced nurses but have never worked in orthopedics before, and they don't know any of their colleagues. The surgery begins with limited introductions or discussion about the case, and the surgeon has loud music playing. He asks one of the two "new" nurses for 20 mL of local anesthetic with dilute epinephrine to put in the knee. The nurse hears only, "Give me the epi." Not knowing what it is for, she hands him a syringe with 20 mL of concentrated epinephrine, which is 1,000 times too much. As a result, the patient suffers a massive heart attack, a near fatal event. If the team had taken time for a short conversation prior to the procedure, what do you think they could have accomplished?

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Because the operating room is a unique environment that often involves an established hierarchy and intense work

The work is stressful

Close teamwork is necessary

People and departments compete for time, space, materials, and personnel

When the patient load requires more resources than are immediately available personnel, supplies, and space.

The model for the team relationships is in transition. Hierarchical

Problems behaviors cause mistrust, frustration, and interpersonal conflict.

The person with problem behaviors uses extreme defensive or aggressive tactics to achieve a level of social comfort.

When personal attempts to resolve conflict fail, then the issue must be referred to management.

When working with people with problem behaviors, one must remember to focus on the behavior, not the person

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Karen is a pediatric nurse with more than seven years of experience. She cares for many sick children: some cases are simple, others complex. Working in this environment, Karen and her colleagues experience emotions ranging from joy to pain.

It has been a particularly hectic week for Karen. Not only are there three staff nurses out on leave, but the float and per diem nurses brought in to help have little pediatric experience. Earlier in the week, Karen switched shifts with another nurse, and she worked an evening shift and then the following morning shift. On the final shift for this long week, Karen is on the evening shift again.

Karen checks the electrodes taped to the chest of a four-year-old girl. After pulling up the bed sheet and helping the little girl get comfortable, she meant to reconnect the lead into the cord from the heart monitor machine located at the bedside. With the machine connected, the staff can monitor the patient's condition from the nurses' station down the hall.

After pulling up the sheet, Karen hears her name called over the intercom. She has an urgent phone call from her daughter. She is at her friend's house and is not feeling well. She needs someone to pick her up and bring her home.

After completing the phone call, Karen remembers she needs to reconnect the heart monitor machine. She returns to the bedside and looks down to find a cable hanging near the side of the heart monitor. She grasps the cable with her right hand. In her left hand, she holds the lead connected to the electrodes on the patient's body. This cable terminates in a circular six- point connector used on EKG leads. To connect the cable to the monitor, the cable has to be held in the proper orientation.

Just as Karen is about to trace the origin of the line in her right hand, Joan, the per diem nurse, sticks her head in the doorway to ask for the telephone number to call to have the bed in the next patient room repaired. Karen looks up. Always willing to help, she explains who to call and what forms need to be filled out. "By the way, the forms are on the intranet. The secretary is gone. I will have to help you print one out."

After helping Joan, Karen returns to the task of connecting the EKG monitor. She again grasps the six-point connector. Little does Karen know that the power cord for the recently purchased portable IV pump, which is delivering medication to the little girl and located near the bedside, has a similar six-point connection. The nurse who cared for the child during the day shift had disconnected this IV power cable from the pump and placed it near the EKG machine. When she handed the patient off to Karen, she forgot to inform her that the pump was running on battery power.

Karen finally attempts to connect the lead in her left hand to the cable in her right hand. At first, she cannot insert the lead connector. She turns the connector to align the prongs and, with some force, pushes the cables together. In an instant, the lethal current of electricity streams through the cord of the IV pump through the EKG lead. The circuit is completed as the current makes its way through the girl's body. Karen immediately realizes her mistake.

If you were redesigning the environment, processes, and systems within which Karen functioned, what design strategy would you use to prevent her from connecting the electrical cord to the EKG monitor?
a) Forcing function
b) Constraint
c) Double check