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How could this patient safety issue have been avoided


Assignment task:

During remodeling and renovation of two patient care areas at a hospital, a new nurse call system was installed. A Code Blue alarm specific to each room was a component of the new system. The other patient care areas in the hospital were to receive the new nurse call system later in the year. After installation of the new system, the nurses were instructed to begin using the Code Blue button in the patient rooms, and they were assured that the alarm and room number would automatically appear on the hospital operator's computer. The new system made it unnecessary to call the operator to request a Code Blue and for the operator to announce the room number because it was done automatically.

Unfortunately, this was a case in which patient safety was overlooked in the excitement of receiving new technology. It was soon discovered that the room number that appeared on the console did not correspond to the room number in which the button was being pushed. The discrepancy was noted with the first Code Blue in one of the renovated areas when the room number that appeared on the console was not a recognized room number in the hospital. Use of the Code Blue button was suspended immediately. The procedure of calling the operator was reinstituted and remained in effect until all clinical areas received the new nurse call system. This gave the clinical engineering personnel time to make sure the new system was functioning appropriately, and it prevented the confusion that would have resulted from maintaining two different methods of alerting the hospital operator of a Code Blue.

Case Study Questions

1.  How could this patient safety issue have been avoided? Need Assignment Help?

2.  Which of the required written safety standards or plans for the environment of care should have been used to avoid this situation?

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