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What's wrong with this picture
What would you do?
Potpourri
100
Situation: Mrs. P. McKrotch in room 104 has a high blood pressure reading. The nurse calls the MD and states "the patient is 103 needs a blood pressure medication", MD responds to give the patient Lopressor 5mg IV and call back with results.
What is: The nurse used the patient room number and not the patient specific information allowing for them to share the same mental model?
100
It is Friday evening and a Maintenance worker changes some settings on the "whatchamajigger" and hopes it will not cause any problems. The nursing staff is not fully informed of the situation. It is now Saturday evening and a shrill alarm is sounding and no one is sure what to do. The Maintenance worker should have done this to ensure the nursing staff were aware of what to do if an alarm sounded.
What is: He should have put out an SBAR? This would allow the various shifts over the weekend to have the same information and have a shared mental model.
100
6 is afraid of 7.
What is: Because 7 8 9?
200
Situation: Mr. C. M. Butz in room 304 is diabetic and needs a special diet. The ward secretary calls the kitchen and states "the patient in room 204 is diabetic so we will need a 3 carb diet", dietary worker responds "there is no patient listed in room 204".
What is: The ward secretary used the patient room number and not the patient specific information allowing for them to share the same mental model?
200
The water supply is interrupted to the northeast part of the building for a planned repair to the water lines. Staff were not aware and now having troubles with the toilet in the bathroom in the lobby. The supervisor in charge of the repair should have done this.
What is: Sent out a hospital-wide SBAR providing specific information about the water supply being interrupted?
200
It is green and red and goes a hundred miles per hour.
What is: A frog in a blender?
300
Situation: 2 patient's both in the ER with complaints of chest pain. Nurse states to the on-call MD, "Your chest pain in ER is puking a lot, can we give them something for vomiting?, MD responds, "The chest pain in ER1 or ER2?"
What is: The nurse used the patient condition and not the patient specific information allowing for them to share the same mental model?
300
The business office has a new procedure for documenting charges. It is the end of the month and 2 departments charges are late because they weren't aware of the changes. The business office should have done this to prepare the staff for the changes.
What is: Sent out an SBAR explaining the new charge process?
300
It is black and white and red all over.
What is: A newspaper? Alternate answer: What is: A sunburned zebra?