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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Results: The Staff Safety Assessment Survey Lisa Lubomski, PhD April 11, 2013 The Staff Safety Assessment Survey You spoke…and we listened. 2 Participants There were: • 46 participants in total • 35 participants from Maryland • 11 participants from Pennsylvania Thank you for participating! 3 The Premise We asked you to please describe how the next patient in your unit/clinical area will be harmed, and to present solutions to prevent or minimize harm. 4 Response: Potential Harm Each response and solution to fell into 6 main categories: 1. Falls 2. Miscommunication 3. Lack of Staff 4. Hospital Acquired Infection 5. Medication Error 6. Other Adversities 5 Problem and Solutions Addressing each potential harm category with the solutions you have proposed. 6 Problem 1 Falls: • can cause an adverse event leading to patient harm 7 Falls Solutions Proposed: • adequate staff present when tending to patients • increase number of bed alarms, designate sitters for high risk patients, have safe lifting equipment available • implement preventative measures (ex. proper socks, yellow band, low bed, et al.) • improved staff communication • increase frequency of rounds for high risk patients 8 Problem 2 Miscommunication: • causes delayed care • leads to instructions not being followed • leads to ignoring others (especially subordinates) • causes unnecessary procedures for patients • causes failure to obtain consent • lack of physician engagement 9 Miscommunication Solutions Proposed: • work to improve communication overall • implement a clear chain of command - with specific duties assigned • have a checklist with pertinent patient information readily available • listening to the concerns of others (regardless of rank) 10 Miscommunication Solutions Proposed continued: • only perform necessary procedures for patients • proper patient screening with informed consent a priority • ongoing meetings with VP of quality to ensure physician compliance with bundles and care planning 11 Problem 3 Lack of Staff: • adverse event leading to patient harm • places too many responsibilities per staff member • late/delayed care or administration of medication • mistakes due to fatigue • mistakes by new staff member 12 Lack of Staff Solutions Proposed: • increasing number of staff (ex. RNs, CCTechs, et al.) • implement a clear chain of command - with specific duties assigned • implement a grassroots campaign to increase staff numbers 13 Lack of Staff Solutions Proposed continued: • ongoing education for personnel, and ensuring an experienced staff member is working at any given time • have a contingency plan for increasing available staff in the event of a sudden influx of patients 14 Problem 4 Hospital Acquired Infection: • cause adverse event leading to patient harm • caused by poor hand-washing practices • can cause VAP- makes it more difficult to extubate, leads to longer time in critical care, increases probability of additional infections 15 Hospital Acquired Infection Solutions Proposed: • continued education for staff -emphasizing the spread of pathogens and good hand-washing practices • monitoring compliance for good hand-washing practices • increased accessibility of hand hygiene products coupled with visible cues and reminders • improved maintenance of central line 16 Hospital Acquired Infection Solutions Proposed continued: • early mobility of patients • implementation of a strict daily device assessment tool • preventative care- while on ventilator follow recommendations for oral care, HOB 30 degrees, sedation vacation, among other tools 17 Problem 5 Medication Error: • can cause an adverse event leading to patient harm 18 Medication Error Solutions Proposed: • pharmacy and medication monitoring • no override of medications until front-line staff approval is obtained • need a pharmacist working in ICU 24/7 • identification of common dosing conversions and unit conversions 19 Problem 6 Other Adversities: • outdated equipment • illness-related death • inconsistent care practices • lack of resources 20 Other Adversities Solutions Proposed: • standardize equipment across units • improved vigilance and monitoring of patients • implement standardized protocol and daily rounds checklist • more resources needed 21 Thank you all very much! The Next Step… Learning from Defects! 22