Transcript Compassionate care, Advanced medicine, Close to home

Making NorthBay a Great Place to Have a Baby
with a continual focus on establishing a
culture of safety
Safety culture has been defined as “the product of
individual and group values, attitudes, perceptions,
competencies, and patterns of behavior that determine
the commitment to, and the style and proficiency of, an
organization’s health and safety management”
(Sexton et al., 2006, p. 2)
Compassionate care, Advanced medicine, Close to home
Clarify Purpose…
Every patient, Every Encounter, Every Time
Communication…Communication…
Communication
Compassionate care, Advanced medicine, Close to home
Clarity of Expectations…
Align Systems…Unleash Talent
2014 CLIN IV GOAL Create a Culture of Debriefs
I will work with the staff, Physicians and leadership to
implement a culture of debriefs. I commit to utilizing an agreed
upon tool will be implemented to assess for system issues
with high risk low volume occurrences, as well as
acknowledge things that went well. The situations that will be
debriefed will be decided upon by the team (maximum 5
mandatory debrief events) and through collaboration,
competence and communication be completed with
consistency at least 50% of time in qtr3 and 75% of the time in
qtr4.
Compassionate care, Advanced medicine, Close to home
Patient Safety Culture Survey 2015
We are informed about errors that happen in this unit.
50%-ile L&D/MBU
In this unit, we discuss ways to prevent errors from
happening again
50%-ile MBU
My supervisor/manager overlooks patient safety
problems that happen over and over.
10%-ile L&D
Compassionate care, Advanced medicine, Close to home
Patient Safety Culture Survey 2015
We are actively doing things to improve patient safety.
25%-ile NICU
We are given feedback about changes put into place
based on event reports.
25%-ile NICU
We are informed about errors that happen in this unit.
<10%-ile NICU
Compassionate care, Advanced medicine, Close to home
Compassionate care, Advanced medicine, Close to home
Communication…Communication…
Communication
Katie to Heather….
Great write up. Let's save these debriefs. I think we
can use them for staff education and our work
around pt safety.
Compassionate care, Advanced medicine, Close to home
Communication…Communication…
Communication
Heather to Clin IVs….
I am seeking your opinion on how to best inform all of
the staff on RIRs as well as sharing the take back
information from various Debriefs. Do you want an
email? Do you want to Huddle about it? Do we want
to make a special bulletin board with the information
on it? What would work best to get this information
back to all of you? Looking forward to hearing all of
your great suggestions.
Heather
Here is what staff said…
I think that if we made a bulletin board then there
would be a good chance that everyone wouldn't
read it. However, an email followed up with a
huddle communication may be a good idea.
Maybe once a month all of the RIR's/Debriefs
could be summarized?
Compassionate care, Advanced medicine, Close to home
Communication…Communication…
Communication…
From Katie to the Chairs of Anesthesia and OB
“Sharing the written debrief from the weekend.
Let me know if you would like these
communications sent to you when I receive them.
As we work on creating a Culture of Safety, we
are tracking debriefs and RIR’s so that we can
look for trends/make improvements and will be
communicating these with staff.”
Compassionate care, Advanced medicine, Close to home
Communication…Communication…
Communication…
“Very Impressive. Having Blood type and
Crossed may be the best choice given the
geriatric speed we get blood product from the
bank. Please continue to keep me in the loop.”
Jesse (Anesthesia Physician Leader)
Compassionate care, Advanced medicine, Close to home
Compassionate care, Advanced medicine, Close to home
Compassionate care, Advanced medicine, Close to home
Compassionate care, Advanced medicine, Close to home
Compassionate care, Advanced medicine, Close to home
From: "Driver, Chastity" <[email protected]>
Date: April 28, 2016 at 2:38:51 AM PDT
To: "Troutt, Heather" <[email protected]>, "Lydon, Katie" <[email protected]>
Subject: Code Blue drill
Just wanted to let you know we did a code blue drill tonight. I've been inspired by my
preceptor, Elisa Jang :-) I've been helping her/shadowing her while she runs code
blue drills during my clinical hours.
It went really well, and it was a good review for the ones that attended the simulation in
February, and a good learning experience for the ones that did not attend that day.
We did a debrief, and some areas that required reminders were to have two people for
the airway (new guideline: one person to hold the mask in order to ensure a good seal,
and the second person to deliver the breaths with the ambu bag), also there was a
reminder to remove the ambu bag off of the bag when the shocks are delivered.
Overall it was great, NICU came, and we used the CPR manikin that we have in the
break room. I ordered some extra pads and an ambubag to use and labeled it
"simulation" for anyone else that wants to do a simulation. The only thing that I
was disappointed about was the fact that the pads don't make good contact with the
manikin, so we couldn't evaluate the depth and rate, or recoil of the compressions, so we
didn't get any feedback from the machine.
Compassionate care, Advanced medicine, Close to home
employees
present: Kathryn Vera, Cherie Wonnell, Ken Nelson, Adel Henry, Maria Lara,
Chris Cruz (he helped me set up as well), Amber Haddon, Corrina Renaud