Reflective Journal Week 13: Maintaining a Culture of Safety Overview

1) I expected to learn ways to maintain a culture of safe practicing nurses for patients.

2) I learned that the best doctor or nurse can make a tiny error that leads to really big consequences for patients. Thus, it is imperative for nurses (and all healthcare professionals) to learn to practice safely, lead by example, and help unify others in maintaining a culture of safety. This can lead to the best and safest results for patients. From the case studies we read, I think I most learned to always question a patient’s situation and think deeper into WHY they are experiencing the symptoms they are. I also learned to educate my patients thoroughly about doctor’s orders, interventions I am performing, and why they are needed. If the patient or family members feel they don’t agree with the care plan, they have every right to disagree. We must remember they are partners in the care plan and a consensus can be reached that is most safe for the patient.

Lastly, I learned from a Quality and Safety in Nursing youtube clip(Vital Smarts India, 2012) that policy is only effective if nurses are willing to follow it. This statement is so true. Rules, policies, and guidelines are in place for patient safety. They were likely created and implemented because of a patient harm that occurred (or by risk management teams foreseeing risks and designing processes to prevent them from occurring). If nurses don’t abide by the rules, then what is the point of having them? No safe care will be rendered to patients. The same mistakes, medication errors, patient harms, and accidental deaths will keep occurring. This unit lesson really taught me the importance of having integrity as a nurse. What I am taught and trained to do, which is best practice for the patient, is what I will always do

3) The team discussion was interesting to me. I felt stopping the IV, continually monitoring the patient for a change in status, and then calling a Rapid Response may have been the most efficient and safe solution to the patient’s situation. Others in my group felt discussing the issue with the charge nurse would be a good idea. Another felt like the hospitalist should come assess the patient. I think calling the Rapid Response team would bring more sets of eyes and hands to come in and assess the patient. They are trained professionals that can have an open dialogue about the patient and their situation—while getting the doctor back on the phone with more specific orders for the patient (i.e. changing antibiotic, dose of IV Benadryl or subcutaneous epinephrine, or a steroid). I feel like just talking to the charge nurse doesn’t really solve any problems. Things actually need to be communicated and implemented as a team to ensure the patient’s safety.

4) This unit lesson really taught me the importance of having integrity as a nurse. I plan to look up evidence-based practice guidelines on online sites such as Up-to-Date and National Guidelines Clearinghouse (www.guideline.gov) whenever I am in doubt about a patient and their situation. This information can guide me to make safe decisions for the patient and open up dialogue with the practitioner to discuss safer options for the patient. This way I will be advocating for the patient. I will also show through my example I support and am implementing a culture of patient safety.  

5) The Case Study about a four-year-old, Noah Lord, who died from post-surgical hemorrhage, possible infection, and dehydration really scared me. It showed me that poor communication among healthcare professionals and the patient/family members can result in patient death. This experience has instilled a desire in me to make all of my actions meaningful as an emergency room nurse. Patients should not be discharged until they feel safe to go home. The right physicians and specialists should be attending to patients. Admitting a patient for observation is always a possibility to ensure their safety.  

Reference

Vital Smarts India (2012). The silent treatment: Patient safety. Retrieved online from https://www.youtube.com/watch?v=ly0wW95Or7I&list=PLUuOgSK-0gzFg1N0A4o_ZbKvzcCXEFyR-&index=3

Reflective Journal Week 12: Errors and Near Misses

1) I expected to learn about errors and near misses with patients in the healthcare setting.

2) I learned just this and more about specific case studies that were so devastating, I don’t think I will ever forget about them! (This is a good thing because it will always remind me to slow down while giving care to patients.) I first watched a playlist movie on the Nursing 4550 Quality and Safety page (Stop MICRA, 2014). It was about Dennis Quaid, his wife, and twins they had long awaited for and were finally born. Both twins developed a staph infection soon after birth and were admitted to the NICU. A nurse accidentally gave a dose of heparin ten times the ordered dose to clear the twins’ lines. The twins were basically bleeding out and unable to clot their blood. Miraculously, they survived, but their stay was extended much longer and their parents had to deal with this traumatic experience. After the event, Dennis Quaid decided to let this information out to the public in hopes of preventing human medical errors in the future. The interviewer on 60 Minutes had even asked the pharmaceutical company why the adult Heparin vial and pediatric vials were so similar—and how come they were not recalled after wards. The representative of the pharmaceutical company basically said it wasn’t their fault and nurses need to carefully read labels before administering medications.

I agree with this statement, but I also can see how these types of errors occur. Human Factors Theory refers to “the relationship between human behavior, system design and safety this is becoming increasingly influential in helping us understand the causation of errors, accidents and failures in health care systems” (Royal College of Nursing, 2015).  There are three main factors that can attribute to human errors, namely job, individual, and environment. Individual nurses may be fatigued, feel rushed, or lack certain training when caring for patients. The system at the hospital may not have many safety rules or procedures to follow. The environment may be dimly lit, chaotic, or lack necessary machines to do one’s job effectively (or the technological equipment is in need of repair). These all contribute to how safely a nurse will render care to her patient. To help solve these problems, risks need to be identified in each of these areas to help prevent potential errors before they occur—because in healthcare, errors that do occur can result in accidental death.

3) I was saddened and surprised after reading the case study (Johnson, Haskell & Barach, 2016) that we discussed as a group. A nurse spiked an enteral feeding bag with IV tubing and administered it to a pregnant patient through her PICC line. The patient was supposed to receive TPN which is compatible with a PICC line and yellow in color. (Vastly different from brownish-gray feeding tube solutions). The patient’s baby died from excessive fat clogging its vasculature, and the patient also coded and died soon after. The error of administering an enteral formula via the patient’s intravenous line was not noticed for 6 entire hours. During this time, the formula continued to infuse and cause the patient to experience more pain and difficulty breathing. The patient’s family was not notified that the error had occurred until the very last minute. In addition, the deceased patient left her husband a widow to raise his 3-year old son alone.

The case study was written by the patient Robin’s mother, Glenda Rodgers. She was a Registered Nurse herself with many years in obstetrics. From Glenda’s perspective she wishes to this day she would have questioned more what was going on with her daughter so they could have intervened earlier and potentially saved Robin’s life. Glenda wonders if she was too trusting. Glenda ended her account by stating that if patients and families are asking questions, they are not questioning your ability and authority as a nurse. They are genuinely concerned, and as their nurse, you should be as well. Diligently seeking out and finding a resolution to questions can help save patient lives.

I also learned about Just Culture. Traditionally, healthcare’s culture has held individuals accountable for errors and mishaps that befall patients under their care.  In contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control (American Nurses Association, 2010, p. 2). A culture that focuses on “no blame” helps clinicians feel more safe and open about reporting errors and near misses that occurred. This way, risk management teams can learn of the errors/patient harms, and intervene quickly by new process implementation, in hopes of preventing the reoccurrence of the event. This leads to better patient safety outcomes and improved processes in a healthcare system.

4) I plan to admit near misses by filing out incident reports. I also plan to slow down when caring for patients, more diligently seek out answers to patient/family concerns, and always follow policies and procedures I’ve been trained on. (If I have not been trained on something, I will openly communicate that with my charge nurse and find ways to safely care for the patient within my scope and with other nurses’ help if needed). I will continue to ask questions when in doubt as well—this is a practice I have always strived to do anyway.

5) I enjoyed this unit immensely. Yes, it was very disheartening to learn about, but reading the cases helped instill important lessons in my mind of listening to and valuing patient concerns. If something doesn’t feel right with a patient, I will further assess the problem to find the safest solutions for the patient.

References

American Nurses Association (2010). Position statement: Just culture. Retrieved online from             http://nursingworld.org/psjustculture

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety:        Foundations for core competencies. Case 18, p. 231-245. Burlington, MA: Jones & Bartlett Learning

Royal College of Nursing (2015). Human factors in patient safety. Retrieved online from             https://www.rcn.org.uk/development/practice/cpd_online_learning/making_sense_of_pati            ent_safety/human_factors_in_patient_safety

  

Stop MICRA (2014). Dennis Quaid talks about his twins and medical negligence. Retrieved from https://www.youtube.com/watch?v=GEDMYsm3Nxs&index=7&list=PLUuOgSK-            0gzFyneo6CVElbN1wWLO1YGth

Reflective Journal Week 11: Building a Culture of Safety

1) I expected to learn about building a culture of safety in the healthcare environment.

2) I actually learned about ensuring risk management teams are available in health care settings to build cultures of safety. In healthcare, there are multiple potential possibilities for death and disability. The vision of risk management is to build resilient systems with a goal of zero avoidable harm. Risk can be measure in terms of likelihood and consequences. Human error, performance limitation and accidents are all potential risks. Safeguards and systems need to be put in place to foresee and plan for risk, implement processes to decrease risk, and recover from adverse events.

Organizing a culture of safety involves leadership commitment, trust in communication, shared importance on safety, teamwork and support/encouragement, and reporting/analysis systems (Pronovost, et al., 2003). Most methods suggest focusing on the clinical microsystem where physicians and patients meet, and then focusing on a meaningful change. Methods also suggest viewing the whole causal system and not just a single root cause.

Risk management aims to ensure healthcare providers are acting in the best interests of the patient. If errors do occur, patients and their family members should be informed about it and the cause of it. Disclosure is very important following errors in hospital settings. This way, improvements can be made and others can learn from the experience to prevent it from happening again.

3) The article “It’s Hard to Kill a Healthy 15-Year-Old” (Johnson, Haskell & Barach, 2012) made me sick inside to read. I was honestly amazed at how poor of communication and care processes this single patient received. The patient was hemorrhaging internally with peritonitis, tachycardia, poor pulses, paleness and abdominal pain. There were so many signs pointing out that something was extremely wrong with the patient.  I mean, when a nurse gives a pain medication, and the pain continues to persist or worsen, other forms of medication should be considered while discontinuing the one causing increased discomfort or symptoms.  A nurse or pharmacist could have double checked to ensure the dosing was proper for the patient, or even determine whether the medication was appropriate for his age category. I was shocked that they were ambulating the patient to relieve him of his “gas pains” while he was hemodynamically unstable. It just makes me sick to think about, and I feel so bad for the mother, father and sister that had to deal with his tragic death.

This depressing and devastating case study proves to me how important wearing a badge is that indicates one’s title and abilities. It proves to me how important communicating with physicians and other experienced professionals is when patients display initial signs of worsening. I appreciated that the parents tracked down the patient’s information and remained diligent in finding his cause of death. What if she hadn’t? No Hospital Patient Safety Acts would have been created to help protect other patients. I hope all health care facilities have risk management teams to ensure safe implementation of processes where risks can be foreseen and prevented.

4) I plan to disclose the cause of errors with patients/family members and filling out an Incident Report form so risk management teams will be aware of problems in the microsystem and can help plan ways to fix them so other patients can be protected. (My goal, of course, is to not let errors occur—as is all well-meaning care providers.)

5) I will restate my personal feelings about the case study. It is entirely devastating that a family lost their son to a chain of errors from incompetent providers. Yes, hindsight makes things easier. A novice nurse being told by a resident physician her patient has gas pains, will likely not doubt and continue to believe this fact (while simultaneously causing more harm to the patient by ambulating him). A more experienced nurse will question what the resident says and look deeper into the problem at hand with the patient. The nurse will also take action to make things better for the patient!

References

Johnson, J., Haskell, H., & Barach, P. (2012). The Lewis Blackman Hospital Patient Safety Act:   It’s hard to kill a healthy 15-year-old. In C.P. McLaughlin, J. K. Johnson, & W. A. Sollecito (Eds.), Implementing continuous quality improvement in health care: A global casebook (pp. 5-14). USA: Jones and Bartlett Learning, LLC

Provonost, P., Weast, B., Holzmueller, C. G., et al., (2003). Evaluation of the culture of safety:    Survey of clinicians and managers in an academic medical center. Quality Safety in Health Care, 12: 405-410.

Reflective Journal Week 10- Informatics

1) Honestly, I wasn’t quite sure what informatics even meant. I assumed it dealt with genes or something.

2) From an online Google search, I learned that informatics is the science of processing data for storage and retrieval (https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=informatics%20definition). Informatics is also the study and application of information technology to the arts, science and professions. In healthcare, according to David Blumenthal, “information is the lifeblood of modern medicine. Health information technology (HIT) is destined to be its circulatory system” (Sollecito & Johnson, 2013, p. 335). Goals for the future of healthcare include designing HIT standards that include precise data definitions for diagnoses/treatments, an architecture for aggregating data for each patient over time and across providers, and protocols for seamless communication among systems (Sollecito & Johnson, 2013, p. 336). Data access, comparability, transparency, and interoperability are needed data system characteristics to ensure the successful future for HIT.  Acts for meaningful use of electronic health records (EHRs) have been passed in order to improve patient quality and safety outcomes. Ensuring that EHRs in both hospital and office practice settings are interoperable would be an example of “meaningful use”.

3) From our discussion, I learned the importance of ensuring processes are firmly outlined when it comes to implementing and transitioning to new electronic charting systems. Most all persons are resistant to change. This makes it especially hard to implement new ideas/processes/goals in a healthcare environment—because healthcare is constantly changing. Our discussion focused on the fact that physicians/mid-levels in a healthcare setting were noncompliant with the new CPOE charting system. As a team, we discussed why this was so and how a QI team could analyze the process, redesign it, and implement it. It seemed the answer would be found by interviewing the physicians as to WHY they weren’t using the new system. We discussed the possibility that the computer system was freezing, contained errors, was slow, or was malfunctioning. Maybe the new system wasn’t meeting the needs of this specific healthcare setting. This would lead to a mistrust in the system by staff and create an immediate need for computer support personnel to fix the problems. We decided that to prevent physician non-compliance with the new CPOE system, a more detailed plan should have been implemented initially. A date of transition would need to be set early on. This way staff could mentally prepare for the change. Trainings on the new system and familiarizing oneself with it would need to take place. Computer support personnel would need to be on-site to answer questions and help users become comfortable with it. This way, they too could see if the system was malfunctioning. A positive attitude and team approach was the best way to ensure the change went as best it could. Lastly, the QI team could analyze their process and determine better ways to go about computer charting changes in the future.

4) I plan to be more positive about a change that will be coming to Intermountain Healthcare here soon. They are changing over form HELP2 to a new iCentra computer charting system in April 2016. I am already excited to learn about it and am trying to help my co-workers be more excited about it too. When people are negative about it, I try to encourage them by stating that “super users” will be on-site to help us get comfortable with the new system, and hopefully it will be more efficient.

5) I enjoyed the material covered. I like how health information is recorded and stored in computers these days—it makes finding and storing information so much quicker and easier. I also like how the ARRA-HITECH act was passed to contribute to health care improvement (Sollecito & Johnson, 2013, p. 353). Increased interoperability and transparency among office providers and hospitals will be difficult to do via one single computer system, but remains the goal for now so information can be communicated to all disciplines about patients. This will increase patient safety and improve continuity of care (for example, an Emergency Department could look up information about a patient that was transferred from a nursing home and vice versa).

Reference

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny's continuous quality improvement in health care. Burlington, MA: Jones & Bartlett Learning.