Archive for the ‘patient safety’ Category


Recognizing and Managing Late or Long-Term Complications in Adult Allo-HSCT Survivors

November 17, 2015

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

Everybody, myself included, thought he was going to die. Another nurse on another floor had administered his stem cell transplant a few weeks prior, but as his primary nurse I was now in charge of managing its aftereffects.

Ben (not his real name, and some details have been changed) was one of the many young patients I’d cared for who suffered from a violent course of complications following allogeneic hematopoietic stem cell transplant (allo-HSCT). Intractable diarrhea and skin sloughing led to graft-versus-host-disease’s usual sequelae: wounds, drug-resistant infections, looming sepsis. The walls of his bladder, scarred and irritated by the myriad of toxic drugs he’d been given, bled. One day, while I slept at home between night shifts, he lost so much blood that they rushed him to the OR. The treatment—never before performed—stopped the bleeding. But it left him in excruciating, around-the-clock pain.

Between regular doses of Dilaudid and PCA pump pushes, he cried out to me, “I can’t do this. I don’t want this anymore.” I couldn’t blame him—his cancer fight raged on endlessly. Watching his boyishly handsome face grimace with so much pain, I remembered other young allo-HSCT patients’ faces, some of them peaceful only in the postmortem.

As it turned out, Ben survived his ICU stay. I heard about his discharge to the bone marrow transplant unit after I returned from a vacation. I lost touch with him, in the way that most ICU nurses lose touch with their patients (as though the unit is earth and the floors are outer planets, foreign and unknown, impossible to visit). I hope he’s home now, though, and a part of me believes he is—living, joining the growing population of allo-HSCT survivors.

As I read Kara Mosesso’s November CE article in AJN,Adverse Late and Long-Term Treatment Effects in Adult Allogeneic Hematopoietic Stem Cell Transplant Survivors (the first of several articles from Memorial Sloan Kettering Cancer Center about cancer survivorship care), I thought of Ben and was glad to be reminded that people like him do survive. While the current population of allo-HSCT survivors is fairly small, it’s growing, and by 2020 may reach around half a million worldwide.

It seems that all nurses—whether caring for allo-HSCT patients in the acute phase, like me, or in the chronic phase in an outpatient setting, must become familiar with the multifaceted long-term care of this population of patients. The table below, from the article, lists various late and long-term allo-HSCT treatment effects and their risk factors. Visit the article link above for more context, sources, and more.

Late and Long-Term Allo-HSCT Effects

(click to enlarge)

Read the rest of this entry ?


Check my Conduct: Committing to a Better Way to Act with Colleagues

November 10, 2015

Christina Purpora, PhD, RN, is an assistant professor at the University of San Francisco School of Nursing and Health Professions. She has 30 years of hospital nursing experience.

Kindness quotation. Photo by Steve Robbins/Flickr

by Steve Robbins/Flickr Creative Commons

I wonder whether any of my nurse colleagues can recall having said or done something less than kind to a peer at work. Looking back over 30 years of nursing, I am aware of times that I could have been kinder. Not too long ago, the way that Emily—a less experienced nurse who was new to our unit—conducted herself in response to my reaction to her request for help taught me that I ought to consider a better way to act.

Request for Help
I was walking out of a patient’s room when Emily greeted me by name, then said, “Ms. S has one of the new IV pumps and the alarm keeps going off. I can’t figure out what’s wrong. Can you please help me?”

I felt annoyed at her for making one more demand on my time when I could barely keep up with my current assignment. Rolling my eyes, I curtly replied, “Emily, I think you can handle it. You had the in-service like everybody else.”

Seemingly unrattled by my terse retort, Emily stood her ground. “Yes,” she told me, “I used the troubleshooting tips I learned. But there’s still a problem. I’m concerned about Ms. S. and I’m uncomfortable that I’ve missed something. I think this is a safety issue.”

I recognized Emily’s use of the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS “CUS” words: Concern, Uncomfortable, and Safety, a tool designed to clearly communicate that a patient is at risk for harm when a first attempt to get a safety threat across to a member of the health care team doesn’t work. The initial irritation I’d felt turned to embarrassment, and I answered Emily’s explanation with, “Okay, let’s go see Ms. S.”

I followed Emily to her patient’s room where, together, we figured out the problem. Ms. S. was unharmed. Outside of the patient’s room, Emily thanked me and asked what she could do for me in exchange for the time I’d spent helping her. When nothing came to mind, she reiterated, “Please let me know if something comes up, because I’d happy to help you.”

My embarrassment grew in the presence of Emily’s team approach. With the potential safety threat averted, we carried on with our respective patient care responsibilities.

Reflect and Amend
For the rest of the shift, I couldn’t stop thinking about my outburst, which stood in glaring contrast to Emily’s professionalism. When I realized that a patient could have been harmed while I was resisting my peer’s call for help, I was horrified. I wanted to apologize to Emily. Read the rest of this entry ?


Preventing Newborn Falls

November 4, 2015
Photo by Joseph Sacchetti.

Photo by Joseph Sacchetti.

An acquaintance of mine once admitted to dropping her newborn baby while feeding her in the middle of the night. At the time I inwardly scoffed—how can someone be that tired, I thought judgmentally. Fast-forward to a few years later when I can now speak as a new mother—and to being that tired.

Sleep deprivation is no joke. And it doesn’t necessarily begin when the baby is born. The last few months of pregnancy and the discomfort that comes with it make for difficult sleep preceding the birth.

Many maternity units now promote “rooming in,” where a newborn baby stays in the mother’s room rather than with the nurses in the nursery. This makes newborn fall prevention an important issue. Take poor sleep in the last months of pregnancy and the physical and mental exhaustion of labor and add pain and limited mobility from the birth itself, especially a C-section birth; large rails on hospital beds making the transfer of one’s baby from bassinet to the mother’s bed difficult; and possible pain meds for mom, and the recipe could spell disaster.

In my case, with an emergency C-section and limited mobility, I found it very hard to pick my baby up from his bassinet and bring him into my hospital bed for a feeding. Luckily my husband stayed in the hospital room overnight and the nurses checked in around the clock, but not all mothers may be as fortunate.

In the November Safety Monitor column, “Preventing Newborn Falls While Supporting Family Bonding,” the Pennsylvania Patient Safety Reporting System highlights examples of such falls, pointing out that most occur “between midnight and 7 AM.” The article also highlights what hospitals—and nurses—can do to prevent these occurrences. Newborn fall prevention programs might include: Read the rest of this entry ?


AJN in November: New Cancer Survivorship Series, Holistic Nursing, Safe Opioid Use, More

October 30, 2015

AJN1115.Cover.2nd.inddOn this month’s cover, a nurse provides care to a patient at Clearview Cancer Institute in Huntsville, Alabama. The photo was chosen as the third-place winner of AJN’s 2015 Faces of Caring: Nurses at Work contest. Photographer Kim Swift shot the photo while shadowing her sister, a nurse, for a day. Swift sought to capture what she calls “the trust factor” between patients and nurses. She found a prime example of that relationship when she noticed the way one patient looked at her nurse as he explained an aspect of her cancer treatment.

To read the first in a series of AJN articles on cancer survivorship from the Memorial Sloan Kettering Cancer Center, see “Adverse Late and Long-Term Treatment Effects in Adult Allogeneic Hematopoietic Stem Cell Transplant Survivors.” This article—the first of several on cancer survivorship—summarizes the identification, evaluation, and management of potential treatment-related effects in adult survivors of hematopoietic stem cell transplants, with special focus on cardiovascular disease risk factors.

Some other articles of note in the November issue:

CE Feature:Imagery for Self-Healing and Integrative Nursing Practice.” Research suggests that that the use of imagery can help reduce patients’ pain and anxiety and improve their quality of life and outlook on their illness. The second article in a five-part series on holistic nursing describes how imagery can be used to encourage patients’ healing process and presents an imagery technique and a sample script to use in practice.

Clinical Feature: Prescription Opioid Analgesics: Promoting Patient Safety with Better Patient Education.” Inappropriate use of prescription opioids has increased sharply in the past two decades in the United States. Patients and caregivers must have an adequate understanding of safe use, storage, and disposal of opioids to prevent adverse drug events in patients and others. Using a case study, the author of this article examines the risks of nonmedical opioid use in postoperative patients and highlights the nurse’s role in patient education to avoid adverse outcomes.

From our Safety Monitor column: Preventing Newborn Falls While Supporting Family Bonding.” Recent studies and reports suggest that newborn injuries, such as falls, may be an unintended consequence of leaving newborns with fatigued parents in the first hours and days of life. This article addresses the circumstances behind newborn falls in hospitals when infants are in the care of family members, and reports on steps hospitals—and nurses—can take to effectively prevent these accidents. Read the rest of this entry ?


Medical Marijuana: A Nurse’s Primer

October 27, 2015

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog.

Illustration by J Paradisi.

Illustration by J Paradisi.

Since I wrote “Marijuana Legalization and Potential Workplace Pitfalls for Nurses Who Partake” in July 2014, a few things have changed. For one, Measure 91 passed in Oregon, making it the third state to legalize recreational marijuana. Medical marijuana, however, has been legal since 1998 in Oregon, currently one of 23 states nationwide.

Also, when I wrote the earlier post, I was an infusion nurse—now, as an oncology nurse navigator, I’m asked about medical marijuana often, and I need to know the answers, as do all nurses practicing in states with legalized medical marijuana. Nurses working in oncology, emergency departments, pain management, infusion clinics, and pediatrics have high exposure to patients with medical marijuana cards.

By ‘knowledge,’ I don’t mean knowing everything, but knowing where to find what you need to know. In Oregon, for example, information about medical marijuana is found at the Oregon Medical Marijuana Program (OMMP). The Web site includes qualifying diagnoses, a downloadable handbook, an application packet with instructions, and a list of approved dispensaries. While retail issues surrounding recreational marijuana are still being sorted out, medical dispensaries in Oregon sell recreational marijuana to clients aged 21 and older.

Patients using medical marijuana are as diverse as the illnesses and side effects they use it to treat: PTSD, seizure disorders, chronic pain, inflammatory illness, and of course the adverse effects of chemotherapy, including nausea and vomiting, anxiety, sleeplessness, anorexia, and hot flashes associated with endocrine suppression therapy. Read the rest of this entry ?


Nursing Ethics: Helping Out on the Unit vs. Teaching Nursing Students Crucial Skills

September 23, 2015

By Jacob Molyneux, AJN senior editor

scalesJust as no two hospital units are exactly alike, rarely are two ethical conflicts exactly alike. There are too many variables, too many human and situational differences. This month’s Ethical Issues column, “Teaching Crucial Knowledge vs. Helping Out on the Unit,” explores potential ethical and practical issues faced by a clinical instructor who must balance the duty to teach essential skills to nursing students against the staff’s need for help in meeting patient care needs.

Will there be an easy, cut-and-dried answer? Probably not. In the course of their analysis of a hypothetical scenario, the authors make the following point:

Because new situations arise all the time, and every situation varies in its ethically relevant aspects, rigid rules often cannot guide ethical action. Instead, analytic skills and transparent negotiation are crucial for resolving conflicts between values as they arise in day-to-day interaction—and for supporting the solutions we choose.

While people skills may be as important as abstract ethical analysis in dealing with real world situations, determining which ethical principles or priorities are coming into conflict may provide us with a certain measure of clarity in our approach. The authors frame the conflict described in the article in the following way:

Read the rest of this entry ?


Evidence-Based Practice and the Curiosity of Nurses

July 27, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

karen eliot/flickr

by karen eliot/via flickr

In a series of articles in AJN, evidence-based practice (EBP) is defined as problem solving that “integrates the best evidence from well-designed studies and patient care data, and combines it with patient preferences and values and nurse expertise.”

We recently asked AJN’s Facebook fans to weigh in on the meaning of EBP for them. Some skeptics regarded it as simply the latest buzzword in health care, discussed “only when Joint Commission is in the building.” One comment noted that “evidence” can be misused to justify overtreatment and generate more profits. Another lamented that EBP serves to highlight the disconnect between education and practice—that is, between what we’re taught (usually, based on evidence) and what we do (often the result of limited resources).

There’s probably some truth in these observations. But at baseline, isn’t EBP simply about doing our best for patients by basing our clinical practice on the best evidence we can find? AJN has published some great examples of staff nurses who asked questions, set out to answer them, and ended up changing practice.

  • In a June 2013 article, nurses describe how they devised a nurse-directed protocol that resulted in fewer catheter-associated urinary tract infections (CAUTIs).
  • A 2014 article relates how oncology nurses discovered the lack of evidence for the notion that blood can only be transfused through large-bore needles. These nurses were able to make transfusions safer and more comfortable for their patients. Read the rest of this entry ?

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