In acute care, a charge nurse is assigned to oversee a unit, and a nursing supervisor oversees the nursing role across a facility. All work together to control the flow of patients in and out of the unit and facility, make staffing assignments, and assist with problems and crises. Consider this situation: A nurse is dealing with a crisis for one patient and misses a second patient crisis—a young woman who died from a postoperative hemorrhage. In this tragic situation, competing crisis events on the unit prevented a nurse from adequately monitoring other assigned patients on the unit. The charge nurse and nursing supervisor stated in the Board of Nursing’s investigation of the event that they depended on the individual nurse to alert them if help was needed.
Question: Describe a systems-based solution that could have prevented this event. (DO NOT state what the nurse should have done differently; you are to describe a systems-based solution, not a personal, professional one.)
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