AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000445662.51660.06
Letters

Missed Care

Clarke, Dana P. BSN, CFRN, EMT-P

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Dana P. Clarke, BSN, CFRN, EMT-P

Houston

It means so much to know that others share the same concerns I do (“Straight Talk About Nursing,” Editorial, December).

I've witnessed many incidents of missed care and barely prevented mistakes. A nurse was sitting outside the glass doors of a patient's room, charting on every required screen, when a monitor alarm went off indicating the patient's oxygen saturation level was 82%. Another almost gave 20 mg of labetalol to a patient with a heart rate of 60 and a blood pressure reading within normal limits because “the doctor ordered it”—an order based on a reading that was at least 30 minutes old.

Like the example of the discharged patient Shawn Kennedy writes about in her editorial, my 85-year-old grandfather (with dementia) was discharged from the hospital with extensive written instructions placed in his bag. He never saw them. Thankfully, a home health aide found them when she unpacked his belongings.

It seems like more and more emphasis is being placed on minute details—document this, in that way—and less on the elephant in the room, which is that patient care is lacking. It doesn't do any good to put stickers and labels everywhere noting that a patient is at risk for falling if we walk away and close the door.

Amid all the recent advances in nursing, I fear we've reverted to the days of simply following an algorithm or order. We need to step back, hit the reset button, and resume practicing nursing the way it was intended.

Dana P. Clarke, BSN, CFRN, EMT-P

Houston

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