Enhancing Patient Safety through Reflective Practice

Introduction

This essay aims to explore the objectives of the Scottish Patient Safety Programme (SPSP, 2008) concerning early intervention in deteriorating patients through reflective practice. Utilizing Gibb's (1988) reflective model, this essay will analyze and assess a personal experience during a clinical placement, demonstrating the application of theory-based knowledge and skills as per SPSP guidelines. It will particularly focus on the monitoring of the Early Warning Scoring (EWS) system, the use of the SBAR (Situation-Background-Assessment-Recommendations) tool, and safety briefings in relation to patient safety.

The essay will follow a structured six-step approach, comprising event description, emotional response, evaluation, analysis, conclusion, and an action plan for future practice. To protect patient confidentiality, the patient will be referred to as Mr. Smith.

Event Description

During my clinical placement on a busy acute medical ward, I encountered Mr. Smith, who complained of abdominal pain. Notably, his skin appeared extremely pale, and he seemed agitated. I promptly conducted a check of his vital signs, revealing hypotension (blood pressure 79/49) and tachycardia (heart rate 123 bpm).

Get quality help now

KarrieWrites

Verified writer

Proficient in: Blood Pressure

5 (339)

“ KarrieWrites did such a phenomenal job on this assignment! He completed it prior to its deadline and was thorough and informative. ”

+84 relevant experts are online

Hire writer

While his temperature, respiratory rate, and oxygen saturations remained within the normal range, his EWS score of 4 prompted me to alert the nurse in charge and the ward's medical team in accordance with SPSP guidelines.

Emotional Response

I experienced a sense of relief knowing that my observational skills and knowledge helped me recognize Mr. Smith's deteriorating condition. Having access to protocols like the EWS driver diagram bolstered my confidence, ensuring I took the necessary action promptly. Mr. Smith received medical attention within ten minutes of my alert, and it became evident that crucial information about his previous gastrointestinal (GI) hemorrhage had not been communicated during the handover report—a detail I deemed vital and potentially detrimental to his care.

Evaluation and Analysis

Gastrointestinal hemorrhages account for 7% of deaths in Scotland (SIGN, 2008). The SPSP, in collaboration with Health Improvement Scotland (HIS), developed the Hospital Standardized Mortality Rate (HSMR) toolkit to study mortality rates and healthcare improvements in Scotland, with the goal of reducing mortality rates and patient harm, including near-misses in acute ward settings (HIS, 2011).

SPSP promotes strategies like SBAR and EWS to identify potential patient risks and enable early intervention. Effective communication among staff, including relevant patient medical history, is crucial for providing specific and appropriate care. The SBAR tool, adapted from other industries, serves to facilitate communication between healthcare practitioners (NHS, Institute for Innovation and Improvement, 2013). EWS, on the other hand, assesses patients' physiological status and identifies clinical deterioration through a scoring system based on vital sign abnormalities.

However, it is important to recognize that errors may occur when using EWS, particularly if scoring is not carried out accurately. Factors such as familiarity with the patient, recognizing signs of deterioration, appropriate referral practices, and the timing of assessments may contribute to potential errors (Odell et al., 2009).

Research has shown that the use of SBAR in healthcare settings reduced communication errors by 50% (NHS, Institute for Innovation and Improvement, 2013). However, it is essential to emphasize that proper utilization of the SBAR tool is necessary to prevent communication errors that could compromise patient safety (Royal College of Nursing, 2013).

Mr. Smith was admitted through Accident and Emergency (A&E) during the night with acute abdominal pain and later transferred to the acute medical ward. It remains unclear whether his previous GI hemorrhage history was known at this point, but it had not been highlighted during the handover report. By the time I assessed Mr. Smith's condition, it was evident from his vital signs, EWS score, pallor, and pain level that he was deteriorating.

While the EWS system prompted the immediate care and intervention that Mr. Smith needed, the SBAR tool could have potentially prevented his deterioration earlier. Proper communication of Mr. Smith's background could have led to earlier implementation of care protocols, such as hourly vital sign monitoring, risk scoring, hematology screening, and endoscopy, in alignment with the Scottish Intercollegiate Guidelines Network (SIGN 105, 2008).

Following the realization of Mr. Smith's deterioration and suspicion of another GI hemorrhage by a medical practitioner, he underwent an urgent abdominal ultrasound scan. His haematology results indicated hypovolemia, necessitating a blood transfusion that was administered following proper documentation protocols, including consent, identity confirmation, double-checking by trained nurses, clear labeling, and countersigning (HIS, 2010). I was responsible for monitoring Mr. Smith's vital signs before, during, and after the blood transfusion to detect any adverse reactions, as severe reactions are more likely to occur within the first 15 minutes of infusion (Ackley et al., 2008).

Mr. Smith's agitation during this process further highlighted the importance of effective communication and patient reassurance. Within approximately 45 minutes, his vital signs improved. He was then escorted for his abdominal ultrasound scan, although his EWS score remained low despite evident pain and distension.

Conclusion

The SPSP's and HIS's aim is to reduce patient harm by implementing protocols that enhance inter-professional communication and promote early intervention through tools like EWS, SBAR, and safety briefings. Mr. Smith's case could have been classified as a "near miss" due to inadequate communication of his medical history. Still, the EWS system effectively identified his deterioration and led to timely interventions, minimizing further harm.

Action Plan

Reflecting on this experience underscores the importance of communication in patient care. It has emphasized the need for comprehensive patient background information to influence care decisions. Furthermore, it highlights the significance of vigilant observation, alongside practical skills like vital sign assessment. Documentation has been reinforced as a critical legal requirement that facilitates comprehensive patient care records for future reference.

My action plan following this experience is to prioritize patient safety by applying a combination of skills, including observational, communication, and clinical judgment. Reflection will continue to play a crucial role in my learning process, helping me recognize both strengths and weaknesses in my practice. This insight gained from reflection will guide my future growth as a nurse, ensuring I consistently provide safe and effective care to patients.