How to be an ACE in Your Place: The Top Three Elements of Nursing Practice to Protect Patient Safety and Avoid Patient Harm Kendra Folh, BSN, RNC-OB
Medical error has been defined as: An unintended act (either of omission or commission) One that does not achieve its intended outcome The failure of a planned action to be completed as intended (an error of execution) The use of a wrong plan to achieve an aim (an error of planning) A deviation from the process of care that may or may not cause harm to the patient
Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3, 2016 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention s (CDC s) third leading cause of death respiratory disease, which kills close to 150,000 people per year. According to the CDC, in 2013, 611,105 people died of heart disease, 584,881 died of cancer and 149,205 died of chronic respiratory disease the top three causes of death in the U.S. The newly calculated figure for medical errors puts this cause of death behind cancer but ahead of respiratory disease
Leading causes of medical error: Missed assessments Missed interventions Failure to communicate patient information to a health care colleague
Assessment Communication Escalation
Assessment
One study reviewed 13,025 interruptions experienced by medical and surgical nurses on 36 units from 9 hospitals and found that that 90% of interruption-related errors resulted in delays of treatment or loss of concentration or focus. Such errors often occurred during documentation, medication administration, or patient care assessments or procedures.
Eliminate Distractions
Mindfulness Paying attention to the present moment, on one's purpose, and doing so in a nonjudgmental manner It provides a framework from which health care workers can work most effectively in the context of numerous interruptions and distractions Mindfulness helps one notice new aspects of things that are familiar
Mindfulness Staying in the moment Non-judgmental awareness of thoughts and feelings Relaxing the mind and letting go of negative thoughts Increased awareness of thoughts and actions enables efficiency in work and focus
How does the culture of your environment affect mindfulness?
Communication
Clinical Communication failures are considered the leading cause of medical errors. A review of reports from the Joint Commission reveals that communication failures were implicated at the root of over 70 percent of sentinel events.
Miscommunication among medical staff while transferring patients contributed to 80 percent of serious medical errors, according to one estimate by the Joint Commission.
23,000 medical malpractice lawsuits and claims where patients suffered some form of harm were reviewed. Out of all these cases, it identified over 7,000 where the problem was directly caused by miscommunication of certain facts, figures and findings.
The most common provider-to-provider communication breakdowns were: Miscommunication about the patient s condition Poor documentation Failure to read the patient s medical record
S.B.A.R The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare.
Situation: What is going on with the patient? Background: What is the clinical background or context? Assessment: What do I think the problem is? Recommendation: What do I think needs to be done for the patient?
The following is an example of a nurse call to a physician using SBAR: Situation "Here's the situation: Mrs. Smith is having increasing dyspnea and is complaining of chest pain." Background "The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128 over 54. She is restless and short of breath." Assessment "My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism." Recommendation "I recommend that you see her immediately and that we start her on O2 stat. Do you agree?"
The I-PASS Study A landmark multi-site research communication and patient safety study involving nine institutions in the US and Canada. An implementation of a bundle of interventions to improve resident physician communication during handoffs of patient care (called the I-PASS Handoff Bundle) was associated with a 30% reduction in preventable adverse events. Implementation was also associated with improvements in verbal and written communication without a negative impact on provider workflow or handoff duration.
I-PASS is a mnemonic facilities can adapt to ensure all of the following information is communicated when providers perform handoffs: Illness severity Patient summary Action list Situation awareness and contingency planning Synthesis by receiver
Escalation
The Goal of Escalation: Timely, appropriate communication between nursing staff and providers as changes in patient conditions occurred Clear need for clarification in communication procedures that are unitspecific and easily implemented Reduce problematic time
Problematic Time Time spent hunting and gathering for the correct information related to whom to call, how to best contact them, and what to do when the primary person was not available. Consisted of 10% to 40% of total providerprovider communication time
Escalation Process Tool Provides nurses with patient parameters for escalation Provides an outline of providers to call along with a timeframe Includes criteria for communicating changes in a patient s condition
kendra.folh@memorialhermann.org