Archive for the ‘Pro ED Guides’ Category
Thursday, October 2nd, 2014
181
Student’s Guide – Advocate for Patient Safety
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, the student will be able to:
- Apply assertive statements or signal phrases to express safety concerns among team members regardless of hierarchy.
- Analyze the conditions for calling team huddles in emergent situations to improve problem solving.
- Explain and adopt new 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:
- 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: Advocacy and Assertion
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.
Advocacy and Assertion: Advocacy and Assertion interventions are invoked when a team member’s viewpoint does not coincide with that of a decision maker. In advocating for the patient and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Failure to employ advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events. You should advocate for the patient even when your viewpoint is unpopular, is in opposition to another person’s view, or questions authority. When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, providing evidence or data for your concerns.
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 could Beth have been more assertive in her advocacy for Tracy?
- Describe the importance of advocacy using examples from this story and from your own experiences.
- What does this story illustrate about the importance of including the family and patient in decision-making for emergent situations?
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Thursday, October 2nd, 2014
180
Student’s Guide – Cross Monitor for Patient Safety
Overview:
This story is about how cross monitoring helps maintain situation awareness and prevent errors. Commonly referred to as “watching each other’s back,” it allows team member to self-correct their actions and provides a safety net or error-prevention mechanism for the team.
Primary Learning Outcomes
After completing this lesson, you will be able to:
- Compare written orders in the context of the entire patient care plan to ensure accuracy.
- Explain and adopt strategies to limit distractions, interruptions, and multitasking during critical care activities.
- Describe the importance of applying cross monitoring skills across the team regardless of position, status, or hierarchy to create trust and prevent errors.
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.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS® Best Practice: Cross-Monitoring
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.
Cross Monitoring: Cross Monitoring is used by fellow team members to help maintain situation awareness and prevent errors. Commonly referred to as “watching each other’s back,” it is the action of monitoring the behavior of other team members by providing feedback and keeping track of fellow team members’ behaviors to ensure that procedures are being followed appropriately. It allows team members to self-correct their actions, if necessary. Cross monitoring is not a way to “spy” on other team members, rather it is a way to provide a safety net or error-prevention mechanism for the team, ensuring that mistakes or oversights are caught early. When all members of the team trust the intentions of their fellow team members, a strong sense of team orientation and a high degree of psychological safety result.
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:
- Why is it important to compare written orders in the context of the entire patient care plan?
- How can we limit distractions, interruptions, and multi-tasking during critical care activities?
- What does this story illustrate about the importance of cross-monitoring?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
179
Student’s Guide – A Fatal Interruption
Overview:
This story is about minimizing distractions during medication administration to prevent adverse drug events. Rigorously following patient identification protocols using the “5 Rights” is crucial to ensure the right patient receives the right medication dose at the right time.
Primary Learning Outcomes
After completing this lesson, the student will be able to:
- Examine the impact of interruptions on patient safety protocol.
- Evaluate the impact of personal stress on individual performance.
- Design strategies to avoid errors due to interruptions in workflow.
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.
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 could Dianne have done to avoid the critical error she made?
- How could this team better manage interruptions during medication administration?
- What protocols should be in place across the team to ensure that errors like this do not occur?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
178
Student’s Guide – If Only…
Overview:
This story is about the lack of preparedness of teams to handle out-of-the-ordinary emergent events, and the dire consequences for patients of the failure of teamwork within and across hospital units.
Primary Learning Outcomes
After completing this lesson, you will be able to:
- Demonstrate understanding of preparedness for infrequent emergent events, including equipment, materials, and training.
- Explain how to modify processes as necessary for ensuring that the right equipment, materials, and properly trained staff are available for infrequently occurring, but life-threatening emergent events.
- Describe the importance of adopting proactive strategies to defeat complacency regarding infrequent, but life-threatening emergent events.
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.
- Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health 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 being prepared for emergent events?
- How could this team have been better prepared for this emergent event?
- What proactive strategies could be put in place in this hospital to avoid a repeat of an incident like the one in this story?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
177
Student’s Guide – The Burden of VTE
Overview:
This story is about when healthcare team members are acutely overburdened at work, the potential for error rises and patient safety is put at risk, especially for Venous Thromboembolism (VTE). Most hospitalized patients have at least one risk factor for VTE, however, appropriate prophylaxis is applied only 39.5% of the time.
Primary Learning Outcomes
After completing this lesson, you will be able to:
- Describe the consequences for patient safety when team members are overwhelmed.
- Identify tools (e.g., task assistance) to support team members who are acutely overburdened and enable them to carry out patient safety tasks, such as VTE prevention.
- Explain and adopt a plan to monitor compliance with evidence-based VTE prophylaxis policies.
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.
QSEN Teamwork & Collaboration Enrichment
TeamSTEPPS® Best Practice: Task Assistance
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.
Task Assistance: Task Assistance is guided by situation monitoring because situation awareness allows team members to effectively identify the need for assistance by others on the team. To a certain degree, some of us have been conditioned to avoid asking for help because of the fear of suggesting lack of knowledge or confidence. Many people refuse to seek assistance when overwhelmed by tasks. In support of patient safety, however, task assistance is expected. One of the most important concepts to remember with regard to Task Assistance is that assistance should be actively given and offered whenever there is a concern for patient safety related to workload. Task assistance may involve asking for assistance when overwhelmed or unsure; helping team members to perform their tasks, shifting workload by redistributing tasks to other team members, delaying/rerouting work so the overburdened member can recover, and/or filling in for overburdened team members when necessary.
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:
- Why was Kathi’s intervention on Deloris’ behalf so critical in this case?
- What does this story illustrate about the importance of developing a culture of teamwork that includes task assistance?
- How did this team successfully monitor compliance with evidence-based VTE prophylaxis policies? What could they improve?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
176
Student’s Guide – Word of Mouth
Overview:
This story is about including patients’ families as members of the healthcare team. Evidence suggests that when they are contributing to the care of their loved ones, risk for VAP will be reduced and VAP rates will decrease. Plus, they will be more satisfied with their care.
Primary Learning Outcomes
After completing this lesson, the student will be able to:
- Explain how the patient’s family and caregivers need to be involved in discussions about the care of their loved ones.
- Generate strategies for including the patient’s family and caregivers in briefings and trainings about how to care for their loved ones.
- Describe and adopt strategies that, wherever possible, allow family members to be involved in providing care for their loved ones.
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:
- What does this story illustrate about the importance of involving the patient’s family and caregivers in discussions and care of their loved ones?
- How did Jimmy’s explanation of VAP
- How did Penelope’s reaction to Gladys’ mistake create a positive patient care experience instead of a negative one?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
175
Student’s Guide – No One is Exempt
Overview:
This story is about how there is often an implicit assumption that Patient Satisfaction is predominantly a function of nursing, whereas these problems may be caused by everyone but nursing. One of the best ways to get to the source of poor ratings is to listen to your patients’ stories.
Primary Learning Outcomes
After completing this lesson, the student will be able to:
- Identify how every staff member who interacts with patients has an impact on and is responsible for patient satisfaction.
- Explain the importance of integrating patient-centered behavior such as appropriate body language and 3Ws into orientation, training, and performance expectations for all clinical and administrative staff who interact with patients.
- Describe how to plan for patient interviews as a regular part of executive data-gathering.
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.
- 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.
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 all staff members being focused on patient care and satisfaction?
- How would the use of the 3Ws have alleviated some of the patient complaints in this story?
- Why is it important that upper management examine patient experiences first hand, as well as monitoring data?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
174
Student’s Guide – It’s Not That Obvious
Overview:
This story is about how when team members don’t communicate effectively with each other and patients about their actions, patient input is sidelined, patients lack sufficient information to make informed choices about their care, and safety can be compromised.
Primary Learning Outcomes
After completing this lesson, you will be able to:
- Describe how establishing shared goals between staff and patients can contribute to patient safety.
- Describe and apply standardized verbal and written communications in emergent obstetric situations as part of a perinatal bundle.
- Explain and adopt a safety climate/perinatal bundle to detect, prevent, and mitigate problems.
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.
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 always focusing on patient safety and care?
- How did Dr. Walters’ lack of teamwork impact Pamela’s experience at the hospital?
- What elements of a perinatal bundle were in place in this story? What elements were absent or poorly executed?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
173
Student’s Guide – Transferring Blame
Overview:
This story is about implementing a follow-up plan when patients are transferred across hospital units or discharged to ensure that their care history is documented and passed on. It also highlights the importance of listening to what patients tell you about their care.
Primary Learning Outcomes
After completing this lesson, the student will be able to:
- Describe the process for information follow-up when patients are transferred into or out of the unit.
- Examine how information and communication gaps can contribute to preventable readmissions.
- Create a plan for involving the patient as a team member by actively soliciting and validating information from them about their prior medications and care.
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:
- What information and communication gaps occurred among the medical staff in this story?
- What steps could this unit have taken to ensure that team members had access to all necessary information about patients when they transfer into the unit, and that they know who to talk to when information is missing?
- What does this story illustrate about the importance of actively soliciting and validating information from patients about their prior medications and care?
Posted in Pro ED Guides, Student Guides | No Comments »
Thursday, October 2nd, 2014
172
Student’s Guide – Checklists – Check!
Overview:
This story is about how all staff members are accountable for following safe practices. When team members diverge, others need to be able to call them on it in a respectful, non-threatening way, without being made to feel uncomfortable.
Primary Learning Outcomes
After completing this lesson, you will be able to:
- Explain how speaking up in the context of potential error can make improvement in patient safety.
- Describe communication tools that can help team members draw attention to potential safety breaches.
- Design methods for practicing the use of evidence-based communication tools that call out errors and hold staff members accountable for their actions.
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: Advocacy and Assertion
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.
Advocacy and Assertion: Advocacy and Assertion interventions are invoked when a team member’s viewpoint does not coincide with that of a decision maker. In advocating for the patient and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Failure to employ advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events. You should advocate for the patient even when your viewpoint is unpopular, is in opposition to another person’s view, or questions authority. When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, providing evidence or data for your concerns
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 Kimberly and Vilma’s advocacy and assertion for their patient improve patient safety?
- What does this story illustrate about the importance of all team members’ roles?
- What tools were employed in this story to help build a culture of patient advocacy among this team?
Posted in Pro ED Guides, Student Guides | No Comments »
