Author Archive
Thursday, September 18th, 2014
118
Student’s Guide – The Perfect Storm
Overview:
This story is about how handoffs are the single most error-prone event in the patient continuum of care. Ineffective communication, coupled with distractions and an incomplete patient assessment, can often lead to a sentinel event.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe and demonstrate a structured patient handoff, including a verbal check back from the team member receiving the patient.
- Describe the importance of designing a team structure that ensures the team leader is not pulled away from coordinating care across the unit.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
- Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS Best Practice: CUS
- Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals.
- A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicate, and the sender verifying that the message was received. Typically, information is called out anticipating a response on any order which must be checked.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- What do you feel was Juan’s biggest error in the story? What should he have done instead?
- How could the use of check-backs helped to avoid the problem in this story?
- How could Chelsea ensure that this problem never occurs in her unit again?
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Thursday, September 18th, 2014
117
Student’s Guide – Empowered to Challenge
Overview:
This story is about how retained foreign objects (RFOs) during surgery can result in significant harm due to infection and other complications, and speaking up is crucial when the instrument count is inaccurate. Protocols must be followed during surgical counts to ensure an RFO is not left behind that could be deadly to a patient.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe safe practices during all surgical procedures related to post-operative counts ensuring that no retained foreign objects remain.
- Recall and describe methods and strategies to ‘stop the line’ when surgical counts are questioned for accuracy.
- Describe and adopt team-based behaviors to successfully manage information conflict between team members.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
- Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS Best Practice: CUS
- Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals.
- The CUS technique provides a framework for conflict resolution, advocacy, and mutual support. Signal words, such as “danger,” “warning,” and “caution” are common in the medical arena. They catch the reader’s attention. “CUS” and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue, but also the magnitude of the issue.
CUS Technique:
- First, state your Concern.
- Then state why you are Uncomfortable.
- If the conflict is not resolved, state that there is a Safety issue.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- Describe safe practices during all surgical procedures related to post-operative counts ensuring that no retained foreign objects remain.
- What does this story illustrate about the importance of using Evidence-Based Practices, like the rules for accounting for all surgical instruments, at all times? Under what circumstances do you feel they can be ignored or altered?
- Describe how Juanita’s use of the CUS technique prevented a larger issue for Mrs. Gatlin. Why was this important?
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Thursday, September 18th, 2014
116
Student’s Guide – Why Not?
Overview:
This story is about how patient choice can improve the patient experience by better meeting patients’ emotional needs. To do this, healthcare professionals must see exceptional care from the patient’s perspective and act as a navigator of the system of care.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Generate strategies and methods to meet the emotional needs of the patient.
- Examine patient and family policies and practices to ensure they provide choice and are patient-centered.
- Describe and adopt strategies to act as a system navigator for patients, not a system enforcer.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Patient-Centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- How were Charlie’s emotional needs met in this story?
- Who in this story acted as a system navigator for Charlie? Who acted as a system enforcer?
- What do you believe are the characteristics of someone who acts as a system navigator for patients?
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Thursday, September 18th, 2014
113
Student’s Guide – Getting to the Heart of the Matter
Overview:
This story is about the importance of recognizing that performance data reports alone may not tell the whole story. Leaders must assess multiple problems and challenges on a unit face-to-face, using walk-rounds and ‘ad hoc’ informal rounding.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe the importance of being willing to speak up, question, and clarify abnormalities that could lead to patient harm.
- Explain the importance of empowering all staff members to create an outstanding patient experience.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Quality Improvement (QI): Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- How might this story have been different if Meg had not visited the floor in question? What opportunities might she have missed if she had not visited the floor?
- How did Meg’s demeanor empower Nancy to become part of the solution to fixing her floor’s problems?
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Thursday, September 18th, 2014
112
Student’s Guide – Trusting Enough to Do the Right Thing
Overview:
This story addresses the issue of cross monitoring as it relates to error prevention. A work environment that encourages staff to openly share concerns related to the safety of patients is necessary for optimal patient care and experience.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe the importance of reporting concerns to ensure patient safety.
- Describe the importance of applying reporting principles without fear of retribution or punishment.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- How did Allison put Sarah’s health and safety at risk in this story?
- What conditions exist in this story that prevented Allison from reporting her concerns about Sarah’s health and safety? How could Colleen address those conditions in the future?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, September 18th, 2014
111
Student’s Guide – When Shared Mental Models Shatter
Overview:
This story addresses the impact disruptive behavior has on teamwork, communication, patient safety, and patient satisfaction. Each person involved in patient care, regardless of position, must conduct themselves in a professional manner.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe the importance of adopting standards of professional conduct.
- Classify individual behaviors as acceptable and unacceptable.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- What does this story illustrate about the importance of adopting standards of professional conduct?
- Describe the behavior in this story that you believe to be unprofessional. What should have been done instead?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, September 18th, 2014
110
Student’s Guide – Double Check Three Times
Overview:
This story addresses the issue of double checking and verifying patient identification before administering medication while dealing with fatigue, and simultaneously anticipating family needs when moving a patient to a new room. Adding fatigue to the situation suddenly opens up the possibility for serious error.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe strategies to assess and manage the effects of fatigue on individual and team performance
- Explain the importance of developing and maintaining communications systems for signaling team members, patients, and family members when changes occur in the plan of care.
- Describe methods for ‘double checking’ high risk patient care practices such as medication administration.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
- Safety:Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- What does this story illustrate about the importance of communicating with team members, especially when fatigue becomes an issue at the end of a shift?
- What could this team have done to alleviate the stress and safety concerns caused by Mr. Pappas’ move to a new room?
- What were some ways that Diane employed “double-checking” during this story? What might the consequences have been if she hadn’t?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, September 18th, 2014
109
Student’s Guide – Seize the Moment
Overview:
This story is about how every staff member’s job is to recognize that what we experience as routine is for the patient a journey that is filled with fear and concern. It emphasizes the positive impact staff members have on patients when they provide reassurance and support.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe how going beyond your role to address the emotional needs of patients can positively impact their experience.
- Describe strategies that can be used by individuals and team members to help deliver an exceptional patient experience regardless of position, role, or status.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Patient-Centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- Explain how this story demonstrates the effect of going beyond your role on the patient’s total experience.
- Describe how Terrell and Olivia’s teamwork helped make Mrs. Ferren’s experience more pleasant and safe.
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, September 18th, 2014
108
Student’s Guide – Decision to Indecision
Overview:
This story addresses the importance of effective and consistent forms of team communication. Staff should feel empowered to speak up, assert, and advocate on behalf of the patient and the team regardless of perceived organizational hierarchies.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Describe and apply assertive statements or signal phrases to express safety concerns among team members regardless of hierarchy, using the CUS Technique.
- Describe the importance of adopting communication methods and strategies for improving team decision-making during emergent situations that include the patient and family.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
- Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
- Teamwork and Collaboration:Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS Best Practice: CUS
- Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals.
- The CUS technique provides a framework for conflict resolution, advocacy, and mutual support. Signal words, such as “danger,” “warning,” and “caution” are common in the medical arena. They catch the reader’s attention. “CUS” and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue, but also the magnitude of the issue.
CUS Technique:
- First, state your Concern.
- Then state why you are Uncomfortable.
- If the conflict is not resolved, state that there is a Safety issue.
Story Directions:
As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- Describe how breaks in Evidence-Based Practice (EBP) put the patient and her baby in danger in this story.
- What do you believe Beth did well in the story?
- Describe the barriers that Beth faced in her attempt to advocate for her patient with other team members. How could use of the CUS Technique have helped her overcome those barriers?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, September 18th, 2014
107
Student’s Guide – Anything Else You Want to Tell Us
Overview:
This story is about bedside handoffs and the opportunities they present to share and receive information with the patient and the family. When done well, trust and connections will be established, resulting in staff members meeting the patients’ needs more efficiently.
Primary Learning Outcomes
After completing this lesson, you should be able to:
- Recall and articulate ways to engage patients and make an emotional connection.
- Describe the importance of examining the accuracy of patient information across the care continuum by including the patient and family members in the assessment and handoff process.
- Demonstrate the ability to articulate a patient-centered approach to bedside handoffs to establish personal connections with patients and families, using the I PASS the BATON technique.
QSEN Pre-Licensure Competencies
The following QSEN competencies are addressed in this lesson:
- Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
- Patient-Centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
- Teamwork and Collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS Best Practice: I PASS the BATON
Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals.
I PASS the BATON is a powerful tool that can be used for handoff of care anytime the complete responsibility for the patient from one entity to another, i.e., department to department or facility to facility. I PASS the BATON is a long acronym and usually the caregivers who adopt this tool build a checklist that uses the acronym as its foundation. The letters stand for:
- I PASS the BATON Technique:
- I (Introduction) Introduce yourself and your role/job
- P (Patient) Name, identifiers, age, sex, location
- A (Assessment) Present vital signs, chief complaint, symptoms and diagnosis
- S (Situation) Current status/circumstances
- S (Safety Concerns) Critical lab values/reports, allergies, alerts
- B (Background) Co-morbidities, previous episodes, current medications, family history
- A (Actions) What actions were taken or are required
- T (Timing) Level of urgency and timing/prioritization of actions
- O (Ownership) Who is responsible for care going forward, including patient and family
- N (Next) What will happen next? What is the plan?
Story Directions: As you listen to and read the story, think about the things that you think the team members did well, and the things you think could lead to errors. Also, consider the questions below as you listen.
Reflection Questions:
- What do you believe were the most critical safety concerns revealed in the story? How could they be prevented in the future?
- How does this story illustrate the importance of making a personal connection with the patient and family? What were some things that Teresa and Cathy did to ensure that they had the patient’s trust and full attention?
- How could a checklist based on the “I PASS the BATON” technique have alleviated some of the issues in this story? What procedures do you think this hospital needs to address and why?
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