Transcript Results: The Staff Safety Assessment Survey

Results:
The Staff Safety Assessment Survey
Lisa Lubomski, PhD
April 11, 2013
The Staff Safety Assessment Survey
You spoke…and we listened.
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Participants
There were:
• 46 participants in total
• 35 participants from Maryland
• 11 participants from Pennsylvania
Thank you for participating!
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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.
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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
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Problem and Solutions
Addressing each potential harm
category with the solutions you have
proposed.
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Problem 1
Falls:
• can cause an adverse event leading to patient harm
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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Problem 5
Medication Error:
• can cause an adverse event leading to
patient harm
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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
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Problem 6
Other Adversities:
• outdated equipment
• illness-related death
• inconsistent care practices
• lack of resources
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Other Adversities
Solutions Proposed:
• standardize equipment across units
• improved vigilance and monitoring of patients
• implement standardized protocol and daily rounds
checklist
• more resources needed
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Thank you all very much!
The Next Step…
Learning from Defects!
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