Name
Chamberlain University
NR-544: Quality & Safety in Healthcare
Prof. Name
Date
A relevant patient care scenario that highlights a safety and quality issue occurred during the COVID-19 pandemic in the Post-Anesthesia Care Unit (PACU). During this time, the Intensive Care Unit (ICU) became designated for patients with severe COVID-19 infections, limiting its capacity to manage other critically ill patients. A neurological patient who remained medically unstable was transferred to the PACU due to the lack of available ICU beds.
This created a significant safety concern. The PACU, while equipped for immediate postoperative recovery and short-term monitoring, is not designed to support critically ill patients requiring prolonged care. Nurses in PACU are trained for emergencies, but workflows, charting systems, and available equipment differ substantially from the ICU. Furthermore, staff shortages and resource limitations exacerbated the risk of providing suboptimal care. This situation posed challenges for maintaining patient safety and delivering consistent, high-quality outcomes.
The transfer of an unstable neuro patient to PACU revealed critical issues related to staffing, equipment availability, and workflow management. The PACU lacked ventilator support and long-term monitoring devices that are standard in the ICU. Additionally, the unfamiliarity of PACU staff with prolonged critical care routines increased the likelihood of errors.
Impact of the problem included:
Patient-related outcomes: Increased risk of clinical deterioration, delayed interventions, and compromised safety.
Organizational outcomes: Inefficient allocation of resources, nurse burnout, and decreased staff morale due to the strain of caring for patients outside the usual scope of PACU practice.
Quality and safety risks: Potential breaches in standards of care and decreased patient and family satisfaction.
The Plan-Do-Study-Act (PDSA) model can be effectively applied to this scenario to address the safety and quality concerns. The PDSA model emphasizes small, rapid cycles of change to test improvements before large-scale implementation.
| PDSA Step | Application in Scenario |
|---|---|
| Plan | Identify the issue of unstable patients being transferred to PACU due to ICU capacity constraints. Develop a temporary protocol for such cases, including staff cross-training and preparing essential equipment. |
| Do | Implement a pilot program where select PACU nurses receive ICU-level training, and backup equipment (e.g., ventilators, infusion pumps) is allocated to the unit when necessary. |
| Study | Monitor patient outcomes, staff workload, and safety indicators during the pilot. Gather feedback from nurses and physicians. |
| Act | Based on evaluation, make adjustments—such as refining workflows, increasing nurse incentives for critical care readiness, or creating a “step-up” care team to bridge gaps between ICU and PACU. |
Applying the PDSA model in this scenario ensures a structured approach to problem-solving.
Patient-related improvements:
Enhanced monitoring and timely interventions reduce risks of deterioration.
Improved nurse-to-patient ratios lead to safer care and greater patient satisfaction.
Organizational improvements:
Optimized bed management reduces strain on ICU capacity.
Cross-trained staff increases organizational flexibility during crises.
Evidence-based planning fosters long-term resilience in handling patient surges.
Through systematic planning, testing, and refinement, healthcare facilities can enhance their ability to adapt during emergencies while maintaining high standards of safety and quality care.
Connelly, L. M. (2021). Using the PDSA model correctly. MEDSURG Nursing, 30(1), 61–64.
Institute for Healthcare Improvement. (2023). How to improve with the model for improvement (PDSA cycles). IHI. https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
World Health Organization. (2021). Patient safety incident reporting and learning systems. WHO. https://www.who.int/publications/i/item/9789240010338
