By Debra Wood, RN, contributor
April 25, 2012 - In the years since the Institute of Medicine called attention to the problem of patient safety in its 1999 To Err is Human report, many nurses, healthcare providers and other organizations have worked to create safer care delivery. While checklists and protocols and technological advances have received attention, health care remains a people business fraught with human factors and fears of speaking up. Many organizations are focusing on improving communication and eliminating the blame game.
Creating a culture of safety
Susan E. Hoolahan, MSN, RN, NEA-BC, called a just culture important for getting staff to speak up before an error occurs.
“A just culture is a comprehensive approach for patient safety that empowers health care providers to voice their concerns about patient safety without fear of retaliation,” said Susan E. Hoolahan, MSN, RN, NEA-BC, vice president of patient care services/chief nursing officer at UPMC Passavant, part of Pittsburgh, Pennsylvania-based UPMC. “We believe it is probably one of the most important things we could do to create a culture of safety.”
UPMC has developed a toolkit to provide leaders with resources to create a just culture. It includes a case study, evidence-based information associated with patient safety and checklists to prevent potential errors. The health system also completed a baseline survey to learn where the culture stood and then developed a decision tree to guide leaders and staff who were exploring reasons an adverse event occurred, so everyone would be asking the same questions. It has involved staff in coming up with solutions and accepting responsibility for ensuring patients are safe.
“We found we often had broken systems,” Hoolahan said. “Sometimes we found that in spite of having policies and procedures in place, someone departed from the procedure.”
Research supports UPMC’s approach to changing the culture.
The American Association of Critical-Care Nurses (AACN), the Association of periOperative Nurses (AORN) and VitalSmarts partnered in a 2011 national study of 6,500 nurses, “The Silent Treatment: Why Checklists and Safety Tools Aren’t Enough to Save Lives.” The study found more than 8 out of 10 nurses said safety tools and checklists warned them of a problem that might have been missed and could have harmed a patient. But more than half of respondents said they didn’t dare to speak up and solve the problem.
Teri Lynn Kiss, RN, MS, MSSW, CCRN, emphasized the importance of good communication for clinicians.
“Many people call communication a ‘soft skill,’” said Teri Lynn Kiss, RN, MS, MSSW, CCRN, director of Medical Unit 2-South at Fairbanks Memorial Hospital in Alaska and treasurer of AACN’s national board of directors. “Communication has been one of the top three root causes of sentinel events reported to The Joint Commission over the past seven years.”
Skilled communication is first among AACN’s Standards for Establishing and Sustaining Healthy Work Environments. The standard requires nurses to be as proficient in communication skills as they are in clinical skills. Kiss explained that nurses’ words and actions need to be congruent, and they must hold others accountable for the same. Care providers must build consensus and focus on solutions and achieving desired outcomes.
“Health care organizations and nurses share responsibility for skilled communication,” Kiss added. “For example, the organization sets up structures and processes to ensure effective information sharing among patients, families and the health care team. It evaluates the impact of communication on clinical, financial and work environment outcomes. The organization also establishes and enforces zero-tolerance policies to address and eliminate abuse and disrespectful behavior.”
In addition to changing the culture, organizations are tackling specific safety concerns.
Patient falls can prove problematic at any facility but perhaps even more so when patients are learning to walk again. Burke Rehabilitation Hospital in White Plains, N.Y., has initiated a comprehensive fall-prevention program, which contributed to its winning a 2011 NDNQI Award for Outstanding Nursing Quality by the American Nurses Association.
Stephanie Campbell, RN, BSN, CRRN (left) and Marie Spencer, Ph.D., RN, CRRN, CNO at Burke Rehabilitation, discuss fall reduction with Vito Arace during his rehabilitation.
At-risk patients are given bed and chair alarms and moved as close to the nursing station as possible. Aides make hourly rounds on patients and nursing supervisors perform weekly safety rounds.
“The aides have caught a few patients starting to get out of bed, and that has prevented a fall,” said Stephanie Campbell, RN, BSN, CRRN, assistant director of nursing at Burke.
Patients at risk of falling and impulsive movements are never left alone. Nurses explain interventions to the patient and family and gain their support.
Good hand hygiene remains pivotal to preventing hospital-acquired infections, which occur in about one out of every 20 patients, according to the Centers for Disease Control and Prevention (CDC). Washing one’s hands correctly or using an alcohol-rub before and after each patient contact is essential.
Several states have instituted campaigns to increase awareness and compliance with good hand hygiene practices, including the Maryland Hospital Hand Hygiene Collaborative campaign and the South Carolina Hospital Association’s “Save Lives: Clean Your Hands!” campaign in association with the World Health Organization.
In addition to good hand hygiene, the CDC has released recommendations to prevent specific hospital acquired infections.
Christi Zuber, MHA, RN, helped lead the KP MedRite program, which has reduced medication errors at Kaiser Permanente.
Kaiser Permanente implemented its KP MedRite program when administering medications and has shared the initiative with other organizations. A key component of the multifaceted program includes nurses wearing a sash or vest to designate that they are concentrating on medications and should not be disturbed. It also includes a lean step-by-step process to incorporate the five rights of medication administration into a teachable approach and warm interaction with the patient. In addition, nurses check allergies and the medication record, wash their hands, turn down the television volume, turn up the lights in the patient room, educate the patient about the medication, and document.
The organization has noted the program has reduced medication errors and increased the speed of medication passes.
“KP Medrite is an excellent example of what can done when nurses and managers understand the real issues, think creatively about the possibilities and work together to implement solutions that really make a difference,” said Christi Zuber, MHA, RN, director of Kaiser Permanente's Innovation Consultancy. “I am very proud to work at Kaiser as we have committed to share these solutions openly with other organizations who want to make strides to reduce medication errors as well.”
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