Patient Safety for the Newly Licensed Practical Nurse

Transcription

1 State of Nebraska Transition Grant Patient Safety for the Newly Licensed Practical Nurse Education Module Copyright 2011

2 Title: Patient Safety Introduction Safety, the freedom from psychological and physical injury is a basic human need. Healthcare provided in a safe manner and in a safe environment is essential for a patient s well being. Providing a safe environment reduces the risk of accidents and health care costs. Safety is a need for everyone but vulnerable groups are more at-risk. Infants, children, older adults, those who are ill, the physically and mentally challenged, those who are illiterate, and the poor are at high risk for safety issues. A culture of safety is an atmosphere of mutual trust in which all staff members talk freely about safety problems and how to solve them, with no fear of blame or punishment. To be effective, the nurse needs to understand the factors that contribute to a safe environment in the home, community and healthcare facility. The nurse assesses the environment for threats to safety. The nurse should be knowledgeable about how alterations in mobility, sensory function, and cognitive function affect a patient s safety. A safe environment means meeting the patient s basic needs, reducing physical hazards and eliminating transmission of pathogens. Accidents in the healthcare environment can be classified in three ways: patient-inherent accidents, procedure related accidents and equipment related accidents. Patient-inherent accidents are those in which the patient is the primary cause of the accident. This category includes: seizures, self-inflicted cuts, injuries, burns, ingestion or injection of foreign substances, falls, fires and other changes in the patient status that places them at risk for injury. Procedure-related accidents are caused by healthcare providers and include medication and fluid administration errors, improper application of external devices, improper performance of procedures such as dressing changes, hand-washing, body mechanics, catheter insertion and improper use of oxygen equipment. Medication errors continue to be one of the most frequent causes of preventable harms in health care. Equipment-related accidents result from malfunction, disrepair or misuse of equipment or from electrical hazards. Nurses need basic understanding of types of disasters such as tornadoes and hurricanes, floods, bioterrorism and chemical spills. When disaster strikes, rapid response is crucial so it is important to know workplace policies related to disaster response. Nurses should develop situational awareness that focuses on the art of patient observation. Being able to periodically observe the patient, family and the environment promotes a safer patient care environment and helps the nurse develop care priorities and focus attention to clinical detail. Nurses must be involved in the creation of a culture of patient safety. This includes using leadership skills, teamwork and effective communication with members of the healthcare team. Teaching and learning should be evidence-based and patient-centered. Learning Outcomes: Upon completion of this education module, the newly licensed practical nurse will: 1. Evaluate the patient s environment for safety hazards. 2. Recognize changes in the patient s condition that make the patient at risk for injury. 3. Discuss the possibility of human error and other commonly used unsafe practices in the health care environment. 4. Utilize appropriate clinical tools for documenting and assessing safety of patients. 2

3 5. Describe factors that can create a culture of safety in your work place. 6. Describe the benefits and limitations of safety enhancing technology. 7. Define terminology related to patient safety such as sentinel event, never event, hand-offs, medication reconciliation, and root cause analysis. 8. Discuss the impact of national patient safety standards, initiatives and regulations of the National Patient Safety Foundation and Joint Commission. Interactive Exercises: 1. Identify the level of safety risk for a patient after completing a fall assessment tool, Braden Scale, Mini Mental Examination and an Activities of Daily Living (ADLs) Tool. (Use the tools at your facility or see Appendix A.) 2. Utilize the 60 second situational assessment found under supplemental resources to evaluate a patient at your work place. Have your preceptor do the assessment as well. Compare your results and discuss the differences. 3. Review the content on Root Cause Analysis at the following sites with your preceptor. Review five incident reports or medication/procedure errors and develop a root cause diagram for the incident. Review the root cause analysis with your preceptor and describe what went wrong and why. How could the incident have been prevented? What is the accountability of the new LPN? Does your quality improvement committee utilize this process? The second website goes through the process of evaluating an incident using an example Research at least five charts for unsafe abbreviations utilized by nurses. Review the Joint Commission site for the Do Not Use List at 5. Volunteer to be a member of your facility s safety committee. Review the guidelines and duties of the committee. 6. Review the medication administration record for five to ten patients. Utilizing the Institute of Safe Medication Practice (ISMP) website to identify which patient medications are on the high alert list and why Monitor UAPs and NAs transfers of patients utilizing mechanical lifts and transfer techniques and identify any safety concerns. Discuss these with your preceptor. 8. Define what is meant by a sentinel event. Discuss the LPN role when a sentinel event has occurred with your direct supervisor. Review the Joint Commission website. 10. Define what is meant by a culture of patient safety. What is included in the culture? After reviewing the following website would you say that the facility you work at has an adequate culture of patient safety? Refer to the website. 3

4 11. Monitor medication aides or other nurses when administering medications and giving patient care. Do they utilize the six rights? Describe safety precautions used or not used in providing care. If you identify any safety concerns, how will you communicate the need for change? Refer to the example below: Excerpts and table adapted from the QSEN Constructive Criticism Tool at Reframing Constructive Criticism Using Reflection Based on the QSEN Competencies When constructive criticism is given, many UAPs, NAs and MAs interpret constructive criticism as uncaring behavior. Worker incivility is frequently triggered when poor performance on the part of the worker necessitates direct constructive criticism from the LPN. Using the QSEN competencies, particularly the attitudes, as a guide, the LPN can reframe the discussions regarding poor performance. Workers can reflect on their performance and extract a realistic appraisal of the level of safe practice they have demonstrated, viewing it from the patient perspective. Such processes of reflection may help the worker arrive at the conclusions that frequently are now communicated directly by the charge nurse and frequently serve as the triggering event for incivility in the charge nurse-worker relationship. Direct Constructive Criticism I am concerned about your performance. Reflection Based on QSEN QSEN Knowledge, Skills and Competencies Attitudes From the patient perspective, if you Patient Centered Care Value: knew this event occurred, would you seeing health care situations feel you were receiving safe, high through patients eyes. quality care? Your patient needs attention now, you cannot leave him like that. If you were that patient lying in that bed, what would be the most important thing the nurse could do for you at this minute? Patient Centered Care: Appreciate the role of the nurse in relief of all types and sources of pain or suffering. 4

5 Can you hear what you are saying and understand what your body language conveys? You spoke to him like he was a child. No wonder he is refusing. Think about how the patient feels being told all day by others, what he has to do. How can you present this to him and still allow him to be part of the decision? Patient Centered Care Value: continuous improvement of own communication and conflict resolution skills Direct Constructive Criticism The report you gave was missing very important information. How will the nurse know what is going on? You need to use SBAR. Reflection Based on QSEN Competencies How could you have ensured that your report included all the information needed so that the receiving nurse could provide safe care to the patient? QSEN Knowledge, Skills and Attitudes Teamwork and Collaboration: Appreciate the risks associated with handoffs among providers and across transitions in care. You are responsible for that lab report not being communicated in a timely manner. How should critical lab reports be managed? Why do we do it that way? Teamwork and Collaboration: Acknowledge own potential to contribute to effective team functioning. You do not assist your peers. What can you do to put that patient at the center of care? Teamwork and Collaboration: Respect the centrality of the patient/family as core members of any health care team. Why would you do it that way? You need to demonstrate immediate improvement. Is there a scientific basis for how you are doing that? What strategies can you use in your own practice to prevent this problem/error/risk? Evidence-based Practice: Appreciate strengths and weaknesses of scientific bases for practice. Quality Improvement: Appreciate the value of what individuals and teams can do to improve care. You need to be more careful. In retrospect, what aspects of your practice in this situation would you change to provide safer patient care? Quality Improvement: Value own and others contributions to outcomes of care in local care settings. 5

6 You are demonstrating unsafe If you were the patient, what would nursing practice. you be concerned about in this situation? Safety: Value your own role in preventing errors. Your medication What role do you play in the administration is disorganized possible causes for what happened? and you need to have a better focus to avoid errors. Safety: Appreciate the cognitive and physical limits of human performance. Direct Constructive Criticism Reflection Based on QSEN Competencies QSEN Knowledge, Skills and Attitudes You must use these strategies to stop making errors. What strategies can you use in your own practice to minimize the risk for this type of error in the future? Safety: Value the contributions of standardization/reliability to safety. The medications have changed since yesterday. You must use the MAR. How should you verify those medication doses? Informatics: Value technologies that support clinical decision-making, error prevention, and care coordination. Example: A medication aide gathers the wrong medications for a patient. While reviewing them, the LPN recognizes the error and guides the med aide to recognize the error also. Correction is made. Afterward, the LPN would address the unsafe practice with the med aide. Direct Constructive Criticism I am concerned about your performance. Gathering the wrong medications is unsafe nursing practice. You need to be more careful. Reflection Based on QSEN Competencies From the patient perspective, if you knew this event occurred, would you feel you were receiving safe, high quality care? What would be your concerns as the patient? In retrospect, what aspects of your practice in this situation would you change to provide safer patient care? Your medication administration is disorganized and you need to have a better focus to avoid errors. What role do you play in the possible causes for what happened? 6

7 I want you to do three checks with medication administration, verifying the medication against the medication administration record and use the six rights as a way of decreasing potential errors. What strategies can you use in your own practice to minimize the risk for this type of error in the future? It is important that you demonstrate immediate improvement so that you provide safe care to patients. What outcome in your own performance would you want to see after this experience? 12. Observe patient identification by other staff members. Discuss with your preceptor your facility s policy on how to identify patients that are alert, children, patients who are confused, and those with sensory problems. Be aware of color coding for bracelet identification and picture identification. 13. Review the policy for fires in the facility and observe staff as they go through a fire drill. Participate in a staff debriefing after the. Identify any issues that resulted from lack of attention to safety. 14. Learn the codes of safety for lost persons, fire, chemical spills, bioterrorism, tornadoes, floods, and poisons. Know where the MSDS instructions are in the facility. 15. Prepare a room for a patient who has active seizure precautions. Include equipment to use with this patient. Review the procedure on care of a client with seizures in your facility policy manual. Is there a patient care guideline that should be followed when caring for this patient? Discuss the policy and guideline with your preceptor. 16. Teach patients how to reduce hazards in their rooms and when discharged to home. 17. What is the agency policy on handling equipment that is broken, non-operable or unsafe? Discuss this with your preceptor. With your preceptor, review equipment on your unit such as wheelchairs, transfer devices, carts, shower chairs, chairs, light fixtures, etc. and identify any safety concerns. How should these be handled? 18. Read the policy at your facility on bioterrorism. 19. Define Never Events. Discuss examples of never events that have occurred by just googling the words never event. Refer to the website about the incident in Fremont Nebraska on unsafe practices by nurses in a cancer clinic Complete a transfer form for a patient leaving the hospital or for a patient being sent to the hospital. Keep in mind the need for medication reconciliation. Why is this important for the safety of the patient? Refer to the ISMP website What is the importance of making sure that your hands off between shifts in complete and accurate? Listen to report on a group of patients. Did you have any questions at the end of report? Give report on a group of patients. Did you include everything in report? 7

8 References Agency for Healthcare Research and Quality (2008). Patient safety and quality: an evidence-based handbook for nurses. United States Department of Health and Human Services. Excerpts retrieved on October 23, 2010 at Altmiller G. (2010). Reframing constructive criticism using reflection based on QSEN competencies. Retrieved on October 23, 2010 at Benner, P., Malloch, K., Sheets, V. (2010). Nursing pathways for patient safety. National of State Boards of Nursing (NCSBN). Mosby, Inc. Council Berman, A., Snyder, S., McKinney. D. (2011). Nursing Basics for Clinical Practice. Pearson Education Inc. New Jersey. Centers for Disease Control and Prevention. (2009). Hand hygiene in healthcare settings. Retrieved on October 23, 2010 at Centers for Disease Control and Prevention. (2009). Infection control guidelines. Retrieved on October 23, 2010 at DeRosier J. and Stalhandske E. (2010). Root cause analysis. United States Department of Veteran Affairs. Retrieved on October 23, 2010 at Finkelman, A. and Kenner, C. (2007). Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education. American Nurses Association. Folstein Mini Mental Examination. Retrieved on October 23, 2010 at Institute for Safe Medication Practices. (2010). Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S., Noble, D., Norton, C., Roche, J., Hickey, N. (2010). The 'five rights' of clinical reasoning: An educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Nurse Education Today, 30 (6), Katz Index of Activities of Daily Living and Barthel ADL Index Assessment Tools. Retrieved on October 23, 2010 at Modak I., Sexton J., Lux, T., Helmreich, R., Thomas E. (2007). Measuring safety culture in ambulatory setting: the safety attitudes questionnaire-ambulatory version. Journal of General Internal Medicine. Retrieved on October 23, 2010 at Never Events. Retrieved on October 24, 2010 at or examples on Potter, P., Perry, A. (2011). Fundamentals of Nursing. (7 th ed.) St. Louis: Mosby-Elsevier. JCAHO Safety Culture. Retrieved on October 23, 2010 at 8

9 Struth, D., Grbach W., Vincent E., Heil J., Simpson C. (2009). 60 second situational assessment. Retrieved on October 23, 2010 at Appendix UPMC Shadyside School of Nursing60 Second Situational Assessment Directions Enter a patient s room and observe the patient, family and environment for up to 60 seconds, while reviewing the following questions in your mind. 9

10 ABC without touching the patient: What data leads you to believe there is a problem with airway-breathing-circulation? Is the problem urgent/non-urgent? What clinical data would indicate that the situation needs immediate action and why? Who needs to be contacted and do you have any suggestions/recommendations? Tubes and Lines: Does the patient have any tubes, or an IV? Is the IV solution the correct one at the correct rate? Does the patient need these tubes, if so, why? Do you note any complications? What further assessment needs to be done? Respiratory Equipment: If the patient is utilizing oxygen what would you need to continue to monitor? How would you know it is functioning properly? Patient Safety Survey: What are your safety concerns with this patient? Do you need to report this problem and to whom? Environmental Survey: What about the environment could lead to a problem for the patient? How would you manage the problem? Sensory: What are your senses telling you: Do you hear, smell, see or feel something that needs to be explored? Does the patient s situation seem right? 10

11 What additional information would be helpful for further clarification of the situation? What questions are unanswered and what answers are unquestioned? Katz Index of Activities of Daily Living 11

12 Abbreviations: I, independent; A, assistance; D, dependent 1. Bathing (sponge, shower, or tub): I: receives no assistance (gets in and out of tub if tub is the usual means of bathing) A: receives assistance in bathing only one part of the body (such as the back or a leg) D: receives assistance in bathing more than one part of the body (or not bathed) 2. Dressing: I: gets clothes and gets completely dressed without assistance A: gets clothes and gets dressed without assistance except in tying shoes D: receives assistance in getting clothes or in getting dressed or stays partly or completely undressed 3. Toileting: I: goes to toilet room, cleans self, and arranges clothes without assistance (may use object for support such as cane, walker, or wheelchair and may manage night bedpan or commode, emptying it in the morning) A: receives assistance in going to toilet room or in cleansing self or in arranging clothes after elimination or in use of night bedpan or commode D: doesn t go to room termed toilet for the elimination process 4. Transfer: I: moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walker) A: moves in and out of bed or chair with assistance D: doesn t get out of bed 5. Continence: I: controls urination and bowel movement completely by self A: has occasional accidents D: supervision helps keep urine or bowel control; catheter is used, or is incontinent 6. Feeding: I: feeds self without assistance A: feeds self except for getting assistance in cutting meat or buttering bread D: receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids Adapted with permission from Journal of the American Medical Association (1963; 185:915), Copyright 1963, American Medical Association. FEEDING Barthel ADL Index 12

13 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent BATHING 0 = dependent 5 = independent (or in shower) GROOMING 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) DRESSING 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) BOWELS 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent BLADDER 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent TOILET USE 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping) TRANSFERS (BED TO CHAIR AND BACK) 13

14 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent MOBILITY (ON LEVEL SURFACES) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards STAIRS 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent TOTAL (0 100): Guidelines 1. The index should be used as a record of what a patient does, not as a record of what a patient could do. 2. The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason. 3. The need for supervision renders the patient not independent. 4. A patient's performance should be established using the best available evidence. Asking the patient, friends/relatives and nurses are the usual sources, but direct observation and common sense are also important. However direct testing is not needed. 5. Usually the patient's performance over the preceding hours is important, but occasionally longer periods will be relevant. 6. Middle categories imply that the patient supplies over 50 per cent of the effort. 7. Use of aids to be independent is allowed. 14

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19 Close your eyes Write a sentence: Draw: Draw Intersecting paragons on the back of this page before testing the subject. 19

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