BSN 436 Assignment 2 Critical Thinking Incident

Introduction and Description of the Incident

A critical event that elucidated the failures in the area of patient safety transpired in a psychiatric unit in a large metropolitan teaching hospital, where staff are busy with constant activity and pay special attention to patients. Mr X, who has a case of severe depression with suicidal thoughts, is a 45-year-old male patient. The patient had a history of suicide attempts in the past, thus explaining why he was considered high risk when admitted. The nursing staff was familiar with his medical situation, and the first treatment plan comprised the restriction of his movements, continuous psychological assessment, and administration of drugs.

However, the incident took place when the unit was on a shift with a critical number of patients due to the absence of several nurses stemming from sickness. In the case of Mr X, it is also not just that the number of patients given to a specific nurse goes beyond several people, who have their own list of emergencies. From the records, Mr X appeared to be in relatively stable condition at some point during the day; however, signs of his agitation were disregarded – maybe due to the nurse’s heavy workload and lack of assistance. However, unlike the actions taken in the hospital, Mr X was left unattended a bit longer, to be precise, and he attempted to commit suicide. Luckily, he was discovered in time and received medical attention as soon as possible, but the case was an eye-opener in that there were some severe gaps in the system.

Incident Analysis

To comprehend what happened in the case of Mr X, it is necessary to consider the elements that led to a breakdown of safe patient care. Considering this, Evidence-Based Practice (EBP)-based organisational research could be useful to determine how and why the incident occurred, provided and/or could have occurred.

To begin with, the lack of personnel can be mentioned as the most prominent. According to EBP, staffing ratios are also significant to secure the safety of patients, and thus, it is crucial to hire adequate staffing to reduce the number of nurses to patients ratio, especially in volatile disciplines, such as psychiatry (Seham Mansour Alyousef and Sami Abdulrahman Alhamidi, 2024). Some studies prove that staff, and especially nurses, are able to deliver only sufficient care when overloaded; the adverse effects might vary between missed assessment and delayed response to the patient to unfavourable patient outcomes. In this instance, the nurse was not able to detect the symptoms of tension in the manner Mr X was acting because of work overload, since the symptoms would have been evident in case of sufficient personnel to attend to clients.

The way in which the decision was reached by the nurse is also doubtful. Although she was quite experienced and may have been sufficiently confident about her diagnostic analysis, it was perhaps a limitation of the number of necessary activities that would allow making rational, holistic conclusions regarding Mr X (Cox et al., 2021). EBP declares that since the needs of the client have to be handled in a holistic way, in the managing of a patient, all his/her state is to be taken into account however, since the environment is a highly charged one, it may have impaired her vision as she was not able to perceive the looming danger of Mr. X., the study revealed the potential existence of prejudice in the decisions made by the nurse.

Incident Reflection

Looking back at the case with Mr X, it is clear that there were several critical failure points, with most of them being a result of understaffing and communication challenges. The mental unit’s nursing staff shortfall resulted in an onerous workload, compromising the nurses’ capacity to efficiently supervise high-risk patients (Whittam et al., 2021). This not only threatened the quality of care provided, but also created an environment whereby warning signals, which were subtle, like the agitation exhibited by Mr X, were overlooked. These systemic flaws directly led to the inability to adequately monitor a patient who is known to be at a high risk of self-harm.

The quality and safety issues had been aggravated by ineffective communication and adherence to laid-down procedures. This nurse, though probably experienced, was not talking in a full interdisciplinary manner, which might have given her other perspectives and indicated that Mr X was getting any worse. Moreover, the inefficiency of the hospital to strictly follow the policy of continuous monitoring of a high-risk patient revealed the flaws in its attitude towards patient safety (Weeks, 2020). Such failures were because of a confluence of high-pressure situations, understaffing, and probably an overdependence on routine operations that resulted in an almost tragic outcome.

Steps to Prevent Such Incidences

A leader or management has to deal with organisational and human issues that led to the breakdowns to prevent the same occurrence in future. To begin with, a sufficient staffing level is essential; this can be achieved through coming up with an elastic staffing plan that will enable it to engage additional resources in the peak demand periods. The enhancement of communication and cooperation among the team is essential as well; interdisciplinary briefings and handoffs need to become routine to make sure that every team member is aware of high-risk patients and any alterations in their health (Dietl et al., 2023). In addition, making safety measures adhered to regularly, e.g. by conducting training sessions and audits, may assist in avoiding a state of complacency and make sure that critical measures are implemented.

Conclusion

To sum up, the severe incident that happened to Mr X reminds us of the complexity and issues of providing patient safety within a healthcare environment in a sad way. In-depth research and reflection show that care failures (understaffing, lack of communication, and failure to adhere to protocols) had a pivotal role in the unwanted outcomes. To address these challenges, healthcare leaders can instil a culture of patient safety by implementing evidence-based policies, including staffing, developing a collaborative culture, and maintaining complete compliance with safety measures. This will reduce the chances of similar incidents.

References

Cox, C. L., Miller, B. M., Kuhn, I., & Fritz, Z. (2021). Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues? Family Practice, 38(5), 654–668. https://doi.org/10.1093/fampra/cmab023

Dietl, J. E., Derksen, C., Keller, F. M., & Lippke, S. (2023). Interdisciplinary and interprofessional communication intervention: How psychological safety fosters communication and increases patient safety. Frontiers in Psychology, 14(14). https://doi.org/10.3389/fpsyg.2023.1164288

Seham Mansour Alyousef, & Sami Abdulrahman Alhamidi. (2024). Psychiatric mental health nurses’ perceptions and experiences of inpatient mental health care safety culture in Saudi Arabia. Journal of the American Psychiatric Nurses Association. https://doi.org/10.1177/10783903241252806

Weeks, K. (2020). Exploring the nexus of patient safety and patient-centered care: a study of high performing hospitals. https://jscholarship.library.jhu.edu/bitstream/1774.2/63813/1/WEEKS-DISSERTATION-2020.pdf

Whittam, S., Torning, N., & Patching, J. (2021). A narrative inquiry approach to understanding senior intensive care nurses’ experiences of working with new graduate nurses. Journal of Clinical Nursing, 30(21-22). https://doi.org/10.1111/jocn.15844