A Sentinel Event Related To Nurse Fatigue Nursing Essay

A Sentinel Event Related To Nurse Fatigue Nursing Essay 12 hour shifts, extended work periods, voluntary and mandatory overtime, and excessive workloads are all factors that dangerously contribute to nurse fatigue, which has led to a number of medication errors and sentinel events (Rogers, Hwang, Scott, Aiken, Dinges, 2004). In the 2004 study by Rogers, Hwang, Scott, Aiken, Dinges, it was found that the longer the shift, the risks for errors increases. Also, when working longer than 17 hours without sleep, nurse fatigue has been shown to demonstrate the equivalence of being under the influence with a blood alcohol concentration of 0.05% (Garrett, 2008). The effects of fatigue on nurses includes problems such as: compromised problem-solving skills, decreased attention span, delayed reaction time, memory lapses, impaired communication, and inability to focus, which are all important for nurses to be aware of in order to provide quality and safe patient care (Warren Tart, 2008). The evidences and dangers of nurse fatigue linked to adverse events from the long work hours and cumulative days of extended work hours has been greatly recognized by The Joint Commission (TJC) issuing a sentinel event alert on December 14, 2011, regarding health care worker fatigue and patient safety (The Joint Commission, 2011). So, I will be discussing the following in the paper that includes: explanation of reviewable sentinel events, a specific sentinel event related to nurse fatigue, and its root cause analysis. Explanation of Reviewable Sentinel Events As defined by TJC, a sentinel event is an unexpected occurrence involving either death, serious physical or psychological harm, or the risk thereof that prompts the need for immediate investigation and response (Sentinel Events Policy and Procedures, 2012). But, for a sentinel event to be considered reviewable, it must meet any of the following criteria: the event resulting in an unanticipated death, coma, permanent loss of function, unrelated to the natural course of the patients illness or underlying condition, or the event is one of the following, but not limited to: suicide within 72 hours of being discharged from a 24 hour care setting rape, sexual abuse/assault elopement abduction (Sentinel Events Policy and Procedures, 2012). A Specific Sentinel Event Related to Nurse Fatigue On July 5, 2006, Jasmine Gant, a pregnant 16 year old high school student, arrived with her mother at St. Marys Hospital in Madison, Wisconsin at 9:30 A.M. for her scheduled induction (Smetzer, Baker, Byrne, Cohen, 2010). The Labor and Delivery (LD) nurse assigned to care for Ms. Gant that day was Julie Thao, 41 years old. Mrs. Thao had been working at St. Marys Hospital since 1993, and worked in the LD department for 15 years. The day before July 5, 2006, Mrs. Thao had voluntarily worked a double shift for a total of 16 hours or more to cover for the units short staff. Mrs. Thao was extremely fatigued by the end of her shift that ended at midnight. She spent the night at the hospital to avoid her hour long commute home and because she was due for her next shift at 7 A.M. So on the morning of July, 5, 2006, the very fatigued nurse Mrs. Thao started her shift caring for one expectant mother. When Ms. Gant presented at the LD unit later that morning, Mrs. Thao spent time with her and her mother completing the admission process that is done with every admitting patient. However, Mrs. Thao did not apply a bar-coded identification band to Ms. Gants arm at this time (Smetzer, Baker, Byrne, Cohen, 2010). When discussing pain management, Ms. Gant expressed the possibility of wanting to use epidural, which Mrs. Thao would relay the message to the obstetrician. At 11:30 A.M., Ms. Gants physician arrived to her room to rupture her amniotic membrane. The physician told Mrs. Thao that he planned to check back before determining with the patient the need for epidural. In the meantime, he had ordered Pitocin, Lactated Ringers (LR) solution, and intravenous (IV) penicillin to treat a strep infection that Ms. Gant had. While Mrs. Thao was in the room, the patient communicated to her that she was anxious about receiving epidural. So, Mrs. Thao thought it would be a good idea to retrieve epidural solution, Bupivacaine, to show the patient and in anticipation since the Anesthesiologist would get upset for not having it readily available. Now, St. Marys Hospital had just started transitioning and training the employees in using the newly installed bar coded medication administration system. Apparently, the hospital was currently having problems with it, so the nurses were instructed to give the medications when needed and document them manually. Well, Mrs. Thao bypassed the system to remove the Bupivacaine, which she also did not have authorization or permission to do so for that medication. Then, she gathered the LR solution and Pitocin before walking back into the patients room. On the way, another nurse handed her the IV penicillin. When Mrs. Thao entered the patients room, she sat the supplies on the counter and began to prepare and initiate the IV infusion. Carelessly, Mrs. Thao made the fatal mistake and grabbed the epidural solution instead of the penicillin, both looking very similar in appearance, administering it intravenously into Ms. Gants arm. Unknowingly of the mistake she had just done that would soon c ost her nursing career and her patients life, Mrs. Thao went on to rewinding the tape on the birthing process to play for the patient, her mother, and the babys father who had just showed up creating lots of tension. Within minutes, the patients mother terrifyingly screamed for mercy. At this point, her daughter was in respiratory distress, seizing, and into a cardiac arrest. The frantic nurse immediately called the rapid response team and code blue. Every effort was made to resuscitate Ms. Gant, but she remained asystolic. Ms. Gant was immediately taken to the operating room to have an emergency cesarean section where the physicians delivered an 8 pound healthy baby boy. The health care team continued resuscitating Ms. Gant, but was pronounced dead by 1:43 P.M. After ruling out several possible causes of her death, it was discovered minutes later that the infusing bag was the epidural solution, instead of the penicillin (Smetzer, Baker, Byrne, Cohen, 2010). Her colleagues reported that Mrs. Thao looked extremely fatigued, which possibly increased her likelihood of making the fatal medication error along with the omission to verify the five rights of medication administration. The Root Cause Analysis A root cause analysis (RCA) is a technique used to help identify the possibilities of causes that led to the end result. When a sentinel event occurs, the hospital is accountable to do a root cause analysis. The point of RCA is not to point out who is to blame. Thus, by conducting a RCA, it allows for a plan of action to prevent the same or similar incidents from occurring. The first part of the RCA is defining the problem or effect. Part two is determining why it happened with the cause and effect technique. Part three is generating solutions and implementing a plan of action to reduce the likelihood of the event from happening again. In the sentinel event above, the problem was a medication error by registered nurse (RN) Julie Thao that had resulted in the maternal death of 16 year old expectant mother, Jasmine Gant. The four cause categories formulated for this specific case are: people, work environment, equipment, and policies and procedures. The nurse Mrs. Thaos fatigued had a tremendous effect on the actions leading to the medication error. She had voluntarily worked a back to back shift of 16 hours or more the night before starting work again the next morning. She expressed the desire to go home halfway through her second shift, too. While taking care of Ms. Gant, the nurse was distracted while preparing the medications. Mrs. Thao reported that there was tension in her patients room when the babys father arrived, so she had intended to administer the IV penicillin and put on the educational video of the birthing process. The work environment of the LD unit that Mrs. Thao worked on was not well organized. The nurses did not directly communicate with the Anesthesiologist making it difficult to have the epidural ready upon their arrival. The unit was also short staffed with several nurses on temporary leave (Smetizer, Baker, Byrne Cohen, 2010). If Mrs. Thao had not worked second shift, they would have been inadequately staffed. The staff and managers did not strictly enforce and comply with the policies such as the identification bands and bar code medication administration system. So, the problems associated with the policies and procedures included the delay of the patients identification bar code band application, omission of verifying the five rights of medication administration, and retrieving the epidural before it was ordered. The issue with the delay of the patients identification band was that it took longer for the bands to be made with the new system. The staff and management were lenient and made it a norm to put it on the patient whenever it was a convenient time. However, Mrs. Thao confessed that she did not comply with the five rights of medication administration. Also, she retrieved the epidural before it was ordered to decrease her patients fear and in anticipation of early epidural. Retrieving the epidural in anticipation upon the Anesthesias arrival was a common practice on the LD floor because of the dissatisfaction expressed by some Anesthesiologist of it not being readily available. For equipment, there was the problem of the newly installed bar code medication administration system and the design of the bag of epidural solution and IV penicillin. The new systems constant problems created low rates on compliance on scanning IV bags, and nurses bypassing the system, which included safety features to prevent such errors from happening. The LD unit staff had inadequate training on troubleshooting the system, especially Mrs. Thao. Instead, management allowed them to hang the medications and document them manually. With the mistake of grabbing the wrong bag, Mrs. Thao had brought all the supplies including the two bags from the anteroom and sat them onto the counter near the patients bedside so that she can converse with the patient directly. The bag containing the epidural solution and the bag of the penicillin looked similar in size, but the epidural was slightly bigger. They were both clear solutions. The two bags both had orange label stickers, but the epidural b ag had an additional bright pink warning label. There is also a design flaw in the interconnectivity making the IV tubing compatible with accessing the epidural bag port like it does with the IV solutions (Smetizer, Baker, Byrne Cohen, 2010).

Conscience vs. Society

Conscience vs. Society Conscience and society are often in conflict with one another. Your culture and the people around you may be telling you to do one thing, while in your heart; you feel that a different way is the way to go. This is exactly what happens in Sophocles’ play Antigone. Ismene, Haimon, and Creon all have a difficult time choosing between following what their conscience is saying and what society thinks, which leads to conflict between the characters. Ismene faces this conflict of conscience vs. society when deciding whether to help Antigone bury Polyneices or not.When Antigone asks her if she is going to bury him with her, and if she even cares about her brothers, Ismene says â€Å"They mean a great deal to me; but I have no strength to break laws that were made for the public good. † (Prologue, 62-63) Ismene wants Polyneices to have a proper burial as much as Antigone does, but she does not feel that it is worth the risk of her own death. She has to ch oose between risking her life to bury her brother, or living with the guilt of Polneices never being fully put to rest. This leads to conflict between her and Antigone because she feels abandoned by her sisters’ choice to not help her.Haimon faces the problem of conflict vs. society when he talks to his father, Creon. After Creon sentences Antigone to death for breaking his law about burying Polyneices, Haimon says; â€Å"For me your judgments and the ways you act on them are good. I shall follow them†¦ don’t let you mind dwell on just one thought, that what you say is right and nothing else. † (Scene 3, 720-21 and 799-800) At first, Haimon is saying that he will follow and agree to anything his father does or says; but then, he goes on to say that his judgments may not be correct and that he should stay more open-minded on his decision.At first, Haimon starts by saying what his father would want him to say, but then changes his mind and speaks of what he k nows is right. This leads to conflict between his father and him because he is not just saying what his father wants to hear anymore. Finally, Creon faces this conflict after Teiresias shares his prophecy. When he tells Creon of his fate if he does not bury Polyneices and free Antigone, he faces a hard decision: â€Å"It’s dreadful to give way, but to resist and let destruction hammer down my spirit, – that is a fearful option too. (Scene 5, 1225-27) He has to choose between what everyone (even the gods) wants to happen, which is to let Antigone go and give her brother a proper burial, and what he thinks is right, which is to kill Antigone off and let Polyneices rot on the battlefield. This is the first time in the play he actually listens to reason, even if it is for his own benefit. This leads to conflict within himself. The characters in this play go through many conflicts, a lot of which have to do with choosing between what society thinks and what that character thinks.Ismene has to choose between following the law and breaking it to bury her brother, Haimon has to choose between following his father or going against him for the woman he loves, and Creon must choose between letting Antigone die and Polyneices stay unburied or burying him and letting Antigone go. This all leads to conflict between the characters and themselves. The concept of conscience vs. society is nothing new and will continue to be a point of conflict in peoples’ lives until the day they die.

How does Friiel use language and stagecraft Essay

Friels main concern, writing in the 1980s, seems to be the struggle for identity. One interpretation of the play is that Irish identity has been continually threatened since 1591. Friel writes his play in 1988 whilst living through Irish civil unrest during the troubles of northern island. By setting making history in 1951, friel is addressing time span and the struggle for identity that he may feel began with the English/Irish power struggle. The book centres on Hugh O’Neil, who is the Earl of Tyrone and at the start of the play is 41 years old. He is described as a ‘ private, sharp minded man’, and he is a good main character because he is an interesting person who has a lot of conflict in his life. Hugh O’Neil changing his accent from English/Irish to Tyrone, is a good use of a languageas he always speaks in an upper-class English accent accept on the occasions specifically scripted. The Tyrone accent usually happens when he is angry about something. ‘ Just to show him I haven’t reverted completely to type- would that be it’, Friel choosing to use this type of lanuguage shows that O’Neil is rebellious and is proud of his irish identity. The arguement between Mary and mabel in the garden shows how Mabels identity and alliegience has changed from English by Irish. This is shown when the two are discussing farming and is asked about the orchards and says ‘No, WE havent’. This use of language shows she conisders herself part of the irish identity. The use of stage craft in this scene shoes the intensity of Mary and Mables conversation ‘ speaks with concern and passion’. This further highlights the conflict between the English and and Irish and the struggle for Mary to accept Mabels new identity. Mabel and the baby’s death is a signifficant point in the play as it is a metaphor for the inabiliity of England and ireland being able to Co-exist peacefully, as the baby would have had both enlgish and irish blood in him.  The timeline from when the audience is first inroduced to hugh and then at the end of the play is a signifficant contrast and change to his identity. The stagecraft used shows this as he is described as being ‘volatile and bitter’ compared to the beginging of the play when he is described as ‘uncharacteristically outgoing and talkative’. Friel and lomabrd are both trying to create history, Friel with the play he wrote and lombard with his Biography of Hugh Oniels life. Lmbard tries to make Hugh appear to be a hero but this displeases hugh as he feels it is not his true identity.’ i dont trust you. i dont trust you to tell the truth’. Each part of the play highlilghts how brian friel has shown the struggle for identity through the use of language and stagecraft. The main use of language that friel has used to convey identity through language is the description of the characters and how each has struggled with thier identity. Potraying the characters in this way is a clever metaphor for the struggles ireland itself has had to go through to keep its identity. The clever use of stage craft and lighting symbolises the struggles ireland have continually faced throughout history. The way Friel describes hugh O’niel in later life, with his declining health and along with Mabel and the baby’s death, symbolises ireland loosing the struggle with england. The use of stage craft at the end of the play where it says ‘O’Neil is now crying. Bring down lights slowly’. is an effective end to the play as it symbolises the end of the struggle between ireland and england.

The Integration Of Immigrants Into American Religious Life

The Integration of Immigrants into American Religious Life What is your definition of an immigrant? My definition of an immigrant is a person who moves to a foreign country and brings with them traditions and cultures, which they assimilate into their new country. During the nineteenth century, the United States was predominately a protestant nation, which experienced high levels of immigration. From countries such as Poland, Ireland, Russia, and Germany. Many of these ethnic groups were Catholic and Jewish parishioners. Immigration impacted American’s religious life in the nineteenth century be result of immigrants religious traditions, the establishment of new laws coinciding with religion, and biblical criticism, which affected†¦show more content†¦The Jews fled Russia because they were persecuted. A rumor spread that a Jew started a fire, which led to a pogrom. A pogrom is a massacre of Jews in Russia and Eastern Europe. Due to the pogrom Jews fled to other countr ies, like the United States. Upon arrival, the Jews created synagogues just as the Irish built Catholic churches. Religion became a comfort to immigrants in their new home lands. For instance, religion was something constant that would not change no matter where they practiced. Additionally, it was a memory of their lives from their home lands. The arrival of mass groups of immigrants strengthened bonds with one another because immigrants of the same ethnicity and religion stuck together. Along with churches immigrants opened schools and hospitals too, which were affiliated with their perspective religions. For example, Catholics established Catholic schools because public schools imposed Protestant beliefs into the school curriculum. The Catholics would not stand for their children to be forcibly taught Protestant ideals. Immigrants changed American religious life because they adjusted to life in America by depending on their religious lifestyles to make them feel as home. Therefo re, giving the Protestants religious competition. Although, immigrants attempted to make America their home, non-immigrants created laws, which were not friendly towards immigrants. Immigrants were victims of quite a few vicious laws. To