The hospital administrator called a meeting to address the high error rate in blood pressure readings taken by nurse aides. Readings by aides were off by over 40 points compared to readings taken by nurses, and one patient nearly lost an arm due to an overly tight cuff. The aides were recruited from other countries due to local shortages, but their training appeared thorough. The administrator wanted the department heads to determine the cause of inaccurate readings and how to address it.

1. Norman Hope Hospital
Memorandum
TO: Key Hospital Personnel
Chiefs Peds, Surgery, OB, Psych, Neurology, Radiology; Directors of
Nursing, Finance, PR, Personnel, Custodial, Insurance
FROM: Dr. Leonard H. McCoy, Hospital Administrator
SUBJ: Blood Pressure Error Rate
At our next monthly staff meeting, we need to see if we can figure out what
is causing our high error rate in blood pressure readings taken by Nurse Aide
personnel.
As you may already be aware from the grapevine, we have had a number of near-
disasters over the past months due to an unacceptably large error term in the
blood pressure readings taken by our Nurse Aides. Whereas the acceptable
error is plus-or-minus five points in both systolic and diastolic, we are
seeing variances of over 40 points between readings taken by our R.N.’s and
the Aides. In addition, some patients have lost sensation in their arms for
long periods of time due to over tightening of cuffs. One woman was saved
from amputation by heroic measures involving hot water, electro-stimulation,
and experimental drugs.
We have recruited these Aides, as you also may know, from Trinidad and Haiti
due to a shortage of local applicants and availability of these people at
very low wages. There may be a problem with our Aides, and we may have to
fire them all and start over. Some of our staff claim that people from other
countries may not be dependable enough for us. I should point out that their
English skills put them at high-average for American high school graduates,
and other academic indicators such as SAT scores seemed also quite good.
Their motivation to do good work has been noted by both their instructors in
our training classes and by their supervisors on the wards.
We went to a great deal of trouble to develop training for our Aides. The
blood pressure unit was developed with the assistance of Dr. Hans Blutdruck.
Dr. Blutdruck developed an excellent instructional package which I understand
will soon be part of a CD-ROM on home medicine to be published by Microsoft
Corp. A copy of the instruction in print form is attached.
A copy of the examination for blood pressure is also attached. Dr. Roentgen
of our Radiology Dept. developed the test himself. The test consists of a 10-
item multiple-choice instrument with a reliability index of .87 (KR-21) and a
range of item difficulty and discrimination which is ideal for this type of
instrument, according to Dr. Roentgen. To improve the test’s ability to
discriminate among individuals (and to avoid “teaching to the test”), a broad
range of content was included on many topics in blood pressure and related
topics which were not treated in the instruction itself. This helped the test
to produce a normal distribution of scores, from which we picked only the top
third to continue as our employees.
Again, however, even the top third of this group may not be good enough--I
don’t know if the people we have hired is the problem or what. At any rate,
we have a problem. Let us come together and see if we can solve it.

2. Norman Hope Hospital
Instructional Module #37
HB/tjr 1/98 ver. 3.6.7
Blood Pressure
RELATED TERMS:
BP; systolic BP; diastolic BP; systolic blood pressure;
diastolic blood pressure
DEFINITION:
Blood pressure is a measurement of the force applied against the
walls of the arteries as the heart pumps blood through the body.
The pressure is determined by the force and amount of blood
pumped and the size and flexibility of the arteries. The blood
pressure is continually changing depending on activity,
temperature, diet, emotional state, posture, physical state, and
drugs.
Practice: (using a piece of paper as a shield, reveal only the
practice item, answer the item, and move the sheet down to
reveal the feedback)
Practice #1: The size and flexibility of ______________
affects blood pressure.
Feedback #1: if you said “the arteries” you are correct. If
not, read the passage again.
Practice #2: The force of blood against the walls of the
arteries is called __________.
Feedback #2: if you said “blood pressure” you are correct! If
not, read the passage again.
HOW TO PREPARE FOR THE BP TEST:
The test can be done at any time. When it is performed for
comparison purposes, it is usually done after resting for at
least 5 minutes. One needs to have a blood pressure cuff and a
device for detecting the pulse in the artery (stethoscope or
microphone).
Practice #3: In order to take blood pressure, you need to have
on hand two items of equipment: a _______________ , and a
_____________

3. Feedback #3: if you said “blood pressure cuff” and
“stethoscope” or “microphone” or “device for detecting pulse”
then you are correct! If not, read the passage again.

4. HOW THE TEST WILL FEEL:
The pressure of the cuff on the arm is felt.
WHAT THE RISKS ARE:
There is no risk.
WHY THE TEST IS PERFORMED:
Most people cannot sense if their blood pressure is high
(hypertension) because there are usually no symptoms. High blood
pressure increases the risk of heart failure, heart attack,
stroke, and kidney failure. For people who have high blood
pressure, it is a way of monitoring the effects medications and
habits have on the blood pressure.
Practice #4: A good example of a “symptomless” condition which
patients can have is _________________
Feedback #4: if you said “high blood pressure” or
“hypertension” then you are correct! If not, read the passage
again.
NORMAL VALUES:
Generally, the systolic pressure is approximately 120 mm Hg and
the diastolic pressure is approximately 70 to 80 mm Hg.
Practice #5: Normal diastolic pressure is: ____________
Normal systolic pressure is:
___________
Feedback #5: if you said “70 to 80 mm Hg” on line one and 120
mm Hg on line two, then you are correct! If not, read the
passage again.
WHAT ABNORMAL RESULTS MEAN:
Mild hypertension: diastolic pressure consistently 90 to 104 mm
Hg
Significant hypertension: systolic pressure above 200 mm Hg or
diastolic pressure above 100 mm Hg.
Practice #6: 90-104 mm Hg indicates: ___________________
over 100 mm Hg indicates: _________________
Feedback #6: if you said “mild hypertension” on line 1 and
“significant hypertension” on line 2, then you are correct! If

5. not, read the passage again.

6. Criterion Test: Blood Pressure
1. What does the chemical symbol “Hg” stand for?
a. High grade
b. Mercury
c. Helium glutamate
d. Hydrogen gas
2. What does “mm” stand for?
a. micro-mini
b. massive mass
c. millimeter
d. micromilliamp
3. The term “systolic” refers to:
a. pressure during heart beat
b. pressure between heart beats
c. an instrument to measure blood pressure
d. a blood pressure reducing drug
4. The term “diastolic” refers to:
a. pressure during heart beat
b. pressure between heart beats
c. an instrument to measure blood pressure
d. a blood pressure reducing drug
5. A consistent diastolic reading of 90 to 104 mm Hg is
generally considered to indicate:
a. significant hypertension
b. mild hypertension
c. normal blood pressure
d. brain death
6. A consistent diastolic reading over 100 mm Hg is generally
considered to indicate:
a. significant hypertension
b. mild hypertension
c. normal blood pressure
d. brain death
7. How high a column of water would normal systolic blood
pressure support?
a. 4.783 inches
b. 120 inches
c. 5 1/2 feet
d, 20 feet

7. 8. Approximately how long does it take a given drop of blood to
circulate throughout the body and return to the heart?
a. 5 seconds
b. 1 minute
c. 4 hours
d. 3 weeks
9. Partial restriction of the renal arteries supplying the
kidneys would be expected to:
a. raise blood pressure
b. lower blood pressure
c. produce mild euphoria
d. produce a craving for ice cream
10. The major blood group systems in humans include:
1. ABO, MN, P, Rhesus, Lutheran, Kell, Lewis, Duffy, Kidd
2. ABC, OK, Q, Chimp, Methodist, Tell, Martin, Tavern,
Adultt
3. NBC, TX, R, Maque, Bhudist, Sell, Abbott, Fibber, Young
4. FOX, NM, S, Sasquatch, Hindu, Nell, Costello, Molly, Old