Pedi-CSI: Pediatric Clinical Safety Investigation Through Virtual Patient Safety Rounds

Transcription

1 Pedi-CSI: Pediatric Clinical Safety Investigation Through Virtual Patient Safety Rounds Training Manual Boston Children s Hospital Medicine Patient Services and Boston College William F. Connell School of Nursing, 1

2 Pedi-CSI (Clinical Safety Instruction) Patient Safety Teaching & Training Manual Purpose: This training manual accompanies the pediatric patient safety vignettes that can be found at It is to provide standardized patient safety curricular materials for use with nursing students who are beginning their inpatient pediatric clinical rotations and for RNs beginning to practice in pediatrics. It is designed to help participants detect patient safety errors and vulnerabilities while developing the necessary critical decision-making skills needed to advance a culture of patient safety. This program is ideal for students and nurses who are new to the hospital environment as it offers an opportunity for individuals to observe and experience patient care activities in a controlled, virtual setting. Studies have shown that adult learners recall information after 3 months at a higher percentage when they are shown and experience the learning material (65%) rather than simply being told the information (10%) (Whitmore, 2002). Through the use of this program, participants will not only learn critical elements of patient safety, but there is a higher likelihood that they retain the information longer. Program Description: This training program was developed as an outcome of an Academic-Practice Partnership between Boston Children s Hospital, Department of Medicine Patient Services, and Boston College s William F. Connell School of Nursing. It was designed to provide individuals teaching patient safety for or in new nurse orientation with a useful tool for communicating critical patient safety concepts in real patient care settings. This program consists of twelve vignettes of real patient care situations. Across the twelve vignettes, overt and subtle safety errors are staged. For each vignette there are two versions, the first is an unedited version of the scenario in the hospital setting. The second version follows immediately after the first and includes edits that identify the scripted safety risks. Program Development. The vignettes were developed in the following manner. 1) A development team was created and consisted of patient safety, curriculum, and media experts. 2) The safety risks to be depicted in the videos were then selected based on the Joint Commission s National Patient Safety Goals and the Joint Commission Standards ( The World Health Organization s (2011) WHO patient safety curriculum guide for medical schools ( was also used as a 2

3 primary reference. The hand hygiene guidelines are based on the World Health Organization (WHO) Hand Hygiene Guidelines and the 5 Moments of Hand Hygiene Campaign ( 3) Scenarios were scripted to embed a variety of safety errors that commonly occur in inpatient settings. 4) After filming and initial editing, the vignettes were shown to a panel of patient safety experts to identify both the errors in the original script as well as other errors the actors made. 5) Productions of the vignette with the safety errors identified then commenced. Vignettes and Patient Safety Risks are listed below: Virtual Rounds # Vignette Title Safety Risks in Vignette Virtual Rounds # 1 Fall Prevention Room cluttered with clothing and wires on floor Bedside table out of reach Bed in high position No hand hygiene by RN upon entering the room RN does not introduce self to patient RN does not verify patient identification before hanging IV medication No hand hygiene by RN prior to administering medication RN does not clean IV site with alcohol RN missed opportunity to educate patient about using call light Stretcher has side rail down IV pole with tubing too far away from patient Surge protector used to expand outlet capacity Patient with bare feet: risk of fall, injury, and contamination Virtual Rounds # 2 Alarm Fatigue Inappropriate conversation about a family while in a public space 3

4 4 Baby not secure during transport Wheelchair not locked during transfer No clear clinician to clinician handoff RN does not introduce self to patient/family RN does not verify patient identification No hand hygiene by RN RN missed opportunity to educate family about cardiac monitoring Bedrails not in high position Crib is unlocked RN missed opportunity to review fall with parents Syringe left on bedside table RN gives incorrect patient age Minimal response by all staff to alarms RN silences alarm from central monitor before checking patient Virtual Rounds #3 Playroom Safety Three patients in playroom left unattended ESD staff cleaning playroom with wet mop while children were in the room ESD staff wears same yellow gown in and out of the playroom Patient on precautions leaves room, enters playroom Patient and mother did not perform proper hand hygiene upon entering room Scissors, glitter, and food

5 5 on table in playroom unattended Virtual Rounds # 4 Discharge Patient on stretcher with side rails down Patient not wearing an ID bracelet RN does not perform proper hand hygiene upon entering room No introductions with parent by RN upon entering room Did not educate family about new medication Did not include child in discharge discussion RN did not verbally review discharge instructions with parent RN did not follow up on missing medication RN missed opportunity to perform medication reconciliation RN missed opportunity to review the follow up plan Peripheral IV not removed Supplies left at bedside Virtual Rounds #5 ESD Cleaning HIPAA spelled incorrectly on binder No communication to ESD regarding precaution room ESD staff does not change gloves when moving between rooms ESD using same cleaning cloth in both rooms ESD staff cleans pole backwards instead of top to bottom ESD staff holds dirty linen close to arms and clothes ESD staff began cleaning

6 6 precaution room without PPE ESD staff puts on precaution gown backwards ESD discards trash improperly ESD cart left in proximity to patients ESD staff touches patient toy with dirty gloves No hand hygiene by ESD staff upon completing task Virtual Rounds #6 Handoff Yelled out patient s name across corridor No protected time and space for handoff Patient information discussed in a public area Flow of handoff interrupted by clinical assistant No use of EMR No standardized format or tool used for handoff No structured format, no specific order for relaying information No family participation during handoff Parent needs not addressed Minimal ability to ask questions No closed loop communication Handoff lacking in accurate relevant information Virtual Rounds #7 High Risk Medications RN holds door open allowing for distractions RN does not verify right patient RN at door is distracted and does not verify actions of other RN

7 7 Inappropriate use of personal cell phone RN does not check orders, right med, right dose, right route, right time RN at door missed opportunity to verify drawn dose Parent distraction during medication preparation RN is dismissive of parent Inaccurate closed loop communication 2.5mg vs 0.25 Computer screen not closed when leaving room Virtual Rounds #8 Medication Administration RN uses top of dirty laundry as a preparation area No hand hygiene by RN prior to donning gloves Touches hair after putting on gloves RN does not properly secure precaution gown Incorrectly bar coded, not attached to patient RN does not identify self to patient Inadequate patient verification RN leaves medication unsupervised at bedside Pt on precautions. Rn doesn t wear gloves while connecting IV RN does not clean IV site properly RN does not program pump for delivery Virtual Rounds #9 Mislabeled/Unlabeled Specimens RN reading facebook at desk RN playing with hair and wearing dangling earrings

8 8 RN brings personal drink into patient area RN does not introduce herself to patient and family No hand hygiene done by RN RN does not encourage parent participation RN does not give clear explanation to patient/family RN misidentifies patient name Bed is moved into high position with side rails down RN does not verify patient identification Nasal cannula not properly positioned Inappropriate procedure for handling air in IV tubing No clean field prepared for procedure Fails to engage parent in helping child during procedure No hand hygiene by RN prior to beginning procedure RN does not verify orders for labs Collection tube falls on floor and is still used RN does not prep IV site with alcohol Does not confirm amount of blood needed Does not don gloves prior to blood draw Missed opportunity to manage pain by using

9 distraction techniques or active needle pain protocol RN does not label tubes at point of care RN does not wear gloves when handling specimens Medical waste not disposed of properly Specimens placed in one bag with another patient s specimens Virtual Rounds #10 Dressing Change RN did not perform proper hand hygiene upon entering the room RN did not introduce herself to patient upon entering the room No patient identification made before beginning procedure Pt is coughing over dressing, RN does not address or give mask to patient RN does not completely remove existing dressing RN does not have clean field set up, uses bed, bedside table for new and used materials RN touches toys on table with gloves RN does not use sterile gloves RN does not perform hand hygiene when removing gloves RN cleans over existing dressing RN does not clean dressing appropriately or for adequate amount of time RN touches own hair and 9

10 10 then continues dressing change Name tag dangles in sterile field RN tapes patient gown to the dressing RN touches toys with dirty gloves RN disposes of medical waste improperly Leaves trash on bed Side rails on stretcher are down Virtual Rounds #11 Transfer of Care O2 tank not transported securely Patient s feet not supported Stretcher not locked Wheelchair locks not put on No hand hygiene by CA prior to connecting tubing Head of bed is not raised No check of O2 settings No patient identification made No clear handoff between CA and RN No introductions between CA and RN CA working out of scope of practice RN silences alarm without investigating cause No hand hygiene by RN prior to connecting tubing RN focused on monitor and does not assess patient and equipment O2 turned to inaccurate settings Side rails on stretcher are

11 down Virtual Rounds #12 Skin Pressure Ulcer Pt right leg in orthotic boot and heel not elevated off bed Side rail down while HOB elevated and patient slouched while sleeping CA returns urinal to bedside without gloves Does not perform hygiene; Cross contamination to phone Urinal left out of reach Incomplete patient identification RN fails to do adequate assessment after patient complains of pain RN not receptive to request for assistance Pt repositioned without putting down HOB Pt not repositioned onto left or right side Classroom Use of the Vignettes: The program serves as an adjunct to standard curricular information on patient safety and can be customized to a variety of pedagogical approaches. These include but are not limited to: 1) an interactive component of a lecture or orientation program, 2) use in clinical post-conferences, 3) incorporated into online learning modules, or as 4) assigned as homework for later review in class. The tool included as Attachment A can be used for this purpose. Evidence of learning can be evaluated by conducting a pre- and posttest (verbally or written), written evaluation of problem solving and decision-making approaches related to patient safety, or measured through observation in simulation scenarios. Participants should be given the opportunity to view the unedited version and identify all of the safety risks that they observed, followed by the second vignette with the safety risks identified. The number and order in which the vignettes are shown is left to the instructor s discretion, however a critical learning element in this training is for trainees to have the ability to discuss each vignette, and ask and respond to questions. 11

12 This will allow the instructor to discuss local policies and procedures, which may be slightly different than what is shown in the videos. Operational Use of Training Materials: Vimeo: The vignettes are available on the webpage Information & Resources: (NCPS Internet) For questions or comments regarding this training manual & materials contact: Acknowledgements The contributions of Boston Children s Hospital and the Boston College William F. Connell School of Nursing volunteers who assisted with this project are thankfully acknowledged. 12

13 Attachment A: Virtual Patient Safety Rounds Video Observations Virtual Round # Patient Safety Violations Identified Please list all Safety Violations that you observe in the Video: 1. Comments after Viewing Safety Risks

14 Attachment B: Questions for Discussion Virtual Rounds # & Vignette Title # 1: Fall Prevention Questions for Discussion # 2: Alarm Fatigue # 3: Playroom Safety # 4: Discharge # 5: ESD Cleaning # 6: Handoff #7: High Risk Medications 14

15 #8: Alarm Fatigue #9: Mislabeled/ Unlabeled Specimens #10: IV Dressing Change #11: Transfer of Care #12: Skin Pressure Ulcer References Whitmore, J. (2002). Coaching for Performance: Growing People, Performance and Purpose 3 rd Edition. Boston: Nicholas Brealey Publishing. 15