Cutting back on nurses education leads to an increase in hospital errors

Managing the huge variety of patients that come through the doors of Emergency Departments is just not that easy.

The way different people’s bodies react to an illness can be surprising. 

That’s why ensuring that time is put aside for continuous nursing education is so important.

An elderly man called Battista was brought in to the Emergency Department by his relatives. Battista was coughing, and complaining of shortness of breath.

The family told the Doctors he’d had a bad cold for several weeks.

“The doctor gave Dad some antibiotic tables, but they didn’t work” explained his daughter. “We didn’t know what else to do.”

When the doctor listened to Battista’s chest with a stethoscope, he could hear coarse crackles in the bottom of both lungs.

Battista was also coughing up thick green sputum.

The Doctors diagnosed a severe chest infection.

He prescribed Battista intravenous antibiotics and told him he would be admitted to hospital for a couple of days.

The family was relieved. At least Battista was getting some attention.

Battista had smoked all his life. He’d worked hard, and was now retired.

“A couple of days in hospital is all he needs” the daughter assured her mother.

Medical records are fragmented and vital information is often missing

Nurses tried to find his medical history. But Battista rarely went to the Doctor. There was very little information available. His General Practitioner did not answer the phone.

It was impossible to get clear information out of Battista as his English was quite poor.

The nurses did Battista’s observations and were concerned that his oxygen levels were quite low. He was visibly struggling to breath and kept coughing up thick sputum.

Nurses wanted to get his oxygen levels up to a normal range and reduce his work of breathing. So they gave him 6 litres of oxygen via a mask.

He was also given inhalers to open his airways, and saline nebs to break down the thick sputum.

With the oxygen and ventolin medications, his shortness of breath seemed to subside. Battista appeared more comfortable. His breathing was not as laboured. He seemed calmer.

A specimen of sputum sent off for testing, to see what type of chest infection he had. 

A bed was found for Battista on a general medical ward in the hospital.

On this ward nursing staff were used to dealing with a range of elderly patients with conditions like infections, cardiac irregularity and dementia.

The ward nurse who admitted Battista checked his oxygen levels. They were still low. She turned up the oxygen mask from 6 litres to 8 litres a minute. She helped him undress and get into the hospital bed. By now Battista was slow moving and seemed a little confused.

The nurse made sure he got his antibiotics on time and checked to see that the sputum specimen had been sent off to pathology.

Nursing staff were busy overnight, and only checked Battista intermittently. The oxygen remained on at 8 litres a minute.

He appeared to sleep soundly.

At 6 am the night nurse had difficulty raising Battista. She thought that was odd.

At that time of the morning the ward lights were turned on and nurses were busy running around doing obs and giving out medications. Most patients were awake and asking to be taken to the toilet.

Despite his oxygen mask still being at 8 litres, his oxygen saturations were still low. She made a note to let the medical team know when they did their morning rounds.

Then she turned the oxygen up to 10 litres a minute.

Too late

As usual the early morning nurses shift was rushed.

Patients had to be sat up for breakfast, given tablets and taken to the toilet. By 9am the doctors were starting their round.

They found Battista lying in his bed, with the oxygen mask on at 10 litres. He was unconscious, barely breathing. His pulse was thready and irregular, his blood pressure was so low it didn’t’ register. His face was extremely pale.

A code blue, or emergency call was made.

The crash team, or resuscitation team rushed in. A  junior doctor took a sample of blood from an artery in Battista’s wrist and sent off for an  arterial blood gas test.

The results showed that Battista had low levels of oxygen, high levels of carbon dioxide and his blood ph was in the acidic range. Type 2 respiratory failure was diagnosed.

Battista was rushed by ambulance to a more advanced hospital, with an Intensive Care Unit.

He subsequently died.

Nurses in this hospital all worked short shifts, seven and a half hours, instead of the normal eight hours. This saved the hospital from paying for an extra half an hour per nurse, per shift. The hospital management thought this was economical.

However it also meant  there was no time available for any formal nursing education to take place. As a consequence, nurses did not revise essential knowledge, like the difference between type 1 and type 2 respiratory failure.

Wikihospitals 2014

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