Recognizing that staff may lack training in certain areas essential to patient care, many nursing homes have begun to implement training programs at their facilities to help teach proper protocols– and hopefully improve patient care. While the training can be quite effective in terms of improving the satisfaction of patients and prevention of medical errors, no amount of training will suffice in order to prevent situations involving harm to patients stemming from a basic lack of common sense or carelessness.
I began thinking about how many common errors involving injuries to patients in nursing homes derive not from improper medical care– but from an even more alarming situation— when staff fail to utilize some of their basic sensible skills that they (hopefully) have accumulated over the course of their lives.
After seeing a news blurb about the death of a patient at a California nursing home— I truly wonder how some people not just obtained advanced degrees— but made it past the fourth grade!
While I’m certain there are many, many, deaths at nursing homes every day, I strongly doubt that there many deaths as senseless as one involving the passing of an 81-year-old patient at Seton Medical Center who died from suffocation when a nurse tending to her left the cap on breathing tube that was placed into the woman’s trachea.
Following an investigation into the incident by the California Department of Public Health, the agency determined that at the time of the incident, the nursing home did not have a policy in effect for properly inserting the breathing tube— commonly known as a ‘t-piece’.
Policies are great when it comes to complex issues or discretionary acts, but remembering to remove the cap on a patient’s breathing tube? Come on, if the staff member involved in this incident can’t remember to remove the cap to a breathing tube, do we really want to given him / her another shot caring for disabled patients after they have had an opportunity to review a policy?
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