NU500-8B-UNIT6-DISCUSSION2-REPLY1: Chaos Theory

NU500-8B-UNIT6-DISCUSSION2-REPLY1: Chaos Theory. When I was a bedside nurse on a pediatric CICU unit, several safety measures were in place to ensure a smooth transition during shift change. Forgetting or not having time to do these safety checks was not an option, as numerous issues could compromise the patient’s health…

NU500-8B-UNIT6-DISCUSSION2-REPLY1: Chaos Theory

Chaos Theory Example

When I was a bedside nurse on a pediatric CICU unit, several safety measures were in place to ensure a smooth transition during shift change. Forgetting or not having time to do these safety checks was not an option, as numerous issues could compromise the patient’s health. A small choice to forgo the handoff safety measures at shift change was a shortcut some nurses chose if they felt confident in doing so.

In one instance, a nurse forgot or chose not to calculate the drip rates of her continuous infusions at the start of her shift, which was part of the safety measures needed during shift change. This exclusion of ensuring the proper dose of life-sustaining medications is reaching the patient proved to be a monumental mistake.

An insufficient amount of medication was delivered, and the mistake was not caught until several hours later. The seemingly small mistake of forgetting to calculate drip rates negatively impacted the patient’s care and endangered their wellbeing. Knowledge of Chaos Theory would have benefited those involved by understanding that a very small decision or change can have an enormous impact. 

Using Theory to Improve Practice

In research from McGrath (2020), the author’s goal was to improve the very problem stated above: improving handoff communication for patient safety. McGrath identifies ineffective handoff communication in a hemodialysis unit as a risk for errors and jeopardizes patient safety, and is a major contributing cause of adverse events. To implement a change in their unit, the researcher utilized Lewin’s Planned Change Theory. This particular theory has three stages: unfreezing, introducing change, and refreezing.

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Unfreezing involves recognizing the need for change and the driving forces that encourage or resist the improvements. The second step is introducing the change to enhance the process or problem. Refreezing is essentially sustaining the new guidelines placed in stage two. Just as the author in this study, I could use Lewin’s model to “unfreeze” the status quo of leniency towards handoff communication and help others on the unit realize the need for consistency regarding drip rate calculations at shift change. The change itself would be a prompt that each nurse must cosign in the documentation. “Refreezing” would be ensuring the change is maintained by audits and coaching if needed. 

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