OVERNIGHT!! One person read the statements in bold and come up with suggestions about how sign out could have been improved to better prepare the overnight team for the following events.
1. Nurse regarding George in room 1: “George is having consistently elevated blood pressures. What should we do?”
a. Teaching Point: include in sign out the possible common side effects of a new medication regimen (ACTH)
2. Nurse regarding Jeff in room 6: “I was told to have RT wean the albuterol nebs but when I just listened to him he was still wheezing. Also, mom is really hoping to leave early in the morning. Would you write him a script for the rest of his Z-pack since he’s going home tomorrow?”
i. On exam, the patient is febrile, tachycardic, tachypneic,
wheezing bilaterally with crackles at the left base and is in moderate respiratory distress. When you look back at the CXR, there is definitely patchy infiltrates, but also an area of consolidation behind the left heart seen best on a lateral film.
b. Teaching Point:Don’t forget that when receiving sign out to question the presumptive diagnosis. Collaborative cross check is a good tool to use in order to come up with this patient’s correct diagnosis. It is also important that disposition is discussed so that appropriate planning can be done by the physician coming on (especially if that is the plan discussed with the family).
3. Nurse regarding Paris in room 3: “She’s starting to have some abnormal movements of her arms and face that she can’t control after we started the amitriptyline. Would you please come and look at her.
a. Teaching Point:providing a full list of the patient’s medication allows the physician receiving sign out to do collaborative cross check about possible interactions and side effects (including dystonia when amitriptyline is added to metoclopramide and phenergan). 4. RT regarding Simon in room 5: “Do you know what James’ home BiPAP setting are? These seem high and I don’t want to give him a pneumothroax. Also, he seems to be requiring an awful lot of oxygen just to keep his pulse oximetry above 92%. What’s going on with him?”
a. Teaching Point: discussing the current condition of the patient and the contingency plan if he decompensates is vitally important in a patient like James. Again, collaborative cross-checking during sign out might have pointed out that he could have aspiration pneumonitis on top of his viral URI and that he may end up needing intensive care. 5. Nurse regarding Paris in room 3: “Christina (Christina or Paris or both??) has started having fevers. Mom thinks she probably gave her the cold that she’s just getting over. I just wanted to let you know. Also, whenever you have a chance, would you come look at her PICC line site, it’s getting a bit red.”
a. Teaching Point:here, the physician giving sign out failed to mention that the patient was on parenteral nutrition and nowhere on the sign out tool does it mention central venous access. This could have been avoided had a contingency plan for fever been discussed during sign out.
6. Nurse regarding George in room 1: “George had thirteen spasms in the last
a. Teaching Point:contingencies were not discussed and, with Andrew, what to do about increased seizure activity is critical.
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