The nurse decided to help another nurse and ambulate Mr. Smith as he said that he wanted to get out of bed and try to walk. The nurse had heard morning report and knew the patient had his surgery the day before. The nurse had Mr. Smith sit up on the side of the bed, and then began to assist him with ambulation. As Mr. Smith walked down the hallway, he suddenly became weak in the knees and started to fall. The nurse attempted to stop the fall by leaning against Mr. Smith so that he could go down to the floor in a gentle manner, breaking the fall. The nurse immediately yelled for help and started to assess the patient. After another staff member arrived, Mr. Smith’s vital signs were taken. His heart rate was 120, respiratory rate 16, temperature 98.6 °F., and his blood pressure 90/60, while lying on the floor. The staff asked Mr. Smith if he could stand long enough to have the staff check orthostatic vital signs, but he stated that he was still dizzy. He felt that he could get up into the wheelchair to go back to his bed with help. The staff successfully moved Mr. Smith to the bed.

Afterwards, the nurse who had been assigned to Mr. Smith initially said the patient had not been out of bed earlier because he felt nauseated each time he tried to sit up and he had refused to walk. His hemoglobin and hematocrit had been low. There were concerns that he might require blood and he had been receiving serial laboratory draws. The physician had just received the laboratory results and was talking to the assigned nurse about initiating a blood transfusion when the fall occurred. The assigned nurse and the physician had been unaware of the other nurse walking the patient.

1.

What role did communication play in this scenario?

2.

Are there any individual and/or system actions that would have increased the likelihood of a safe patient outcome?

3.

Use Table 10.1 and identify a few structures, processes, and outcomes that should be set up and periodically reviewed for this type of patient.