Weekly Must Reads in Patient Safety (June 5, 2015) – Nursing Workflow & Risk Management

Three improvement tips for this week’s must reads focus on:

  • Nursing Workflow
  • Risk Management
  • Process

Nursing Workflow

In an article in ADVANCE for Nurses, “Capnography Improves Nursing Workflow and Patient Satisfaction”, Mary Jo Valentine (director, nursing professional development, Methodist Hospitals, Gary and Merrillville, Ind.) writes:

We were not only able to improve our standard of care, but were able to this while also improving nursing workflow and patient satisfaction …

Methodist Hospitals have been able to strengthen our patient safety measures by expanding its use of capnography to monitor patients using PCA to regulate their pain after surgery. After expanding its use of capnography to monitor the respiratory status of our patients outside of the operating room, adverse respiratory events at Methodist Hospitals have declined. Not only is this a win for patient safety, but it has helped our nurses provide better and more efficient care to their patients.

#Capnography Improves Nursing Workflow and Patient Satisfaction #ptsafety Click To Tweet

Risk Management

At the recent American Society of Anesthesiologists’ Practice Management 2015 conference, Brian M. Parker, MD (anesthesiologist, Cleveland Clinic; chairman, Cleveland Clinic’s Medical Legal and Clinical Risk Management Committee) Dr. Parker discussed strategies for effective communication, because “about 70% of adverse events (AEs) can be traced back to gaps in communication”.

Said Dr. Parker:

Many times we blame adverse events on an ill-defined process, the environment of care, lack of education, lack of training or equipment malfunction, but typically they stem from human error or lack of communication

70% of #AdverseEvents can be traced back to gaps in communication #ptsafety Click To Tweet


The Institute of Medicine report, “To Err is Human: Building a Safer Health System”, reminds us:

The majority of medical errors do not result from individual recklessness or the actions of a particular group – this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. 

Anesthesiology News reports “A cutting-edge anesthesia management system developed at the University of Washington (UW) Medical Center, in Seattle, has generated an estimated return of $1 million annually for the hospital while providing a major boost to patient care.”

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