By Debra Wood, RN, contributor
March 17, 2011 - No one heads to work wanting to make an error, especially nurses, but people are human. Mistakes happen. Nurses and their colleagues must develop a safety mindset and work together to implement evidence-based practices that protect their patients from preventable errors.
“While all disciplines play a role in patient safety and infection prevention, nurses are more of a patient advocate than anyone else,” said J. Renee Watson, RNC, BSN, CPHQ, CIC, manager of infection prevention and epidemiology at Children’s Healthcare of Atlanta. “They spend more hands-on time with the patient and their families, and they have the biggest opportunity to impact patient safety.”
Coordinating care, nurses are gatekeepers of care and are trusted by patients, Watson added. But touching patients all day, they also have more opportunities for infection breeches. In addition, she said, they have a responsibility to monitor other care providers to ensure they follow safe practices. The paybacks are high, while the failures can prove tragic.
“Iatrogenic deaths are an overlooked problem, and yet it is the third leading cause of death in the United States,” said Jason Hwang, M.D., co-founder and executive director of Health Care at the Innosight Institute, a not-for-profit think tank based in Mountain View, Calif. “It results in enormous losses financially and to reputation when these things happen.”
Hwang considers medication administration, infections and patient falls the three adverse events nurses have the greatest role in preventing. Some specific interventions have been shown to help nurses avoid the more common nurse-related safety events.
Christi Zuber, RN, MHA, reports that Kaiser’s new programs for medication administration and bedside shift reporting have been successful in reducing errors.
Kaiser Permanente developed the KPMedrite program to decrease medication errors.
Knowing research shows interruptions are a primary driver of errors, Christi Zuber, RN, MHA, director of the Innovation Consultancy Kaiser Permanente in Oakland, Calif., and a team observed nurses giving medications. They found nurses dealt with multiple questions from colleagues and physicians while pouring and administering drugs. That led to the KPMedrite program, which includes following a standard medication administration process, preparing medications while standing in a special quiet zone, and wearing a sash to signal to colleagues not to ask questions.
“It’s a very visible and well-known signal that medications are being given, and they are not to be interrupted,” Zuber said. “It also triggers a certain behavior in the nurses.”
Consequently, medication errors have dropped by more than half, Zuber reported.
Devices and poor, look-alike labeling can contribute to errors. Nurses must take additional precautions when administering medications that come in bottles that can easily be confused. Ultimately, Hwang said, manufactures need to change labeling to correct the problem. In the meantime, bar-coding medication and confirming the correct dose, route, time and rate for a drug being given to the right patient, can help prevent mistakes.
Patient falls often occur when patients attempt to get up on their own to use the bathroom or pick up something out of reach. Nurses frequently hear downed patients say, “I didn’t want to bother you.”
The Studer Group, a consulting firm, came up with the idea of hourly rounding and subsequently found that a nurse or aide checking on the patient every hour during the day and every two hours at night, asking if the patient needs to go to the bathroom and making sure items such as tissues and the television remote control are within reach, reduced patient falls by 50 percent.
Subsequently many hospitals have implemented hourly rounding. San Francisco General Hospital and Trauma Center reported at a Center for Nursing Research & Innovation fellows conference in San Francisco a 30 percent decrease in falls within two months of implementing hourly rounding on a medical-surgical/oncology unit. Northeastern Hospital in Philadelphia experienced a 65 percent decrease in its fall rate after starting the rounding.
Kaiser Permanente nurses conduct hourly rounds and that has allowed nurses to more easily conduct a Nurse Knowledge Exchange, giving shift report at the bedside while interacting warmly with the patient.
“Seeing the patient and hearing [report] sets up a different level of understanding, and it gives the patient better comfort about who is taking care of [him or her],” Zuber said.
Hand hygiene remains incredibly important in preventing infections. In addition, Watson said, nurses must disinfect equipment and other items in the environment to ensure settings are not changed or lines disturbed, and they must wear personal protective equipment.
For a long time, clinicians considered infection an accepted risk, especially in critically ill patients, but now, through initiatives by the Institute for Healthcare Improvement, Johns Hopkins University and the Michigan Health and Hospital Association (MHA) Keystone Center, nurses know they can prevent patients’ infections.
The Institute for Healthcare Improvement packaged bundles of best-practice interventions into handy checklists that have been shown to reduce infection rates. For instance, to prevent central line bloodstream infections, nurses should use appropriate hand hygiene, use chlorhexidine for skin preparation, ensure full barrier precautions are taken and a sterile field maintained during insertion, and ask daily if the line can be removed. To prevent ventilator-associated pneumonia, nurses should keep the head of the bed elevated and perform daily oral care with chlorexidine. The bundle also includes daily sedation holidays and peptic ulcer and deep venous thrombosis prophylaxis.
While following the bundles helped, clinicians found they could achieve even greater success when combining the checklists with the Comprehensive Unit-based Safety Program (CUSP), a team-based approach to learning more about safety, identifying hazards on the unit and addressing those risks.
“When we first looked at CUSP, we thought we had the bundles in place,” said Mary Guaracino, RN, chief nursing officer at Memorial Regional Hospital South in Hollywood, Fla., where infection rates have declined to zero in the most recent reporting quarter. “But if the doctor didn’t have a cap on, before someone would not speak up. Now staff feels comfortable saying, ‘Let me get you a cap.’ Everyone is looking out for the patient, and everyone is participating in every piece.”
Guaracino urged nurses not to become discouraged. Changing a culture takes time.
“It takes tenacity to know the end part—the lives saved by preventing infection,” Guaracino said. “You have to keep working until you get there. You will get there.”
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