Nurses As A Key To Prevent Cardiovascular Diseases This is the rubric for the article. APA style 6 pages and one reference page. 1. Focus purpose. paper d

Nurses As A Key To Prevent Cardiovascular Diseases This is the rubric for the article. APA style 6 pages and one reference page.

1. Focus purpose. paper demonstrated an in depth reflection on and understanding of selected concepts presented in the course. viewpoints and interpretation are insightful and well presented.

2. Bloom Taxonomy, evaluate the concept and create new meaning, structure and form judgments.

3. main idea, clearly present a main idea and support it throughout the paper.

4. organization, well planned and well thought out. include title, introduction and statement and use specific facts, evidence and examples.

of main idea, transition and conclusion.

5. all paragraphs have clear ideas, are supported with examples and have smooth transition.

6. well presented and argue, idea are detailed, well develop and use APA style. Journal of Cardiovascular Nursing
Vol. 34, No. 1, pp. 6–8 x Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Progress in Prevention
Nurses Are Key in Preventing Deadly Diagnostic Errors
in Cardiovascular Diseases
Downloaded from by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3d0gbN0a5/T8FXXKiOa10N/O5WahZlQXlvp9CnixpyQo= on 01/17/2019
Kelly T. Gleason, PhD, RN; Penny Greenberg, MS, RN, CPPS;
Cheryl R. Dennison Himmelfarb, PhD, RN, ANP, FAAN
iagnostic errors affect an estimated 12 million people each
year in the United States and cause
serious harm in an estimated onethird of cases.1,2 Cardiovascular
diseases, particularly strokes and
myocardial infarctions, have heavy
consequences if the diagnosis is missed
or delayed.3–5 The major impact of
diagnostic errors on public health
was highlighted by the National
Academy of Medicine’s report, Improving Diagnosis in Healthcare, and
the report’s first recommendation
is to “facilitate more effective teamwork in the diagnostic process among
health care professionals, patients,
and their families.”2 The report specifically recommends enhancing nursing engagement in the diagnostic
process. Nurses are, and always have
been, essential to the diagnostic process, and there is an urgent need for
Kelly T. Gleason, PhD, RN
Assistant Professor, School of Nursing, Johns
Hopkins University, Baltimore, Maryland.
Penny Greenberg, MS, RN, CPPS
Senior Program Director, Patient Safety
Services, Controlled Risk Insurance
Company Strategies Boston, Massachusetts.
Cheryl R. Dennison Himmelfarb, PhD, RN,
Professor, School of Nursing, Johns Hopkins
University, Baltimore, Maryland.
The authors have no funding or conflicts of
interest to disclose.
Kelly T. Gleason, PhD, RN, Johns Hopkins
School of Nursing, 525 N. Wolfe St, Baltimore,
MD 21225 (
DOI: 10.1097/JCN.0000000000000542
the medical world to change the outdated view that diagnosis is solely
a provider responsibility. Cardiovascular nurses have tremendous
potential to reduce unnecessary cardiovascular deaths from misdiagnoses
and lead efforts to address diagnostic
errors in both independent and collaborative practices.
The importance of the nurses’ role
in identifying the signs and symptoms of dangerous cardiovascular
diseases and contributing to a correct
diagnosis cannot be underestimated.6
To highlight how crucial it is for
nurses to own their role in diagnosis, we conducted a review of the
Controlled Risk Insurance Company
Strategies’ repository of malpractice claims, which contains approximately 30% of US claims. This review
determined that, in 155 diagnostic
error cases from 2007 to 2016, nursing was accused as the primary responsible service. Cardiovascular
diseases were involved in 28 of the
cases, and more than half of misdiagnoses of cardiovascular diseases
(59%) resulted in patient death. A
real case of an alleged missed myocardial infarction is described hereinafter to highlight how important
it is to educate future and current
nurses on their role in diagnosis.
Case Example
Patient: 81-year-old man with a history of Parkinson’s disease, dementia,
hypertension, chronic kidney disease,
cardiomegaly, and atrial fibrillation.
12:46—Emergency medical service
called to the patient’s skilled nursing
facility. The patient complained of
chest pain and abdominal pain.
13:31—The patient arrived at the
emergency department with atrial
fibrillation, severe chest pain, and
mild shortness of breath. Chest
x- ray is done and showed unchanged
13:45—Electrocardiogram (EKG)
shows right bundle branch block
and no ST elevations. Troponin level
was 0.082 (nondiagnostic). The
emergency department physician
was concerned for acute coronary
syndrome. Nitropaste was applied
to the chest and relieved some chest
pain. The patient was admitted for
18:41—An internal medicine physician saw the patient who reported
that the chest pain improved. The patient had a regular heart rate in sinus
rhythm, with no murmurs or thrills.
Questionable ST depression was noted.
Computed tomographic angiogram
showed no pulmonary embolism or
aneurysm. The diagnosis was acute coronary syndrome versus costochondritis.
Continuing Nitropaste, metoprolol,
serial troponins, and serial EKGs was
20:22—Computer-read EKG
showed myocardial infarction. No
physician was called by monitor tech
to inform of EKG change.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Invitation Only-Progress in Prevention 7
20:55—Laboratory called a nurse
to inform of troponin at 57.2 (high).
The nurse did not immediately
inform any physician.
21:00—The patient complained
of increased chest pain.
21:22—Rapid response team
called. Hospitalist came to bedside
and noted EKG showing 3- to
5-second pauses in heart rate. At this
time, the nurse informed the hospitalist of troponin level at 57.2. Serial
troponin was drawn again (later came
back at 103).
21:29—EKG showed septal Q
waves. The hospitalist called an interventional cardiologist at another
hospital to arrange emergency transport to their cardiac catheterization
22:05—The patient was transferred
via emergency medical services. The
patient coded in the ambulance en
route. The ambulance returned to
the first hospital, and resuscitation
attempts were made 30 minutes.
22:44—The patient could not be
resuscitated and died. Autopsy showed
acute myocardial infarction of the
anterior wall of the left ventricle with
ventricular free wall rupture.
What Can Cardiovascular
Nurse Leaders and Educators
Do to Prevent Unnecessary
Cardiovascular Deaths From
Missed Diagnoses?
How can we best prepare nurses to
meaningfully contribute to the diagnostic process and reduce unnecessary
cardiovascular deaths? In the case
described previously, the guidelines
for suspected acute coronary syndrome were followed.7 Serial EKGs
were done because the patient was
symptomatic after an initial nondiagnostic EKG. Cardiac troponin was
measured. Unfortunately, the change
in the EKG to an alarming rhythm
and high troponin was not communicated to the provider although the
nurse was notified. This case highlights that nurses are crucial in the
diagnostic process. The importance
of nurses’ roles in serving as sentinels
for our patients, coordinating care,
and communicating status changes
to other interprofessional team members cannot be underestimated. There
are multiple ways nurses can reduce
diagnostic error:
1. Patient engagement: Nurses already
play key roles in patient education and engagement. Understanding patients’ major diagnoses, being
the advocate of patients as they navigate healthcare, optimizing communication between the patient
and the care team, educating about
the diagnostic process and diagnostic tests, and helping patients
with the emotional burden of not
knowing a diagnosis yet or learning
of a tough diagnosis are all recommendations from the National
Academies of Medicine report.2
2. Interprofessional teamwork: Nurses
play crucial roles in care coordination and facilitation of team
communication. The nurse is often
the central team member who must
relay critical observations including increased chest pain and troponin levels across professions to
ensure rapid intervention. Ensuring that strong teamwork across
nurses, physicians, patient care
assistants, laboratory technicians,
and other allied health professionals applies to diagnosis can
go a long way. Preparing future
nurses for this major responsibility is important, and the value
of teaching communication tools
such as Subject, Background, Assessment, and Recommendation
is tremendous.
Interprofessional education, a
requirement by licensing bodies
of both physicians and nurses,
includes understanding the roles
and responsibilities of both professions, engaging in effective communication, and collaborating
around shared ethics and values.8
Applying these preexisting requirements to training opportunities
related to the diagnostic process
and the role of teams in achieving
diagnostic accuracy could help
prepare both future physicians
and nurses.
3. Diagnostic triage: Nurses directly
engage in a primary component
of diagnosis when they triage.6
Whether it is in the emergency
department, a home health visit,
or a medical surgical floor, nurses
constantly make decisions about
the level of medical attention
needed by the patient. Making
this diagnostic triage function explicit could reduce cardiovascular
deaths through earlier recognition
of clinical red flags for dangerous
conditions such as pulmonary embolus and myocardial infarction.
Education will be important to
increasing nurses’ self-efficacy and
confidence in their role as diagnostic team members. Educational
interventions focused on specific
high-risk cardiovascular diagnoses
can result in cardiovascular nurses
reporting higher knowledge and
confidence in assessing and managing the health problem.9
Patients are unnecessarily dying from
cardiovascular diseases that were
missed on presentation.4 Cardiovascular nurses play an incredibly crucial
role in identifying and monitoring
signs and symptoms, educating patients, and working with interprofessional team members. It is aligned
with the role of the nurses to meaningfully participate in the diagnostic
process. Cardiovascular nurse leaders
and educators can join the effort to
reduce diagnostic errors by training
and encouraging nurses to engage
their patients in the diagnostic process, to leverage their central role on
the interprofessional team to facilitate
an efficient and accurate diagnosis,
and to acknowledge their existing role
in diagnostic triage.
The authors thank CRICO/Risk
Management Foundation of the Harvard
Medical Institutions.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
8 Journal of Cardiovascular Nursing x January/February 2019
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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