Key Points on Nursing and Medical Errors

Medical Errors and Nursing Failures

Third Leading Cause of Death: Medical error, including nursing failure to rescue, is now the third leading cause of death in the U.S., with over 250,000 deaths annually.
Failure to Rescue: Occurs when adverse outcomes, including death, follow life-threatening complications that could have been avoided with timely recognition and intervention by nurses and healthcare teams.

Clinical Instability: Nurses must recognize early signs of clinical instability to prevent adverse outcomes.
Patient Deterioration: Most patients show visible deterioration 6-24 hours before cardiac arrest, especially in med-surg units with high nurse-patient ratios and less experienced nurses.

Routine Vital Signs: Should never be considered routine; they are often the first indicators of change.
Key Changes to Recognize:
- Respiratory: Abnormal respiratory rate (especially tachypnea), decreasing O2 saturation, increased oxygen needs, and shortness of breath.
- Cardiac: Elevated heart rate, reduced systolic blood pressure, and chest pain.
- Other Factors: Abnormal temperature (usually high) and neurologic changes like altered mental status.

Respirations: Increase in respiratory rate (tachypnea) is the priority sign and a sensitive indicator of potential complications.
Neglect of Respiratory Rate: Often neglected; in one study, only 14% of charts from ICU to ED transfers had respiratory rates recorded.

Understand the Physiologic 'Why': Nurses should ensure knowledge is applied at the bedside, not just "cookbook" nursing by numbers.
Responsibility: Embrace the responsibility, recognizing that a nurse literally holds a life in their hands.
Professional Growth: Focus on being the best to avoid harming or killing patients.

Encourage interaction by sharing personal takeaways and engaging with content for continuous learning and improvement.
Emphasize the importance of being well-prepared for practice.