NursingCenter’s In the Round

A dialog by nurses, for nurses

Free CE for Perioperative Nurse Week!

clock November 11, 2013 00:34 by author Lisa Bonsall, MSN, RN, CRNP

Happy Perioperative Nurse Week! To celebrate your hard work and commitment to patient safety, the 2 continuing education articles in the November issue of OR Nurse 2013 are availabe at no charge! That's 4.8 contact hours for FREE! 

 Review of processes to reduce colorectal surgery site infections: An OR perspective
2.3 contact hours

 Tetralogy of Fallot: The evolution of congenital heart surgery
2.5 contact hours 

After reading the articles, just click 'Go to CE Details' to take the test and get your free CE. For even more savings, check out our CE collection on Surgical Site Infections.

Have a great week!

Standardizing nursing handoffs

clock March 29, 2013 02:54 by author Lisa Bonsall, MSN, RN, CRNP

Handoffs are a known “trouble spot” when it comes to patient safety. As nurses, we participate in handoffs any time we transfer care to another provider, whether at change of shift, transfer to another floor or unit, or transfer to another facility. Errors that occur during these times can result from a variety of barriers, many of which are human factors, ranging from understaffing and interruptions to fatigue and information or sensory overload. 

The Joint Commission requires a standardized approach to patient handoffs; it is one of the National Patient Safety Goals (2006 National Patient Safety Goal 2E). During her presentation “Effective Handoff Communication: A Key to Patient Safety” at Nursing2013 Symposium, JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS, shared several acronyms that can be used to help guide a well-organized transfer of information and minimize errors and omissions during patient handoffs. 

SBAR + 2 (See also The Art of Giving Report and The impact of SBAR.)
  Question & Answer

5 P’s Model


  Safety Concerns

What is the standard for nursing handoffs where you work?


Cairns, L., Dudjak, L., Hoffman, R., & Lorenz, H. (2013). Utilizing Bedside Shift Report to Improve the Effectiveness of Shift Handoff. Journal of Nursing Administration, 43(3). 

Riesenberg, L., Leisch, J., Cunningham, J. (2010). Nursing Handoffs: A Systematic Review of the Literature. American Journal of Nursing, 110(4). 

Schroeder, S. (2006). PATIENT SAFETY: Picking up the PACE: A new template for shift reportNursing2006, 36(10).  

Pause and listen

clock February 4, 2013 02:53 by author Lisa Bonsall, MSN, RN, CRNP

How many times has a patient said “I feel funny” or “I don’t feel right” and then proceeded to code shortly thereafter? That happened to me twice.

How many times have you felt pulled in different directions – between call lights, alarms ringing, medications to be administered, dressings to be changed, patient education to be provided, etc.? For me the answer is TMTC (too many to count!)

How many times has a patient deteriorated quickly or coded without any warning signs? I’d say several.

I wonder if during any of those times a patient was trying to reach out to me to say “I feel funny” or “I don’t feel right” and the opportunity to intervene passed without my knowledge because I was busy with other tasks.

Just thinking…

I wish that we had enough time during our day to just pause and listen. Wouldn’t that be nice?


Nurses call to action

clock December 21, 2012 09:27 by author Lisa Bonsall, MSN, RN, CRNP

I have been trying to limit my watching of the Newtown, Connecticut events on television. I feel guilty about it, as those directly affected by the horrible massacre that occurred December 14th must face the tragedy every minute of every day. Like you, I am experiencing all sorts of feelings of sadness and anxiety and my thoughts and prayers are with the victims, their families, and the first responders.

I have not limited my reading though. I feel that by reading the stories shared by family members, I am getting to know the victims and in some small way, I am honoring them. I am reading the stories shared by the survivors and feeling that in some small way, by doing so I am helping them process the events by “listening.” I am reading the thoughts and feelings of how others are processing what happened, hoping to contribute to the discussion and let our voices be heard so that changes can be made to make our nation a stronger and safer place for ourselves and our children. 

Now I turn to the feelings of “How can I help?” and “What can I do?” I encourage you to see posts from our colleagues at AJN’s Off The Charts and Nursetopia for lists of resources and ways to help. Also, the American Nurses Association has assembled a list of more than 30 nursing organizations joining forces to call for change. 

“The nation’s nurses call on President Obama, Congress, and policymakers at the state and local level to take swift action to address factors that together will help prevent more senseless acts of violence. We call on policymakers to: 

• Restore access to mental health services for individuals and families 

• Increase students’ access to nurses and mental health professionals from the elementary school level through college 

• Ban assault weapons and enact other meaningful gun control reforms to protect society”

Nurses – we are the largest single group of health care professionals. We see the devastation caused by weapons and violence. We care for patients with mental illness and know there is need for improved services and access to treatment. It is time to take action.

To Those Affected By Hurricane Sandy...

clock November 2, 2012 08:29 by author Lisa Bonsall, MSN, RN, CRNP

What to say here? I am still in shock by the devastation caused by this hurricane. 

I grew up on Long Island. My parents, my brother and his family, and many childhood friends still live there. Yes, they experienced loss of ‘things’ and remain without power, but they are all safe. As the stories emerge of lives lost, I know how lucky we are. 

The accounts of hospitals closing and patients being evacuated are amazing. I am in awe of those who’ve worked so hard and continue to work so hard to keep patients safe and provide care to those in the hospital as well as out in the community. The evacuation and transfer of patients, especially of NICU babies from NYU Langone Medical Center, is incredible to me. As a mom of 2 NICU graduates, I remember well the challenges of repositioning a sick premature baby in his isolette; I can’t imagine moving across New York City during a hurricane. What more can I say but THANK YOU to our nurse colleagues and the other healthcare professionals who managed this incredible feat. 

To those dealing with loss, I imagine you will never see this post. If, by chance, you do come across this writing someday, know that at this moment, my thoughts and prayers continue for you. I hope that you have rebuilt your home, whether in the same location or somewhere new, and you’ve been comforted and supported in your grief. 

American Journal of Nursing has created a list of helpful resources (open access) to help us cope now and be ready for future emergencies. 

Wishing everyone safety and good health during recovery efforts. 

Resources for Alcohol Awareness

clock April 13, 2012 04:55 by author Lisa Bonsall, MSN, RN, CRNP

I was taken aback when I read that “one in five patients admitted to a hospital suffers from alcohol use disorder” in Managing alcohol withdrawal in hospitalized patients in the April issue of Nursing2012 (here’s the pdf for the best view). With numbers like this, it really is critical that we are aware and able to assess all patients for signs and symptoms of alcohol withdrawal. I’d like to bring this article to your attention because there are some great resources included to help assess patients and also care for those experiencing alcohol withdrawal. There is a table on timing of symptoms – when they might occur in relation to the last drink – and also a copy of the Clinical Institute Withdrawal Assessment for Alchohol Scale, Revised (CIWA-Ar), which is the gold standard for assessing for withdrawal. The CIWA-Ar is not copyrighted – so go ahead and print it out, share it, and use it (in accordance with your facility policy, of course.)

April is Alcohol Awareness Month. While those of us in the hospital setting may come in contact with patients at risk for or experiencing alcohol withdrawal, we all know that a critical component of alcohol awareness is prevention. This year’s theme is “Healthy Choices, Healthy Communities: Prevent Underage Drinking."  Won’t you read more about this and help spread the word?

One of those quirky nursing things

clock March 23, 2012 06:52 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever cared for one of those patients who is ‘borderline’ unstable? You know --- kind of stable, but not well enough for you to feel too optimistic that they won’t crash? In the Medical Intensive Care Unit where I worked, I can recall many times where we had this one habit to help us get through the shift and keep a patient stable. Sounds silly, almost superstitious, but sometimes it worked…and I’m wondering if any of you have similar quirks or traditions that you use in your own practice. 

What is it? Here are some examples:

A patient is admitted and we settle him in his room – ECG monitor on, vital signs taken, alarms set, I.V. access established, history taken, and physical assessment completed. He seems fairly stable but when you walk out of the room, his alarm sounds for a systolic blood pressure of 90 mm Hg. His initial blood pressure had been 116/78. Your colleague asks, “Do you want some I.V. fluids?” to which you reply “Yes, let me just keep it in the room.” 

Another patient, who had been on the unit for a few weeks and had resolving ARDS (acute respiratory distress syndrome) was extubated 2 days ago and had been doing well breathing on her own. Throughout the shift, however, her oxygen requirements are increasing and her breathing is becoming more labored. The respiratory therapist asks “Do you think she’ll be reintubated?” and you reply “Please bring a ventilator to her room, just in case.” 

I can think of many patient scenarios similar to these, where we’d bring I.V. catheters, vasopressors or other medications, even urinary catheters, into the room but then didn’t need to use them. I know part of this is being prepared and having a treatment or intervention ‘ready to go’ is something that, as nurses, we do all the time. However, sometimes it seemed that the act of bringing something into the patient’s room was enough to keep him or her stable. Just coincidence? Probably. But if it works…

The impact of SBAR

clock January 30, 2012 15:52 by author Lisa Bonsall, MSN, RN, CRNP

A while back, I wrote a blog post about using SBAR (Situation-Background-Assessment-Recommendation) as a method to help organize change-of-shift report. First implemented by the U.S. Navy to reduce miscommunications, use of this tool is becoming more widespread in healthcare settings. It has been theorized that the use of a standardized approach such as SBAR creates a “common language” among healthcare professionals and thereby decreases communication errors and may even impact our behavior. A recent study published in Health Care Management Review explored this potential impact of SBAR on the daily activities of nurses.

The researchers interviewed nurses, nurse managers, and doctors in two hospitals where implementation of the SBAR protocol was in its early stages. Analysis of the data revealed two findings: first, that most thought of SBAR as strictly a means of standardizing communication, and second, that SBAR actually had a “more far-reaching effect than just being a communication tool.” 

So what are these “far-reaching effects?”

1. Schema development – SBAR facilitated the development of schemas which help nurses make intuitive decisions.

2. Contribution to the accumulation of social capital – The common language of SBAR serves as a means to integrate nurses into the organization.

3. Providing legitimacy – The common practice also helps individuals gain credibility.

4. Shift in logic – SBAR supports a shift from individual autonomy to standardization and formalization of the nursing profession.

Interesting findings! This fairly simple tool does have far-reaching implications – for our individual practice and our profession. If we communicate more effectively, make decisions more easily, and are integrated into the organization as a credible member of the healthcare team as a nursing professional, won't that ultimately lead to better patient care and outcomes?

Reference: Vardaman, J.M., Cornell, P., Gondo, M.B., Amis, J.M., Towensend-Gervis, M., Thetford, C. (2012). Beyond communication: The role of standardized protocols in a changing health care environment. Health Care Management Review 37(1), 88-97.


clock June 12, 2011 06:54 by author Lisa Bonsall, MSN, RN, CRNP

I was on orientation in the Medical Intensive Care Unit and I had the most amazing preceptor. She really did know everything. I still have yet to meet a smarter nurse, or person, for that matter. Her knowledge of physiology, pathophysiology, medications, technology, and random entertaining facts to keep us going during night shift astounded me! Not only that, she was (and is) an amazing nurse --- caring, compassionate, a good listener, excellent at time management, and all things nursing!

And her teaching skills? Amazing.

I was a new graduate fortunate to work with and learn from this nurse every day. I had worked in this MICU as a nursing assistant for over a year, so I knew some of the basics (where to find supplies and knowing which room is which is huge when you are just starting out, right?) I’ll never forget this one time…

Amy (not her real name, of course) would often stand back in the corner of a patient’s room while I did my assessment at the start of a shift. Sometimes I’d forget she was there until she’d start with “the questions.” During this particular shift she said, “Lisa, what if all of a sudden the ventilator alarms for a high peak airway pressure?” I started to go through my list of troubleshooting ventilator alarms: look at the patient - is he in distress, what is his oxygen saturation, how is his color, listen to his breath sounds, is his endotracheal tube in place - and then moved on to the ventilator - any water in the tubing, is everything connected as it should be, etc.

Amy then said “Okay, you don’t find any concerns, but the high pressure alarm is still sounding. Now what?”  I replied, “I would disconnect the patient from the ventilator and bag him.” Amy said “Yes, and what else could you do to search for a reason for the alarm?” I could tell by Amy’s face that I was missing something.

She pretended to take a picture. Huh? I must have looked confused, because she did it again. I thought for a minute and then it hit me --- a chest x-ray!

8 rights of medication administration

clock May 27, 2011 00:10 by author Lisa Bonsall, MSN, RN, CRNP

Chances are that some of you may not have known that in addition to the well-known 5 right of medication administration, some experts have added 3 more to the list.When it comes to patient safety, it’s never a bad time to review some of the basics and increase your awareness of newer recommendations.

Please add any of your own tips and medication safety advice by leaving a comment. For more reading and learning related to this topic, please explore our CE collection on medication safety. Thank you!

Rights of Medication Administration

1. Right patient

  • Check the name on the order and the patient.
  • Use 2 identifiers.
  • Ask patient to identify himself/herself.
  • When available, use technology (for example, bar-code system).

2. Right medication

  • Check the medication label.
  • Check the order.

3. Right dose

  • Check the order.
  • Confirm appropriateness of the dose using a current drug reference.
  • If necessary, calculate the dose and have another nurse calculate the dose as well.

4. Right route

  • Again, check the order and appropriateness of the route ordered.
  • Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

  • Check the frequency of the ordered medication.
  • Double-check that you are giving the ordered dose at the correct time.
  • Confirm when the last dose was given.

6. Right documentation

  • Document administration AFTER giving the ordered medication.
  • Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

7. Right reason

  • Confirm the rationale for the ordered medication.  What is the patient’s history? Why is he/she taking this medication?
  • Revisit the reasons for long-term medication use.

8. Right response

  • Make sure that the drug led to the desired effect.  If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
  • Be sure to document your monitoring of the patient  and any other nursing interventions that are applicable.

Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.

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