I chose to attend the Telluride Experience because patient safety is a significant topic and conversation that needs to remain at the forefront of our profession. Recognizing the various challenges faced in healthcare and the importance of effective communication affects the quality of care amongst patients. Throughout my first year in the hospital I’ve experienced pressure on many levels. Whether it be an order placed that as a new nurse, you get that feeling that it probably isn’t appropriate to give or the many ethical situations that arise during a shift. Learning priority and time management, as well as dealing with the fear of a medical error and when to speak up and advocate for my patient are challenges faced in the field.
I currently work on a Renal Medical Surgical unit and took part in the care of a patient that was placed on our floor for treatment of bacterial pneumonia. After receiving report, I began my rounds where I met a patient’s daughter who had a concern for her mothers’ cough while sleeping. The prior nurse had passed it on saying she had pneumonia and coughing was to be expected. I explained to her that this was true and but I would continue with my assessment at that time. I began with vitals which were all stable except for her oxygen saturation which varied between 88-90%. I realized she had an order for a nebulizer treatment, so I reached out to respiratory therapy. Unfortunately, they were in the middle of a code and was unable to come to the unit. I reached out to the on-call physician which was also unavailable at the time. I decided to give the nebulizer treatment myself and called my charge nurse as something just did not feel right. I noticed that throughout all of my physical assessment and treatment the patient did not wake up. The daughter let me know that her mother was not a heavy sleeper. I continued to try to get in contact with the physician and decided to call a rapid response instead. With the help of my charge nurse and fellow nurses, we were able to draw labs as the response team put in additional orders and placed the patient on a BiPaP machine. It was later seen in the x-ray that the patient had aspirated on her dinner. She was originally on a mechanical soft diet but the family was not informed and brought her dinner and coffee.
That was an experience I will carry with me though out my career. At any point either I or the family could’ve been dismissive believing that the patient was just resting, and the story could’ve resulted differently. Learning to find that voice to advocate and speak up when something doesn’t feel right is something I’ve learned to exercise. I am content with being wrong and taking a learning experience if it means ensuring my patients safety and well-being.
I look forward to learning further tools and collaborate with the group to increase patient safety and effective communication within our field.