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Nurse’s Role in Implementing Principles of Quality & Patient Safety
AuthorsDr. Ali S. Al-Qahtani
Dr. Farouk M. MessahelRevised & Edited
Prof. Tawfik A. Khoja
First EditionJumada’I 1434 - April 2013
ExEcutivE Boardof thE
Health Ministers’ Councilfor
cooperation council States
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© Excutive Board of the Health Ministers’ Council, 2013 King Fahd National Library Cataloging-in-publication DataAl-Qahtani, Ali S. Nurses role in implementing principles of quality & patient safety. / Ali S. Al-Qahtani ; Farouk M. Messahel - Riyadh, 2013.118 P. ; 24 cm.ISBN: 978-603-90338-6-81- Nurses - Performances 2- Nurces - Practice 3- Nursing services I- Farouk M. Messahel (co.author) II- Title 362.173 dc 1434 / 2771
Executive Board Of the
Health Ministers’ Council For Cooperation Council States
P.O.box 7431 Riyadh 11462 Tel. 0096614885262 - Fax. 4885266
E-mail: [email protected]
L.D. No. 1434 / 2771ISBN 978-603-90338-6-8
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In the name of Allah the most gracious
the mostmerciful
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To our ParentsMy Lord! Bestow on them thy
Mercy even as they cherished
me in childhood
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Contents No.- Preface............................................................................... 11- Foreword........................................................................... 15- Brief History of Quality and Patient Safety.................... 21- Principles of Quality and Patient Safety......................... 33- International Patient Safety Goals (IPSGs).................... 34- IPSG1:CorrectPatientIdentification........................... 43- IPSG2: Effective Communications ................................. 44- IPSG3: High-Alert Medications ..................................... 51- IPSG4: Correct Patient, Procedure and Site of Surgery 53- IPSG5: Prevention of Infection ....................................... 56- IPSG6: Prevention of Falls .............................................. 58 - Nurse’s Role in Quality and Patient Safety..................... 65- Patient Assessment........................................................... 69- Medication Management................................................. 72- Communication................................................................ 80 - Infection Prevention and Control................................... 80- Emergency Management................................................. 82- Pain Management............................................................ 83- Reducing Pressure Ulcers................................................ 86- Emergency Department Overcrowding......................... 92- Patient Education............................................................. 94- Challenges to Nurses Involvement in Quality Improvements 103- Appendix I: Disaster Plan Response................................ 108- Appendix II: List of High-Alert Medications................. 114- Appendix III: “Do not use List” ...................................... 115- Conclusion ........................................................................ 116- Acknowledgement ............................................................ 117
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In the name of Allah the most gracious the most merciful
Preface
Praise be to God, prayer and peace upon Hadi al-Bashir mercy of Prophet Mohammed
Upgrading and promotion, is a major cause of health systems, and the ongoing work and to improve health services and develop the best is first identifying the purpose and features of the health system without controversy., In order to achieve better health and health services distinct Gulf program was “patient safety» is a high priority in Gulf health systems development at the level of the GCC as a whole one of the most influential and powerful activities good reputation at all levels national, Gulf and regional and global ... One of the positive outcomes of the study calendar for the Executive Office (end in 1420, early in 2002), as described under item No. (11) of paragraph (d) of chapter III, future directions: «development of Gulf Programme quality assurance».
Indeed, unsafe health care represent a serious problem at the global and regional levels – and certainly the Gulf – despite significant progress made in recent decades in improving quality and patient safety, but there are still many gaps as well as high rates of injury to patients from accidents resulting from health care.
In this sense, the Health Ministers Council adopted the slogan “safety and security of patients» as one of the important priorities for quality health events, in particular, under resolution No. (5) of the Conference (57) Geneva (April 2004, May 2004).
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It should be noted that this programme and its modern and dimensions in improving health systems performance output includes events and activities of the three main Gulf saying its programmes under this concept:
a- quality health care. b- patient safety programme. c- infection control program.
Despite the short time since the beginning of the program, important developments and players is growing this concept and seen in all the GCC health strategies and attention as a cornerstone in strengthening health security in all Aldo ...
I should like here to refer to the seventh nursing Symposium in the Gulf city of Dubai U.A.E. from 20-22/12/2006 (h) equal 9-11/1/2007 under the slogan «patient safety ... The responsibility of nursing» and to give effect to the findings of those Gulf Technical Committee has developed a seminar to nursing patient safety Gulf strategy during the twenty-second meeting, held in Kuwait from 5-6 Safar 1428 (h) equal 24-25 March 2007 included: medicine safety patient safety the safety of blood transfusion workforce reliance errors as a result of medical equipment the patient and bed sores fall infection control and deal with nursing care environment.. In this regard, issued recommendation No. (13) of the sixty-sixth meeting of the Executive Body held in Riyadh during the period of 14-16 February 1428 (h) equal 2-4/4/2007, paragraph (1) and which stipulates that: «the Member States activating nursing strategic Gulf patient safety and Technical Committee Gulf nursing follow-up implementation plan and submit to Executive Office reports sequential» ... On another level, I have a declaration ...
On another level, the State has issued the Declaration of U.A.E. «friendly sanitation initiative patient safety» by the Minister of health within the GCC seminar nursing seventh, sixth Conference of UAE nursing initiatives under the banner of “patient safety-nursing responsibility» which was held in Dubai (20-23/12/1427H, 9-11/1/2007).
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Adopted by resolution No. (2 b) of the third Conference of the Council of Ministers of health, held in Geneva on 29/4/2007, 16/5/2007.
The book «the nursing role in applying the principles of quality and patient safety» culmination of these achievements is the fundamentals story lists vital mechanisms applied by nursing personnel representing more than 40% of all human groups in the health sector, and how much I should focus on the most important global objectives of patient safety and investigating the whole three Gulf events referred to above. And I’ve seen the great effort expended and scientific methodology, safety and smooth offer interesting scientific knowledge by his brothers: Dr. Ali Al-Qahtani and Dr. Farooq messahel choose everything ...
Wishing you all the best.
Prof.TawfikA.M.Khoja
Director General
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Foreword
Throughout our work in the healthcare system, our idea and belief in the nursing profession have not been shaken. The nurses are the front line caregivers and the backbone of the health service.
Nurses spend the most time with patients. Patients and families count on nurses to keep them informed, to connect them to their clinicians and other caregivers, to listen to them, to ease their anxiety, and to protect and watch over them during their healthcare experience. Because of these high expectations of nurses, it is no wonder that nursing performance, and more specifically, the nurse patient relationship, is so central to patient care, quality, and satisfaction.
At the same time, nurses feel valued when asked for their expert opinions, especially when making contributions to innovations and improvements for patients. When nurses serve as patient advocates and participate on interdisciplinary quality improvement teams, they can add value to their work. When nurses’ efforts go beyond providing care and they actually improve the quality of care (for example, by participating in improvement projects and patient safety initiatives), they experience more joy in their work.
We, and others, acknowledge that getting started in adopting, implementing, and improving quality in healthcare may be difficult. However, among all healthcare professionals the nurses are uniquely positioned to take the challenge and serve their patients according to plans. What nurses need are guidance and direction, that is besides appreciation.
Since nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. In this guidance book, we are trying to throw some
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light on what would be the role of the nurses in quality and patient safety. Such role, we believe, should be included in their nursing upbringing during studying and training. We trust that nurses will take it seriously and enthusiastically, and will apply it skilfully.
Dr. Ali S. Al-Qahtani Dr. Farouk M. Messahel
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Patient’s centered healthcare system:
Admin
Patient
Transport
X-ray
Nurses
OR Pharmacy
DoctorsICU
PT Lab
Logistics&
Supply
Warehouse
Maintenance
Security
Laundry
QPS
HRPatientsServices
ReligiousAffairs
Kitchen
Clinical and non-clinical departments, directly or indirectly, serve the patient.
Admin: Administration, HR: Human Resources, QPS: Quality & Patient Safety, Lab: Laboratory, PT: Physiotherapy, OR: Operating Room, ICU: Intensive Care Unit
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Medical Schools
Patient
PharmaceuticalIndustry
Technical Schools Nursing Schools
InfrastructureEquipment
The patient is at the center of attention of all of the healthcare system.
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The role of the nurses is pivotal in the healthcare system. They are the front line
caregivers and the backbone of the service.
Please note that in this book:
1. hospital, healthcare facility, health organization, health Establishment: they all carry the same meaning.
2. Quality improvement: Synonyms include: continuous quality improvement, continuous improvement, organizationwide performance improvement, and total quality management.
3. customers or clients in healthcare are:a) External customers: * Patients * agencies and contractorsb) internal customers: * all Employees
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BRIEF HISTORY OF QUALITY AND PATIENT SAFETY
When authors write on Quality, they usually mention the ancient Greeks and Egyptians then they jump directly to recent history of Quality in Japan and United States. By this, they are ignoring a shining part of history and that is the Islamic era. Through many Quranic verses, and sayings and deeds of The Prophet Mohamed (PBUH) the roots and foundations of Quality have been laid down. This shining part of history and the Islamic principles of quality will be the subject of another publication by the authors. However, we would like to mention at this stage a well known example following the appearance of Islam, that of one of the female companions of The Prophet Mohamed (PBUH): Rofaida Al-Aslamiah (may Allah be pleased with her). She was one of the prominent nurses looking after the wounded in battlefields1. Her performance had laid down many of today’s Quality concepts, such as:● Medical service● Nursing care● Team work● Patient care ● Patient safety● Accreditation● Incentives
QUALITY IN MODERN HISTORY:The story of the birth of quality in modern time is fascinating and
inspiring. It started first in industry. The decade 1970-1980 was a period in which major United States manufacturing industries lost considerable market proportion. Japanese companies, recovering from the aftermath of the destruction, defeat, and occupation by the USA in the second world war, captured 60% of the US market in television sets and 19% of the market in automobiles2. The story was the same in wrist-watches, where Japanese competition caused the Swiss world-wide market share to drop from over 70% to below 25%. The Japanese had captured the market with quality low cost products. Setbacks in various industries
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led a number of US loosing companies to re-examine their management methods.
Then it came a moment in history. On 24 June 1980 at 9.30pm, a documentary was shown on the American television (NBC Network). The program did not draw a great market share, instead it started a revolution in the industry of the United States. The documentary was entitled “If Japan can…Why can’t we?” and featured W Edwards Deming a consultant in statistical studies. Here was a man completely unknown in the United States, given credit for Japan’s secret for producing quality, cost-efficient products. Deming was honored by Emperor Hirohito with Japan’s Second Order Medal of the Sacred Treasure and the citation, was also honored by the Japanese Union of Scientists and Engineers (JUSE) with the establishment of the annual Deming Prize for industry.
That historic broadcast marked the start of a major change within American Industry, the change was a new focus on Quality.
The period 1980-1990 has been characterized by the US manufacturing industry’s re-focus on quality. Once American industry recovered from the initial shock of losing market share, it began the rebuilding process by focusing attention on the quality of its products and customer service.
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EVOLUTION OF QUALITY AND PATIENT SAFETY IN THE HEALTHCARE SYSTEM
This is a brief description of the milestone and progress of quality in medicine in recent history.
1847: Work on ward cleanliness and the link between germs and good post-operative health studied by a Hungarian doctor called Ignaz Semmelweiss in Vienna General Hospital, who insisted that doctors wash their hands in calcium chloride after an operation and before visiting a new patient. Deaths fell from 12% to just 1%.
1853: Once British soldiers arrived in Turkey involved in the Crimean War, they began going down with typhus, cholera, dysentery and malaria. Within a few weeks an estimated 8,000 men were suffering from these diseases. The British Nurse Florence Nightingale volunteered her services and took a group of thirty-eight nurses to Turkey. She managed to dramatically reduce the death rate by improving the quality of the sanitation. When returned to England, she gave evidence to the 1857 Sanitary Commission, which eventually resulted in the formation of the Army Medical College.
1865: Joseph Lister, Professor of Surgery at Glasgow University, Scotland, known as the Father of Antiseptic Surgery, believed that it was microbes carried in the air that caused diseases to be spread in wards. People who had been operated on were especially vulnerable as their bodies were weak and their skin had been cut open so that germs could get into the body with more ease. Lister decided that the wound itself had to be thoroughly cleaned. He then covered
Ignaz Semmelweiss
Florence Nightingale
Joseph Lister
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the wound with a piece of lint covered in carbolic acid. His success rate for survival was very high. Lister then developed his idea further by devising a machine that pumped out a fine mist of carbolic acid into the air around an operation.
In the year 1906 President Theodore Roosevelt of the United States signed the Food and Drugs Act. It was the response to the appalling conditions in the American slaughter houses and meat packaging.
1910: The American clinician Ernest Amory Codman proposed the measurement of effectiveness of hospital treatments. He recorded in a pocket-sized card: patient’s case number, diagnosis, names of operating team, procedures and results. He used the cards to study outcomes, the basis for quality improvement.
Codman helped initiate the American College of Surgeons and its Hospital Standardization Program (1934). The latter eventually became the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1951.
1918: On-site inspection of hospitals began. The American College of Surgeons (ACS) developed Minimum Standards for Hospitals. Only 13% of 692 hospitals met the minimum standards.
Joseph Lister’s carbolic spray apparatus (Huntarian Museum, Glasgow University,
Scotland, UK).
President RooseveltBook describing situation in American slaughter houses
Ernest Codman
Logo of the American Collegeof Surgeons
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1926: The first Quality manual was published in the United States. It contained 18 pages.
1943: Kaoru Ishikawa introduced his famous Cause and Effect Diagram (known as Ishikawa Fishbone Diagram) used in: Product Design and Quality Defect Prevention.
1945: Edward Deming and Joseph Juran said: ”We have learned to live in a world of mistakes and defective products as if they were necessary to life. It is time to adopt a new philosophy in America”. They contributed to quality improvement in industry, healthcare, government, and education.
1948: World Health Organization’s (WHO) Constitution came into force on 7 April 1948
1948: The establishment of the National Health Service (NHS) in the United Kingdom (one of the biggest civil organizations in the world) to provide free medical treatment for the British population.
NHS was launched by the then minister of health, Aneurin Bevan, on July 5 1948, it was based on three core principles:● that it meet the needs of everyone ● that it be free at the point of delivery ● that it be based on clinical need, not ability to pay
1950 (1370H) Establishment of Ministry of Health in Kingdom of Saudi Arabia.
1951: Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was formed in the United States.
Kaoru Ishikawa
NHS
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1954: Deming and Juran went to Japan. They helped restructure Japanese production methods. They influenced the Japanese to embrace Total Quality concepts. They said: “It is most important that top management be Quality-minded. In the absence of sincere manifestation of interest at the top, little will happen below”
Plan
Check
DoAct
Deming is also known by his PDCA Cycle
Deming suggested that the Japanese can achieve their goal in 5 years. To his surprise they did it in 4 years.
Juran’s Trilogy: Dr. Joseph Moses Juran was born in December 24th of 1904 at Braila, Romania, he graduated as an electric engineer in 1924. He introduced his Trilogy, which shows how an organization can improve every aspect by better understanding of the relationship between processes that plan, control and improve quality as well as business results. It was created in the 1950’s and defines managing for quality as three basic quality-oriented, interrelated processes:
Joseph Juran
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Juran’s Trilogy
● Quality Planning● Quality Control● Quality Improvement
1965: Congress passed the Social Security Act Amendments. These conferred “deemed status” for accredited healthcare organizations to participate in Medicare and Medicaid.
1966: Avedis Donabedian who was an Armenian born in Beirut in 1919 graduated from the American University of Beirut in 1944, later moved to Boston in the USA in 1954. In this year he wrote the book: “Evaluating the Quality of Medical Care.”5
This is based on:● Structure: environment in which health care
is provided● Process: method by which health care is
provided ● Outcome: consequence of the health care
provided
Donabedian’s seven pillars of Quality are:
Avedis Donabedian
Efficacy
Efficiency
Optimality
Acceptability
Legitimacy
Equity
Cost
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1970: The National Academies of Science established the Institute of Medicine (IOM).
1979: The Accreditation Association for Ambulatory Healthcare (AAAHC) was formed to improve quality of care provided to day-surgery patients. Currently, it has accredited over 2100 organizations.
1986: Deming predicts that it would take 30 years for Americans to match the progress of the Japanese and that the United States was still falling behind.
1986: The Malcolm Baldrige National Quality Award (MBNQA) was introduced in the USA.
1989: The Agency for Healthcare Research and Quality (AHRQ) was established with a mission to support research to improve the quality, safety, efficiency, and effectiveness of healthcare of the American nation.
1980s to 1990s: The title: Total Quality Management (TQM) was introduced.
DefinitionofTQMincludes:● customer focus.● involvement of all employees.● continuous improvement.● integration of quality management into the total organization.
1991: The Institute of Healthcare Improvement (IHI) was founded. It campaigns for healthcare changes nationally and worldwide.
1996: The National Patient Safety Foundation (NPSF) was established.
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1996: The Joint Commission established the Sentinel Event. This policy mandates an organization’s response to a significant unexplained/unanticipated patient outcome (e.g, death, serious transfusion reaction, wrong site surgery).
1997: Joint Commission International (JCI) was established as the international arm of The Joint Commission (United States).
1999: The Institute of Medicine (IOM) published “To Err is Human: Building a Safer Health System” This report was a turning point in the history of medicine.
1999: The establishment of The National Institute for Clinical Excellence or NICE, which is a special health authority of the National Health Service (NHS) in England and Wales, United Kingdom.
2000: King Abdul Aziz Quality Award was established in the Kingdom of Saudi Arabia to promote quality level in both the public and the private sectors. Currently, criteria for applying for the award are under revision.
2001: JCAHO established specific standards for patient safety.
2002: The National Patient Safety Goals (NPSGs) were established to help accredited organizations address specific areas of concern in regards to patient safety.
2003: The National Academies published 20 priority areas needing action in order to transform healthcare Quality. These priority areas included:
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- Asthma.- Care coordination.- Children with special healthcare needs.- Ischemic heart disease.- Major depression.
2003: JCAHO announced the first set of National Patient Safety Goals
- Improve accuracy of patient identification- Improve safety of using high-alert medications
2005: Establishment of the Central Board for Accreditation of Healthcare Institutions (CBAHI) in Kingdom of Saudi Arabia by a Ministerial Decree 11/144187 under the umbrella of the Health Services Council.
2005: The National Institute for Health and Clinical Excellence (NICE) was formed in the UK. NICE publishes guidelines which have acquired a high international reputation as a role model for the development of clinical guidelines.
2007: Reporting results of study in selected hospitals in the United States 6 years after the IOM report “To Err is Human” in New England Journal of Medicine,7 has found that: Harm to patients resulting from medical care was common, and the rate of harm did not appear to decrease significantly despite substantial national attention and allocation of resources to improve the safety of care.
2009: 10 years after the IOM report “To Err is Human”: - 1,000,000 lives have been lost - Billions of $ wastedThe report is questioning any improvement in the healthcare system
by asking: Is patient care safer 10 years after that landmark report?
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2009: The Lucian Leape Institute at the National Patient Safety Foundation (LLI) has articulated 6 concepts for healthcare transformation:
Of the 6 concepts, consumer engagement, or “nothing about me, without me” provides information about the problems in healthcare systems and helps transform healthcare. Engaging consumers in care partnerships is essential to achieving healthcare quality and safety.
2011: The Joint Commission International (JCI) published its latest
International Patient Safety Goals (IPSG) in its 4th edition of the Joint Commission International Accreditation Standards for Hospitals. These goals are:
Transparency
Integrated Care
Consumer Engagement
Joy and Meaning in Work
Medical Education Reform
Safety of the Healthcare Workforce
International Patient Safety Goals (IPSG)
1 Identify Patients Correctly
2 Improve Effective Communications
3 Improve the Safety of High-Alert Medications
4 Ensure Correct Site, Correct-Procedure, Correct-Patient Surgery
5 Reduce the Risk of Health Care-Associated Infections
6 Reduce the Risk of Patient Harm Resulting from Falls
QUALITY DOING THE RIGHT THING
RIGHT FIRST TIME RIGHT EVERYTIME
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PRINCIPLES OF QUALITY AND PATIENT SAFETY
Quality and Patient Safetyare the responsibility of all employees
of a healthcare facility.
What is Quality?: Quality is to do the right thing, right from the first time and every
time. It is a continuous improvement process.
However,thereareotherdefinitionsofQuality:● Customer satisfaction. ● Meets or exceeds customer expectations.
Quality of Care: The degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Safety: The degree that the organization’s buildings, grounds, and equipment
do not pose a hazard or risk to patients, staff, or visitors.
Patient Safety:is defined as: the prevention of harm to patients.
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Components of Quality:
QUALITYSystem Control System Improvement Staff Development
1. System control: means the basis and documentation of Quality in the form of: • StrategicPlanning• Vision• Mission• Values• Goals• Policy&ProceduresGuidelines(PPGs)• WorkInstructions
2. System improvement:improvingqualityofservicee,g,conductingAudits,Benchmarkings,Surveys,andothermethodsofqualityandpatient safety improvement.
3. Staff development: improving the knowledge and skills of allemployeesutilizingeducationalandtrainingprograms.
Strategic Plan: Strategic or long-range planning is to assist the organization in
establishing priorities and to better serve the needs of the customers; both internal and external. A strategic plan must be flexible and practical and yet serve as a guide to implementing programs, evaluating how these programs are proceeding, and making adjustments when necessary.
Vision: A statement by the organization explaining the reason for its
existence.
Mission: The mission statement outlines how to implement the vision.
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Values: Titles adopted by the organization and its workforce to adhere to while
providing service e.g, Faith, Fairness, Trust, Equity, Accountability, Transparency, Respect, ..
Goals: Observable and measurable end result having one or more objectives
to be achieved within a more or less fixed timeframe.
Job Description: is a list that a person might use for general tasks, or functions, and
responsibilities of a position. It outlines the frame of work which an employee should perform.
Priviliges: are the rights of a clinician to provide specific diagnostic or therapeutic
services to patients. Clinical privileges are limited by the individual’s professional license, experience, and competence.
Policy & Procedures Guidelines (PPGs): Documents containing principles, rules, and guidelines formulated
or adopted by an organization which describe an organization’s policies for operation and the procedures necessary to fulfill the policies..
Work Instructions: Documents containing detailed instructions that specify exactly what
steps to follow to carry out an activity. A Work Instruction contains much more detail than a procedure and is only created if very detailed instructions are needed.
Organizational Chart: A graphic representation of titles and reporting relationships in an
organization, sometimes referred to as an “organogram” or “organization table.”
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Standard Precautions:1. Consider every person (patient or staff) as potentially infectious
and susceptible to infection2. Wash hands 3. Wear gloves4. Use physical barriers 5. Use antiseptic agents6. Use safe work practices7. Safely dispose of infectious waste 8. Process instruments9. Linen 10.Patient placement
Accreditation Survey: is a process in which a Healthcare Facility is assessed by an
accrediting body to determine if it meets a set of standards designed to improve quality of care.
Main Accrediting Organizations in Kingdom of SaudiArabia:1. CBAHI: The Central Board for Accreditation of Health Institutes2. JCI: The Joint Commission International
Standard: A statement that defines the performance expectations, structures, or
processes that must be in place for an organization to provide safe and high-quality care, treatment, and service.
The Six Aims of The Institute of Medicine: The American Institute of Medicine (IOM) six “aims” for improving
the delivery of patient care and outcomes:
Safe Avoiding preventable injuries, reducing medical errors
Effective Providing services based on scientific knowledge (clinical guidelines)
Patient Centered Care that is respectful and responsive to individuals
Efficient Avoiding wasting time and other resources
Timely Reducing wait times, improving the practice flow
Equitable Consistent care regardless of patient characteristics and demographics
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Who is a Patient?: An individual who receives care, treatment, and services. Each patient
is unique, with his or her own needs, strengths, values, and beliefs. For JCI standards, the patient and family are a single unit of care.
Family of a Patient: The person(s) with a significant role in the patient’s life. This may
include a person(s) not legally related to the patient. This person(s) is often referred to as a surrogate decision maker if authorized to make care decisions for a patient if the patient loses decision-making ability e.g, if patient is unconscious.
Patient and Family Rights: Patients exercise their rights without regard to gender, cultural,
economic, educational or religious background or the source of payments for care.
Confidentiality:1. The restricted access to data and information to individuals who
have a need, a reason, and permission for such access.2. An individual’s right to personal and informational privacy, including
for his or her health care records.
PatientConfidentiality:Confidentiality means that a clinician may not disclose any medical
information belonging to a patient without the consent of the patient.
Informed Consent: Agreement or permission accompanied by full information on the
nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins the procedure or treatment. After receiving this information, the patient either consents to or refuses such a procedure or treatment.
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Team Work: Teamwork is work performed by a team towards a common goal. A
team consists of more than one person with different responsibilities.
What is “do not use” list?: A written catalog of abbreviations, acronyms, and symbols that are
not to be used throughout an organization—whether handwritten or entered as free text into a computer—due to their potentially confusing nature. (List is attached Appendix III).
Quality Improvement Methods:Clinical Audit:
is a Quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.
Benchmarking: Is a continuous process of measurement of products, services and
work processes, against those recognized as leaders.
Team Work is essential component of QUALITY & PATIENT SAFETY
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Level of Service Indicator (LSI): A measurable step that sets the level of performance in vital aspects
of a department function that must always be at high standard.
What is PDCA?:is the Plan-Do-Check-Act (PDCA) quality improvement cycle of
Deming.
Plan
Check
DoAct
● Plan to improve your operations first by finding out what things are going wrong (that is identify the problems faced), and come up with ideas for solving these problems.
● Do changes to solve the problems on a small or experimental scale first. This minimizes disruption to routine activity while testing whether the changes will work or not.
● Check whether the small scale or experimental changes are achieving the desired result or not.
● Act to implement changes on a larger scale if the experiment is successful. This means making the changes a routine part of your activity. Also act to involve other persons (other departments, suppliers, or customers) affected by the changes and whose cooperation you need to implement them on a larger scale.
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QualifiedIndividual:An individual or staff member who can participate in one or all of the
organization’s care activities or services. Qualification is determined by the following: education, training, experience, competence, applicable licensure, laws or regulations, registration, or certification.
High-risk or high-alert medications: Those drugs that carry a risk for errors that can lead to significant
adverse outcomes. (Appendix II)
Near miss: Any process variation that did not affect an outcome but for which
a recurrence carries a significant chance of a serious adverse outcome. Such a “near miss” falls within the scope of the definition of an adverse event. Also see adverse event.
Tracer Methodology: is an auditing method used by either member of the organization or by
a surveyor from JCI to analyze the organization’s systems by following individual patients through the organization’s health care process in the sequence experienced by the patients. Depending on the health care setting, this may require visiting multiple care units, departments, or areas within an organization or a single care unit to “trace” the care received by a patient.
There are 2 types:1. Patient Tracer: The process used to evaluate an individual patient’s
total care experience within a health care organization. Explanation in the following diagram:
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SURGICAL WARD:Patient ready for discharge:
Medical records review.
Observation.
Staff interview.
Patient interview.
Review of educational materials
Patient admitted from EREMERGENCY ROOM
Staff interviewObservation
RADIOLOGYStaff interviewObservationRadiation protection policy
LABORATORYStaff interviewObservationEquipment maintenance
OPERATING ROOMStaff interviewDocumentationObservation
Laboratory tests
Patient had x-rays
Patient had surgery
2. System Tracer: Evaluating high-priority safety and quality-of-care issues on a system wide basis throughout the organization. Examples of such issues may include infection prevention and control, medication management, staffing effectiveness, and the use of data.
Point-of-Care Testing: Analytical testing performed at sites outside the traditional laboratory
environment, usually at or near where care is delivered to patients.
Transfer: The formal shifting of responsibility for the care of a patient from
(1) one care unit to another, (2) one clinical service to another, (3) one qualified practitioner to another, or (4) one organization to another.
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INTERNATIONAL PATIENT SAFETY GOALS (IPSGs)
Introduction:The purpose of the International Patient Safety Goals (IPSGs) is to
promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence and expert-based consensus solutions to these problems.
Recognizing that sound system design is intrinsic to the delivery of safe, high-quality health care, the goals generally focus on system wide solutions, wherever possible. IPSGs are part of the standards of the JCI and already included in the 4th edition of Accreditation Standards for Hospitals effective January 2011. They are also required standards of CBAHI. Because of their special status The Accreditation Decision Rules of the Joint Commission International (JCI) consider compliance with them as a separate decision rule.
Implementation of the IPSGs represents proactive strategies to reduce risk of medical errors and reflect good practices. What is more important than accreditation is fostering an atmosphere of continuous improvement within healthcare organizations. It is expected that the list of IPSGs will increase by the addition of more safety goals whenever there is evidence-based management of issues related to patient care and safety.
The IPSGs are:
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1. Patient Identification
INTERNATIONAL PATIENT SAFETY
GOALS (IPSGs)
6.Preventionof Falls
5.Prevention of Infection
2.Effective Communications
3.High-Alert Medications
4.Correct: Site, Procedure, Patient
IPSG.1:ImproveAccuracyofPatientIdentifications:Accurate identification of patients is important, first, to reasonably
identify the individual as the person for whom the service or treatment is intended, and second, to match the service or treatment to that individual. Throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. Between November 2003 and July 2005, the United Kingdom National Patient Safety Agency reported 236 incidents and near misses related to missing wristbands or wristbands with incorrect information.1 Patient misidentification was cited in more than 100 individual root cause analyses by the United States Department of Veterans Affairs (VA) National Center for Patient Safety from January 2000 to March 2003.2 Fortunately, available interventions and strategies can significantly reduce the risk of patient misidentification.
According to the Joint Commission of the United States, acceptable identifiersinclude:● The individual’s name ● An assigned identification number ● Telephone number ● Date of birth
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● Social Security number ● Address ● Recent photograph ● Other person-specific identifiers
Problems with wristbands:Wristbands are widely used
worldwide to identify patients. But they carry potential problems if not properly used and guidelines are not followed. These are some of the problems:
High vigilance should be observed when dealing with common names. In an analysis of major transfusion errors reported to the Food and Drug Administration (FDA) over a 10-year period from 1976 to 1985, 10 patient deaths were found in which the actual and intended patients shared the same last name, and five deaths were found to coincide with sharing the same hospital room.
Moreover, a random sample of 60 patients in a Chinese hospital were selected to see if their full names were shared with other patients attending the same hospital. A total of 32 of the 60 sampled patients (53 percent) shared a common full name with one to 101 other patients attending the same hospital. Name confusion and mistaken identity is especially relevant in communities where most people’s names are not unique.
These are sound reasons to use at least TWO identifiers (e.g, patient’s name and medical record number) to identify a patient. Obviously, it should not include the use of the patient’s room number or location. The identification should persistently take place in the following situations:1. Before administering medications, blood, or blood products.2. Before taking blood and other specimens for clinical testing.3. Before providing treatments and procedures.
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Problems with Wristbands:
• Absentwristband• Wrong wristband (i.e, another patient’s
wristband)• Canbedifficulttofittonewborns,obesepatients,
patients with an allergy to plastic.• More than one wristband (wristbands contain
conflictinginformation)• Partiallymissinginformationonwristband• Partiallyerroneousinformationonwristband• Illegibleidentificationinformationonwristband
NewMethodsofPatientIdentification:Patient identification errors have sparked safety initiatives worldwide.
This has led to the introduction of new methods. These are:1. The Barcode2. Biometric Technologies
1. The BarcodeAnother method for
patient identification involves the substitution or supplementation of the traditional wristband for one with a unique bar code patient identifier. All patient specimens, medications, and released blood products then receive the patient’s unique bar code ID. No procedure or treatment can occur unless the patient’s ID is scanned with a portable scanner and matched with a bar code generated by the doctor’s order. For example, a phlebotomist would
Electronic identification of a patient using the barcode on the wrist addressograph bracelet
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carry the scanner, check the patient’s ID against a bar coded specimen label or collection list, and draw blood only in the event of a match. Similarly, for administration or treatment, the patient’s ID and the intended therapeutic would be scanned at the bedside with a portable reader. If a match exists, the transfusion or medication is allowed and the time and date are recorded. The data is then transmitted directly to the hospital computer system. The nurse’s bar code ID can also be scanned and a timed administration record can be created. If there is no match, an alarm is sounded, and the administration will be delayed until the problem can be resolved.
2. Biometric TechnologiesFingerprints, iris and facial are the three most prominent commercially
available biometric technologies. Palm vein recognition, a new and relatively untested technology, is also advertised for healthcare applications.
Each technology has different features and limitations. To select the one that’s best for a particular application, biometric experts start by identifying the performance issues that are critical for the application.
Accuracy: Patient ID applications require zero-error accuracy. The maximum accuracy of each biometric is limited by the uniqueness of the feature used for identification. A single fingerprint can be used to verify an otherwise-established identity, but accurately finding an identity in
Electronic identification of unit of blood prior to transfusion.
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a large database requires multiple fingerprints. Facial technology is limited by the relatively small number of distinguishing facial features and is incapable of the accuracy required for patient care. Palm-vein vendors claim high accuracy, but these claims are based on their own testing under lab conditions, or studies by their paid consultants. The iris is the most accurate of the biometrics. No two irises on the planet are the same--even identical twins have different iris patterns. The abundance of detail in the iris, its variability and lack of genetic dependence all make iris identification far more accurate than either fingerprints or facial.
The digital cameras used in iris systems do not touch the patient, so there is no risk of disease transmission and no additional sterilization step is needed. Iris ID systems also provide excellent patient comfort. The digital cameras do not use a flash or any other irritating or harmful illumination. The patient just looks at the camera and their identification is complete.
The capabilities of iris identification have been scientifically verified in reliable, independent long-term tests by the U.S. National Institute of Standards and Technology (NIST), U.S. Department of Defense and similar United Kingdom government studies.
Iris recognition is not as useful with children due to their inability to hold the head in position for the camera. Also it can be affected by cataract surgery.
It is critical that staff are engaged in the implementation of patient identification technologies and that effective communication, training and support strategies are put in place if these initiatives are to succeed.
Regardless of the technology or approach used for accurately identifying patients, careful planning for the processes of care will ensure proper patient identification prior to any medical intervention and provide safer care with no or significantly fewer errors.
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ExampleofPatientIdentification3
Policy
Emphasize that health-care providers have primary responsibility for checking/verifying a patient’s identity, while patients should be actively involved and should receive education on the importance of correct patient identification.
AdmissionUpon admission and prior to the administration of care, useatleasttwoidentifierstoverifyapatient’sidentity,neither of which should be the patient’s room number.
Patient Identifiers
Standardize the approaches to patient identificationamong different facilities within a health-care system. For example, use white ID bands on which a standardized pattern or marker and specific information (e.g.name and date of birth) would be written. Develop an organizational protocol for identifying patients without identification or with the same name. Use other non-verbal approaches, such as biometrics, for comatose patients.
InterventionEven if they are familiar to the health-care provider, check thedetails of apatient’s identification to ensurethe right patient receives the right care.
Patient Involvepatientsintheprocessofpatientidentification.
PotentialBarriersforPatientIdentification:There are several issues which may jeopardize the correct patient
identification and every effort should be done to eliminate them. These are: ● Difficulty in achieving individual behavior change to comply with
recommendations, including the use of short cuts and workarounds.● Process variation among organizations within a geographic area.● Process variation where there may be regional facilities staffed by
the same practitioners (for example, color-coded wrist bands with different meanings in different organizations).
● Costs associated with potential technical solutions.● Integration of technology within and across organizations.
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● Perception by health-care providers that relationship with the patient is compromised by repeated verification of patient identity.
● Technological solutions that fail to consider the reality of clinical care settings.
● Increase in staff workload and time spent away from patient care.● Typing and entry errors when registering patients on computerized
systems.● Cultural issues, including:
- Stigma associated with wearing an identification band.- High risk of patient misidentification due to name structure, close
similarity of names, and inaccuracies in birth dates for elderly patients.
- Patients using health cards belonging to other individuals in order to access services.
- Clothing that conceals identity.- Lack of familiarity with local names for increasing number of
foreign health-care workers.● Insufficient generally accepted research, data, and economic
rationale regarding cost-benefit analysis or return on investment for implementing these recommendations.
References:1. Wristbands for hospital inpatients improves safety. National Patient
Safety Agency, Safer practice notice 11, 22 November 2005. http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf.
2. Mannos D. NCPS patient misidentification study: a summary of root cause analyses. VA NCPS Topics in Patient Safety. Washington, DC, United States Department of Veterans Affairs, June–July 2003 (http://www.va.gov/ncps/TIPS/Docs/TIPS_Jul03.doc
3. Patient Identification. World Health Organization 2007.
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IPSG.2: Improve the Effectiveness of Communication among Caregivers:
This goal concentrates on effective communication in case of the clinician orders the administration of medications during an emergency while he/she is physically present, or in case of relaying critical laboratory result which does not wait the routine process so that immediate action to correct the abnormality should start without delay.
The steps to be taken are as follows:a. Verbal Order:
i) Is given to a staff nurse by a clinician who is physically presentii) The complete verbal is written down by the receiver of the order
or test resultiii) These are reserved for code/emergency situation onlyiv) Clinician must sign the order as soon as emergency is over
b. Telephone Order and Laboratory Result:i) Is an order given by a clinician on the phone to a charge nurse or
a critical laboratory resultii) The complete telephone order or test result is written down by
the receiver of the order or test resultiii) A read-back of the complete order or test result by the person
receiving the informationiv) The order or test result is confirmed by the individual who gave
the order or test result.
Although this goal deals with important side of communication that is the aspect of verbal/telephone orders for obvious and understandable reasons, the role of the ward nurse in communication is unlimited and it deserves praising and acknowledgment on the part taken by the nurse in the overall responsibilities in the healthcare system. The following diagram represents the extent of the role of the nurse in communication when on duty in a hospital ward:
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PatientFamily
NURSE OR
DON
Nurses
Doctors
Lab
ICU
X-ray
PT
Transport
Patient Service
IS&T
Porters
Kitchen
TQM
Maintenance
Housekeeping
Religiouss Affairs
Switchboard
Laundry
Infection ControlSecurity
Phamacry
We must acknowledge the role of the nurse in communication. This diagram illustrates the extent of the role of the ward nurse in dealing with patients and their families and with all departments in the facility with different methods of communication (verbal, in writing, by phone, by intranet, even by person).
Leadersensureeffectiveandefficientcommunication among clinical and
nonclinical departments, services, and individual staff members.
Joint Commission International
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IPSG.3: Improve the Safety of High-Alert Medications:
This is another patient safety issue of great importance. Certain types of medications have been repeatedly shown to cause adverse drug events and should be viewed as particularly serious threats to patient safety. The existence in the hospital of a list of high-alert medications reflects its endeavors to prevent adverse events associated to these medications.
The organization should develop policies and/or procedures to address the identification, location, labeling, and storage of high-alert medications. This includes drugs and non-physiological solutions (see list). When such PPGs are implemented, concentrated electrolytes are not present in patient care units unless clinically necessary, and actions are taken to prevent inadvertent administration in those areas where permitted by policy. They should be clearly labeled and stored in a manner that restricts access.
Different containers of potassium chloride – a High-Alert Medication.
Colored labels to be attached at different locations to the intravenous giving set
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High-Alert medications are locked away in a secure place to prevent errors.
A warning sign should draw the attention of staff to High-Alert Medications inside locker.
THIS CUPBOARD CONTAINSHIGH-ALERT MEDICATIONS
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While most medications have a large margin of safety, a small number of drugs have a high risk of causing injury when they are misused. These are called «high-alert medications» to draw attention to this characteristic so that all involved in their use will treat them with the care and respect that they require. Errors may or may not be more common with these drugs than with the use of any others; however, the consequences of the errors are more devastating. For this reason, special considerations are required. These medications often need to be packaged differently, stored differently, prescribed differently, and administered differently than others.
It is estimated that eight high-alert products, including insulin, morphine and heparin, are involved in 31 percent of all harmful medication errors, while 60 percent of fatal or life-threatening errors involve intravenous drugs. Containers of High-Alert Medications have been provided by manufacturers with a safety label featuring a 20 percent increase in font size, a unique color combination and a large red cautionary tear-off label.
The American Baxter Corporation introduced the system of The Paralytic Identification Bands, an innovative approach to eliminating medication errors associated with paralytic agents or Neuromuscular Blocking Agents (NMBAs). The bands are plastic sleeves specific to high-alert medications. They add a forcing function to routine administration by requiring users to remove an additional cover at the point of care. This extra safety step is instrumental in
High-dose heparin was repackaged (right) to make errors less likely.
Special precautions intro-duced by Baxter Corporation
in connection with muscle relaxants vials.
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preventing serious life-threatening medication events. Users have both a visual and a tactile alert for paralytic agents. Warm red “Warning” labels and a differentiated ‘feel’ from traditional injectable drug vials promote safe administration and facilitate compliance to the JCAHO 2004 National Patient Safety Goals inside the United States and the JCI 2011 International Patient Safety Goals outside the United States.
IPSG.4: Ensure Correct-Patient, Correct-Procedure, and Correct-Site Surgery:
Policies and procedures are developed that will support uniform processes to ensure the correct patient, correct procedure, and correct site surgery, including medical and dental procedures done in settings other than the operating theatre.
SURGERY SITE
CORRECT
DOCUMENTS
EQUIPMENT PATIENT
PROCEDUREFUNCTIONING EQUIPMENT
Six items to be checked to eliminate or drastically minimize the surgery-related errors
1. The organization uses an instantly recognizable non-erasable (stands draping for the surgery) mark for surgical-site identification and involves the patient in the marking process.
2. Included in the protocol is marking the surgical site for procedures involving incisions, percutaneous punctures or Equipment for marking the site of the
procedure.56
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insertions with respect to laterality (e.g., right/left distinction, like eyes, lungs, kidneys), levels (e.g., spine), or multiple structures (e.g., fingers, toes).
3. The organization uses a checklist or other process to verify preoperatively the correct site, correct procedure, and correct patient and that all documents and equipment needed are on hand, correct, and functional. The widely used ckecklist is produced by the World Health Organization (WHO) as an initiative from the World Alliance for Patient Safety.
4. One of the crucial moments in the prevention of surgical errors is the time prior to skin incision. The full surgical team conducts and documents a time-out procedure just before starting a surgical procedure.
Reports are coming now in which the marking may print a mirror-image on the opposite side when the limb comes in touch with the skin of the
contralateral side.1
Surgical safety checklist adapted to suit regional hospital
Reference: 1. Knight DMA, Wedge JH. Marking the operative site a lesson learned.
CMAJ 2010 August 3, doi:10.1503/cmaj.091860
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IPSG.5: Reduce the Risk of Health Care–Associated Infections:
The Centers for Disease Control and Prevention (CDC) of the United States estimates that 2 million health care–associated infections occur in hospitals every year,1 and more than 1.5 million occur in long term care facilities.2 Add that to the well-publicized outbreaks of West Nile virus, the threat of “bird flu” spreading to humans in the United States and elsewhere, the increase of cases of HIV and hepatitis, and the persistence of multidrug-resistant organisms (MDROs) such as vancomycin-resistant enterococci and MRSA (methicillin-resistant staphylococcus aureus) infection, and it is no wonder that infection control (IC) is high on the list of concerns for most health care organizations.
Many types of infections can result from ineffective IC practices, including surgical site infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, health care–associated tuberculosis, and other communicable diseases associated with bacterial infections, such as Clostridium difficile. Infection presents a serious threat to patients who are already frail and/or have weakened immune systems such as infants, the elderly, and cancer or AIDS patients; those in intensive care units; and those who have been rendered susceptible to infection by inappropriate use of antibiotics.3 Thus, an effective, well-integrated IC program is vital for any health care organization.
Infection control comprises the tasks of surveillance (identifying risks of infection), prevention and control, and reporting. An organization’s IC program should be ultimately concerned with reducing the risk of infection to patients, health care workers, and visitors, so it must be designed based on the type and scope of care provided, as well as the patient populations served. All areas of the organization must be aware of and observant of IC practices, and representatives from each area/department, including nurses, should be included in the design of the program.
One component of an effective IC program is specific interventions that can help reduce the risk of the spread of infection. The following are some common interventions found in IC programs:
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1. Handwashing2. Equipment cleaning3. Proper use of antibiotics
●Handwashingprotocols. Comprehensive hand hygiene is the most effective way to prevent the spread of infection. All organizations should have policies that outline when and how staff members should wash their hands. Nurses should be familiar with these policies and follow them. The simple act of regularly washing hands can help prevent infections and save lives.
●Equipment cleaning policies. To make sure that equipment and supplies are cleaned properly, organizations should have policies and procedures in place that address which equipment and supplies must be cleaned, as opposed to those that are disposable; when they must be cleaned; how they must be cleaned; and who must clean them. Nursing, IC professionals, housekeeping, food service, and biomedical staff should all be involved in developing and following these policies.
●Policiesthatcovertheproperuseofantibiotics. Antibiotics can be used to treat bacterial infections as well as to prevent infections in surgical procedures. If used inappropriately, the power of antibiotics is not only lessened, but a pathogen’s immunity to antibiotics can increase. The longer an infection exists in a patient the more likely it is spread to another patient or a health care worker. To ensure the proper treatment and prevention of bacterial infections, organizations should have specific policies and monitoring systems in place for antibiotic use. If possible, a multidisciplinary team should be involved in creating those policies, including nurses, physicians, surgeons, and pharmacists. The use of clinical pathways and national guidelines to develop antibiotic use policies can be helpful.
HAND HYGIENE IN HEALTH CAREHealth care-associated infection (HCAI) is acquired by patients
while receiving care and represents the most frequent adverse event.
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However, the global burden remains unknown because of the difficulty to gather reliable data. HCAI affects hundreds of millions of people worldwide and is a major global issue for patient safety. At both the level of the country and the health-care facility, the burden of HCAI is significant, although it may be difficult to quantify at this stage.
The impact of HCAI implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, a massive additional financial burden for health systems, high costs for patients and their families, and excess deaths. In Europe, HCAIs cause 16 million extra-days of hospital stay, 37 000 attributable deaths, and contribute to an additional 110 000 every year. Annual financial losses are estimated at approximately 7 billion euro, including direct costs only. In the USA, approximately 99 000 deaths were attributed to HCAI in 2002 and the annual economic impact was estimated at approximately 6.5 billion dollars in 2004.4
The World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care present the evidence base for focusing on hand hygiene improvement as part of an integrated approach to the reduction of (HCAI). Implementation is of utmost importance to achieving an impact on patient safety5.
In general, and by their very nature, infections have a multifaceted causation related to systems and processes of health-care provision as well as to political and economic constraints on health systems and countries. They also reflect human behaviour conditioned by numerous factors, including education. However, acquisition of infection, and in particular cross-infection from one patient to another, is in many cases preventable by adhering to simple practices.
Hand hygiene is considered to be the primary measure necessary for reducing HCAI. Although the action of hand hygiene is simple, the lack of compliance among health-care workers continues to be a problem throughout the world. Yet hand hygiene improvement is not a new concept within health care. Many health-care facilities around the world
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already have well-established policies and guidelines and undertake regular training program in this area. Increasingly, actions are being undertaken to introduce alcohol-based handrubs at the point of care. However, long-lasting improvements remain difficult to sustain, and many facilities worldwide have not yet begun to address hand hygiene improvement in a systematic way. This is due to numerous constraints, particularly those relating to the very infrastructures and resources required to enable attention to turn to hand hygiene
According to the US Center for Disease Control and Prevention (CDC), clean hands are the single most important factor in preventing the spread of dangerous germs and antibiotic resistance in health care settings,6 yet the compliance rate among staff in health care organizations ranges between 25% and 50%.7,8 There are several reasons that health care workers fail to comply with hand hygiene, including the following:● Perceived lack of time. According to at least one expert,
there is a reverse correlation between how s i c k patients are on a unit, how busy the unit is, and how frequently caregivers wash their hands9.
● Irritation and dryness caused by hand-washing agents.
● Belief that gloves eliminate the need for hand hygiene.
● Doubt about the value of hand hygiene.● Lack of role models such as colleagues and superiors who engage in
frequent hand hygiene.
The gold standard of hand washing is using hot
running water and soap
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The US CDC (in 2002) and the WHO (in 2005) released new guidelines for hand hygiene. The guidelines advise, among other things, the preferential use of alcohol-based hand rubs for routine hand hygiene, as well as traditional soap and water and sterile gloves when appropriate to protect patients in health care settings.
Signs and posters should be visibly located to catch the sight of the employees of the healthcare facility
with demonstrations, checking rounds, and auditing of hand washing among staff.
Antiseptic dispensers should be available everywhere in the hospital for the use of staff and visitors
Wall mounted infrared sensor operated antiseptic dispenser.
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Recognizing a worldwide need to improve hand hygiene in health care facilities, the World Health Organization (WHO) launched its Guidelines on Hand Hygiene in Health Care (Advanced Draft) in October 2005. These global consensus guidelines reinforce the need for multidimensional strategies as the most effective approach to promote hand hygiene. Key elements include staff education and motivation, adoption of an alcohol-based hand rub as the primary method for hand hygiene, use of performance indicators, and strong commitment by all stakeholders, such as front-line staff, managers and health care leaders, to improve hand hygiene10.
My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.
How do you wash your Hands?1. Wet hands (and forearms if needed)
thoroughly, apply 5 ml Surgical Scrub2. Rub palm to palm3. Right palm over left dorsum & left
palm over right dorsum4. Palm to palm finger interlaced5. Back of fingers to opposing palms with
fingers interlocked6. Rotational rubbing of right thumb
clasped in left palm and vice versa
Posters may be located at washing sinks and may be laminated in a pocket-sized cards.
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7. Rotational rubbing, backward and forward with clasped fingers of right hand in left palm & vice versa
8. Rinse, dry hands (forearms) thoroughly
References:1. Centers for Disease Control and Prevention: National Nosocomial
Infections Surveillance System (NNIS). http://www.cdc.gov/ncidod/dhqp/nnis.html (accessed Mar. 1, 2007).
2. Kohn K.T., Corrigan J.M., Donaldson M.S.: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
3. Joint Commission Resources: Joint Commission Guide to Priority Focus Areas, 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources, 2003.
4. Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. World Health Organization 2011
5. Save Lives, Clean Your Hands. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Publications of the World Health Organization 2009
6. Centers for Disease Control and Prevention: CDC Releases New Hand-Hygiene Guidelines. http://www.cdc.gov/handhygiene/pressrelease.htm (accessed Jun. 28, 2006
7. Lankford M.G., et al.: Influence of role models and hospital design on the hand hygiene of health-care workers. Emerg Infect Dis 9, Feb. 2003. http://www.cdc.gov/ncidod/EID/vol9no2/02-0249.htm.
8. Pittet D., Mourouga P., Perneger T.V.: Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126–130
9. Boyce J.M., Pittet D.: Guidelines for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Centers for Disease Control and Prevention. Oct. 25, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
10.WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization; 2005. [http://www.who.int/patientsafety/events/05/HH_en.pdf]
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IPSG.6: Reduce the Risk of Patient Harm resulting from Falls:
Falls are big problem in hospitals. Patient falling is the most common patient safety incident reported to National Patient Safety Agency of the UK.1 Falls can cause very serious injury and even death. They may delay hospital discharge with high costs to the patient and the hospital. There may initiate litigation against the organization. Obviously, healthcare workers must prevent falls and the harm that they can lead to.
WHY DO PATIENTS FALL?
Patients can fall as a result of multitude of reasons:• Age: Older patients are
more prone for fall than young ones.
• Poor vision: Patients may not be able to see well, can trip over things they cannot see.
• Confusion: Confused patients may not pay attention to dangers. They may try to stand up when their muscle are too weak; they may fall down stairs, and they may try to walk to the bathroom in a dark room without calling for help.
• Some medications: Many patients fall because they are taking a medication that makes them sleepy or dizzy. Others may fall from medications that lower blood pressure when they stand (postural hypotension).
• Poor balance, coordination, gait and range of motion (ROM): A person will fall when they can’t keep their balance. Many older
Fall risk symbol
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patients and those that have had a stroke have poor balance and poor gait and coordination.
• Weak muscles: People that have weak muscles or damaged nerves will fall if help, safety and good patient care are lacking.
• Disease conditions: Such as arthritis, stroke, Parkinson’s disease, heart disease, and seizures.
• Surrounding factors: Rooms that have clutter, poor light or have no nurse call bell are not safe. They can make a person fall or trip. Glare also adds to falls.
• Patient foot wear: Shoes and slippers that are not skid proof are a danger. All patients must have sturdy, skid proof shoes or slippers that fit well.
• No answers to calls for help: Calls for help must be answered right away. A nursing assistant or nurse must go to the patient room right away when a patient calls for help and/or turns on their nurse call bell. This is important if the person is at risk for falls.
• Broken equipment. Broken cane, walker, wheelchair or mal-functioning wheelchair brake can make a person fall.
How to Prevent Falls?Falls are big problem in hospitals. Falls
can cause very serious injury and even death. They may delay hospital discharge with high costs to the patient and the hospital. Obviously, healthcare workers must prevent falls and the harm that they can lead to.
All admitted patients are at risk of falling due to different causes. Preventing falls is a team effort. All healthcare workers taking care of patients must make sure that their patients are safe. The organization implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition or medications, among others. Measures are implemented to reduce fall risk for those assessed to be at risk. Measures are monitored for results, both successful fall injury reduction and any unintended related
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consequences. Policies and/or procedures support continued reduction of risk of patient harm resulting from falls in the organization.
If the patient is at risk of fall, a fall risk sign should be placed on the patient’s room entrance or at the bed if more than one patient shares a single room. Patients at risk of fall may be positioned in rooms closer to the nursing stations and have nurse-call buttons and alarms handy and functioning.
Other special fall risk care items, measures, and precautions should be in the care plan for fall risk patients such as:● Low beds● Changing the patient’s medications, when possible, to lower the risk
of dizziness, sleepiness and/or blood pressure changes. ● Regular patient monitoring and observation● Using protective, gym type, mats on the floor next to the bed to
lower the risk and extent of injury if a patient falls ● Balance, gait, muscle and/or range of motion exercises and training● Assistive devices, such as canes, walkers and Merry Walkers● High toilet seats
All patients must have a safe room and patient care area that is:● Well lit and with no glare● Kept clean, dry and uncluttered● Skid proof and dry● Sturdy, non skid shoes and footwear● Equipped with handrails and grab bars,
especially in the bathrooms and in areas where patients walk, like the hallways
● Filled with stable and sturdy chairs at a good height and with armrests to assist the patient or resident with standing
● Free of wires, cords and other tripping hazards
● Free of side rails and restraints
High Risk, Slip-Resistant Patient Safety Footwear.
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Hip shield protectorAn alternative to side rails, the Roll Guard allows easy bed entry and exit while helping to
protect lucid patients from falling out of bed.
References:1. National Patient Safety Agency (2007). The Third Report from the
Patient Safety observatory: Slips, trips and falls in hospitals.
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NURSE’S ROLE IN QUALITY AND PATIENT SAFETY
We illustrated in a previous chapter the important role played by the nurses in just one aspect of routine hospital duties and that is communication. We take the advantage of writing on quality and patient safety in healthcare, and under the title of this chapter to give an account on the role of the nurses elated to this side of patient care. We would like also to take this opportunity and praise the commitment and dedication of the Saudi nurses in their part of providing high quality nursing care to their patients. However, we believe that, due to several factors, they are not getting enough attention and support, let alone national strategic nursing plan.
Registered nurses (RNs), regardless of specialty or work setting, treat patients, educate patients and the public about various medical conditions, and provide advice and emotional support to patients’ family members. RNs record patients’ medical histories and symptoms, help perform diagnostic tests and analyze results, operate medical machinery, administer treatment and medications, and help with patient follow-up and rehabilitation.
RNs teach patients and their families how to manage their illnesses or injuries, explaining post-treatment home care needs; diet, nutrition, and exercise programs; and self-administration of medication and physical therapy. Some RNs may work to promote general health by educating the public on warning signs and symptoms of disease. RNs also might run general health screening or immunization clinics, blood drives, and public seminars on various conditions.
When caring for patients, RNs establish a care plan or contribute to an existing plan. Plans may include numerous activities, such as administering medication, including careful checking of dosages and avoiding interactions; starting, maintaining, and discontinuing intravenous (IV) lines for fluid, medication, blood, and blood products;
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administering therapies and treatments; observing the patient and recording those observations; and consulting with physicians and other healthcare clinicians. Some RNs provide direction to licensed practical nurses and nursing aides regarding patient care. RNs with advanced educational preparation and training may perform diagnostic and therapeutic procedures and may have prescriptive authority.
The role of the nurses is pivotal in the healthcare system. We consider them the backbone of health service. Nurses are the health care professionals with whom patients have the most contact, and nurses bear a critical responsibility in identifying, addressing, and representing the needs and interests of patients. They provide care, treatment, and services in a variety of settings and are critical to the provision of safe, high-quality care. Nurses’ actions or lack thereof can have a direct and immediate impact on the safety and quality of care provided by a health care organization.
All types and ranks of nurses: registered nurses, licensed practical nurses, vocational nurses, and nursing assistants comprise more than half of all health care workers1. Consequently, they are the care providers that patients are most likely to encounter, and they spend more time supervising patients than any other health care giver. Because nurses are often present or most visibly present in a patient’s experience with a health care team, they are in the best position to discover unsafe processes and errors and minimize risk associated with these processes and errors2. Their near continuous presence with patients allows them to know the patient and his/her condition at any given point. Because of the important role they play in monitoring and observing patients, nurses, and nursing care team members are the first line of defense in keeping patients safe.
Researchers have outlined the link and relationship between nursing care and patient outcomes, highlighting the vital role of nurses in the delivery of high-quality, safe patient care. It was concluded by one study that a greater number of patient deaths are associated with having fewer nurses3. Another survey reported that fewer hours of
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nursing care (means less time patients) are associated with higher rates of infection, gastrointestinal bleeding, pneumonia, cardiac arrest, and death from these and other causes4.
On the other hand, a study by the Institute of Medicine (IOM) found overwhelming evidence that as levels of registered nursing staff rose, the quality of patient care and safety improved because nurses had more time to monitor patients and more readily detect changes in their conditions.1 The study also showed that nurses’ vigilance was responsible for intercepting 86% of medication errors made by clinicians, pharmacists, and others before the patient received the medication1. Effective nurses understand not only the relationship between health, illness, and disease, but the effects these relationships have on a patient’s life. Quality nursing care reflects a genuine, respectful connection between nurses and patients. This relationship can transform a patient’s experience in a health care setting and help reintegrate the patient into his or her daily life. For example, an effective nurse can influence how a patient recovers from surgery, or maintains clinical outcomes2.
HOW NURSES BECOME ACTIVELY INVOLVED IN THE PROCESS OF PATIENT CARE AND SAFETY?
To effectively provide safe and high-quality care, nurses should be aware of and participate in quality initiatives that exist within their organization. The following are examples of what nurses can do to improve patients’ care and safety:
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PAIN MANAGEMENT
NURSES ROLE IN PATIENT
CARE & SAFETY
PATIENT ASSESSMENET
MEDICATION MANAGEMENT
PATIENT EDUCATION
INFECTION PREVENTION & CONTROL
PREVENTION OF FALLS
EMERGENCY MANAGEMENT
EFFECTIVECOMMUNICATION
1. Patient Assessment
What is assessment? Historically, the role of the nurse has been to record but not
interpret observations including blood pressure, pulse, temperature, respiratory rate and consciousness level. By accurately recording this information, the nurse is able to prioritize patient care.
The objective of observation is to monitor patients’ progress, thus ensuring the prompt detection of adverse events or delays in recovery.
Assessment of patients nowadays becomes more elaborate with more than one discipline taking part. Obviously, the nurse’s role here is primary and important. Forms have been designed to standardize initial patient assessment and to serve as a record to which progress and changes in patient’s condition may be added.
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The initial assessment of a patient (outpatient or inpatient) is critical to identifying his or her needs and starting the care process. The initial assessment provides information to:
• understand the care the patient is seeking; • select the best care setting for the patient; • form an initial diagnosis; and • understand the patient’s response to any previous care.
The initial assessment of patients should contain the following: 1. Physical condition 2. Psychological assessment 3. Nutritional status 4. Pain assessment 5. Educational level 6. Social status 7. Fall assessment 8. Economic factors
1. Physical condition: Includes an evaluation of the patient’s medical status through a
physical examination and health history which includes:- Inspection: Observations using visual, auditory, and olfactory senses- Palpation: Technique using the sense of touch to gather information
about temperature, turgor, texture, moisture, vibrations, and shape- Auscultation: The act of listening to sound produced within the body
with a stethoscope- Percussion: The act of striking one object against another for the
purpose of producing sound (tympany, resonance, hyperresonance, dullness, flatness)
2. Psychological assessment: Determines the patient’s emotional status (e.g, if he or she is
depressed, fearful, or belligerent and may harm him- or herself or others).
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3. Nutritional status: To identify those patients in need of nutritional interventions.
4. Pain assessment: All inpatients and outpatients are screened for pain and assessed
when pain is present. When the patient is treated in the organization, a more comprehensive assessment is performed. This assessment should be appropriate to the patient’s age and measures pain intensity and quality, such as pain character, frequency, location, and duration. This assessment is recorded to facilitate regular reassessment and follow-up according to criteria developed by the organization and the patient’s needs.
5. Educational level: Information about patient’s knowledge, health beliefs and level of
understanding This is important in tailoring healthcare information given to the patient regarding his or her medical condition and its management.
6. Social status: There has always been an association between health and social class
and, despite the improvement in health in all sections of societies over the years, this discrepancy remains. It applies to all aspects of health, including expectation of life, infant and maternal mortality and general level of health. Social class is a complex issue that may involve status, wealth, culture, background and employment.
7. Fall assessment: Evaluation of patients’ risk for falls is essential to prepare an action
plan to reduce the risk of falling, and to reduce the risk of injury should a fall occur. The evaluation could include fall history, gait and balance screening, walking aids used by the patient, and medications-and-alcohol-consumption review. This will help in establishing a fall-risk reduction plan based on appropriate policies and procedures.
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8. Economic factors: Economic factors are assessed as part of the social assessment or
assessed separately when the patient and his or her family will be responsible for the cost of all or a portion of the care while an inpatient or following discharge
The nursing assessment includes two steps:1. Collection and verification of data from a primary source (the patient)
and secondary source (the family, health care professionals) 2. The, analysis of that data to establish a baseline for recording and
future comparison
Medical, nursing, and other individuals and services responsible for patient care collaborate to analyze and to integrate patient assessments.
A patient may undergo many kinds of assessments outside and inside the organization by many different departments and services. As a result, there may be a variety of information, test results, and other data in the patient’s record. A patient benefits most when the staff responsible for the patient work together to analyze the assessment findings and combine this information into a comprehensive picture of the patient’s condition. From this collaboration, the patient’s needs are identified, the order of their importance is established, and care decisions are made. Integration of finding at this point will facilitate the coordination of care provision.
The process for working together is simple and informal when the patient’s needs are not complex. Formal treatment team meetings, patient conferences, and clinical rounds may be needed for patients with complex or unclear needs. The patient, his or her family, and others who make decisions on the patient’s behalf are included in the decision process when it is needed.
As the number of acute admissions increases, nurses are under greater pressure to prioritize care, make clinical judgements and develop their role.
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In a qualitative study, found broad agreement from experts about the core assessment skills that are required for nurses working in this field.
TriageIn nurse triage, nurses initially assess patients and prioritize the order
in which they are seen by medical staff. It started to become widespread in the United Kingdom around the mid-1980s. Triage has evolved and now triage nurses implement initial treatment, such as analgesia and first aid.
In today’s climate of clinical effectiveness and value for money, a greater level of skill is required of nurses. They need a sound knowledge of basic anatomy and physiology to facilitate the interpretation of observations as well as of the pathology and nursing management of common illnesses and injuries.
Nurses should be proactive in undertaking physical examination. While it is acknowledged that many nurses in critical care and specialist roles are doing this, many in general areas have still to make this transition. This may initially provoke apprehension and scorn from others who claim this is not a nurse’s job. However, if a nurse is the first staff member the patient meets, it is her or his job to ensure an accurate initial assessment is obtained. Nurses have a key role in the assessment of wounds and deciding which dressings are appropriate. They are also pivotal in carrying out risk assessments for falls. It is therefore not such a great leap to that of physical assessment, as long as training and development issues are appropriately addressed.
By expanding the role of the nurse to include physical assessment, communication is also further improved. The nurse is able to provide more information to patients, and patients’ and relatives’ anxieties can be addressed more promptly and effectively.
Advances in the recording of vital signs make it possible for nurses to monitor patients continuously, be it their heart function, arterial blood pressure, central venous pressure or oxygen saturations. The recordings
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generated by this equipment must be interpreted according to the patient and in conjunction with other observations. The concern is that nurses may become too reliant on using technology to carry out assessment. Burman et al (2002) describe how staff who are used to equipment can feel insecure assessing patients without this equipment to validate their findings.
2. Medication Management:
Medication errors top nearly every health care setting’s problem list. The process of medication management encompasses the key elements of selection, procurement, storage, prescribing/ordering, preparation, dispensing, administration, and monitoring. Errors can surface at any point in the process from incomplete or illegible orders to inaccurate labeling or incorrect dosage.
One of the most problematic areas in medication use today centers on making sure that organizations have an accurate list of patients’ current medications upon admission and that the list is updated during treatment and passed on to the next care setting, provider, or practitioner. Organizations need to develop a process (known as medication reconciliation) to obtain and document a complete list of each patient’s home medications and then compare that list to the admission, transfer, or discharge orders. Having this type of process in place can help prevent errors by ensuring that required home medications are continued while in the health care facility, contraindicated home medications are discontinued, discrepancies in dosages or routine are resolved, and missed or duplicate doses are avoided. Nurses play a critical role in the medication reconciliation process as they are involved in almost all aspects of medication management. Consequently nurses should play an active role in developing, implementing, and maintaining a systemized reconciliation process.1
Another important issue in health care organizations is the use of verbal orders for medications. Ideally, the use of verbal orders should be eliminated in an organization. However, in reality, verbal orders are
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sometimes necessary. An organization should have a verbal orders policy that stipulates when verbal orders are appropriate and defines a consistent procedure for their use. At minimum, the process should stipulate that a qualified person writes down the verbal order and reads it back verbatim to the practitioner who initiated it. The practitioner should then verbally confirm that the order is correct. Nurses should familiarize themselves with their organization’s policy and follow its requirements.
Another important issue in medication management is the use of various types of technology, including computerized clinician order entry, electronic medical records, computerized decision support systems, smart pumps, computerized notification about critical test results, computerized adverse drug event monitoring, and bar-coding technology to assist with accurate administration. Nurses who work in organizations that have these tools should embrace this technology and use it to help improve communication, easily access key drug information, calculate appropriate patient doses, monitor patients’ medication use for contraindications, and prevent medication errors due to poor handwriting.
Although technology can dramatically reduce the risk of medication errors, technology alone cannot prevent them. Organizations using technology must integrate it into existing care processes that focus on safety and quality. Health care organizations must understand the organizational and cultural changes that will take place when they implement major clinical information systems and assess their readiness for these changes5. Leaders and staff, including nurses, must also assess the overall security of each program and determine what changes in care processes will be required to make the best use of it. Nurses should actively participate in technology training to ensure that they are comfortable
Syringe pump used in the accurate delivery of medication doses.
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with and knowledgeable about any new medication management technology—such as electronic medical records, smart pumps, or bar-coding systems. They should incorporate technology into daily practice and make suggestions for ways to use it to reduce errors.6
References:1. Institute of Medicine: Keeping Patients Safe: Transforming the Work
Environment of Nurses. Washington, DC: National Academy Press, 2004
2. Carroll V.: Is patient safety synonymous with quality nursing care? Should it be? A brief disclosure. Q Manage Health Care 2005; 14:229–233
3. Aiken L., et al.: Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288:1987–93
4. Needleman J., et al.: Nurse staffing levels and the quality of care in hospitals. N Engl J Med 2002; 346:1715–1722
5. Kuperman G.J., Bates D.W.: Using information technology to improve health care quality and safety. In Joint Commission Resources: From Front Office to Front Line:Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources, 2005, pp. 65–90
6. Must-Have Information for Nurses About Quality and Patient Safety: 2007 by The Joint Commission on Accreditation of Healthcare Organizations.
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3. Communication:
As previously mentioned, it is essential that staff, patients, and family members communicate effectively to ensure safe and high-quality care. To ensure effective communication throughout an organization, nurses should participate in initiatives that minimize communication breakdowns, such as the use of structured communication techniques, verbal order read-back procedures, and documentation tools that ensure comprehensive communication. Nurses should not be afraid to speak up when they see something inappropriate, incomplete, or unclear. Nurse leaders should foster an environment of open communication, and encourage nurses to report issues and events that are problematic.
4. Infection Prevention and Control:
The Center for Disease Control and Prevention estimates that 2 million health care–associated infections occur in hospitals in the United States every year,11 and more than 1.5 million occur in long term care facilities.1 Add that to the well-publicized outbreaks of West Nile virus, the threat of “bird flu” spreading to humans in the United States and elsewhere, the increase of cases of HIV and hepatitis, and the persistence of multidrug-resistant organisms (MDROs) such as vancomycin-resistant enterococci and MRSA infection, and it is no wonder that infection control (IC) is high on the list of concerns for most health care organizations.
Many types of infections can result from ineffective IC practices, including surgical site infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, health care–associated tuberculosis, and other communicable diseases associated with bacterial infections, such as Clostridium difficile. Infection presents a serious threat to patients who are already frail and/or have weakened immune systems such as infants, the elderly, and cancer or AIDS patients; those in intensive care units; and those who have been rendered susceptible to infection by inappropriate use of antibiotics.12 Thus, an effective, well-integrated IC program is vital for any health care organization.
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Infection control comprises the tasks of surveillance (identifying risks of infection), prevention and control, and reporting. An organization’s IC program should be ultimately concerned with reducing the risk of infection to patients, health care workers, and visitors, so it must be designed based on the type and scope of care provided, as well as the patient populations served. All areas of the organization must be aware of and observant of IC practices, and representatives from each area/department, including nurses, should be included in the design of the program.
OnecomponentofaneffectiveICprogramisspecificinterventionsthat can help reduce the risk of the spread of infection. Following are some common interventions found in IC programs:●Handwashingprotocols. Comprehensive hand hygiene is the most
effective way to prevent the spread of infection. All organizations should have policies that outline when and how staff members should wash their hands. Nurses should be familiar with these policies and follow them. The simple act of regularly washing hands can help prevent infections and save lives.
●Equipment cleaning policies. To make sure that equipment and supplies are cleaned properly, organizations should have policies and procedures in place that address which equipment and supplies must be cleaned, as opposed to those that are disposable; when they must be cleaned; how they must be cleaned; and who must clean them. Nursing, IC professionals, housekeeping, food service, and biomedical staff should all be involved in developing and following these policies.
●Policiesthatcovertheproperuseofantibiotics. Antibiotics can be used to treat bacterial infections as well as to prevent infections in surgical procedures. If used inappropriately, the power of antibiotics is not only lessened, but a pathogen’s immunity to antibiotics can increase. The longer an infection exists in a patient the more likely it is spread to another patient or a health care worker. To ensure the proper treatment and prevention of bacterial infections, organizations should have specific policies and monitoring systems in place for antibiotic use. If possible, a multidisciplinary team should be
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involved in creating those policies, including nurses, physicians, surgeons, and pharmacists. The use of clinical pathways and national guidelines to develop antibiotic use policies can be helpful.
5. Emergency Management:
Health care organizations must prepare for every kind of emergency from natural disasters to fires to plane crashes. They need a well-conceived plan that addresses how the organization will effectively provide care, treatment, and services during an emergency.
To develop an effective plan, organizations must identify all the emergencies that could occur within the organization and community and prioritize them according to how likely each event is and what effect it would have on the organization and community. This process allows leaders to prioritize the emergency management plan and concentrate resources on the most likely and potentially serious events.
Many factors must be considered when planning for an emergency, including maintaining internal and external lines of communication, ensuring patient and staff security, finding room for a large influx of patients, maintaining supply inventories, calling in extra staff, and providing transportation and food for patients and staff. A plan should even address how a facility should be evacuated, if necessary.
To ensure an effective response to an emergency, health care organizations should have an “all-hazards command structure,” also called an incident command system. This system goes into effect when an emergency occurs to provide an organized response and overall site management for the facility. It designates responsibilities and reporting relationships for leaders and staff members during the emergency. For
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the system to work effectively, it should be flexible enough to adapt to a wide variety of situations, clearly understood by everyone in the organization, and integrated with appropriate community response groups.
To test the effectiveness of an emergency management plan, organizations must conduct regular and comprehensive drills that involve the community and take into consideration the escalating nature of a potential emergency. Nurses help design these drills and actively participate in them. It is through these drills that staff will learn how to effectively respond to an emergency and preserve patient and staff safety. (Disaster Response Plan: Appendix I).
6. Pain Management:
Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is always subjective and is whatever the person says it is, existing whenever the person says it does. The clinician must accept the patient’s report of pain.
The nurse’s primary commitment is to the health, welfare, comfort and safety of the patient. Self-awareness, knowledge of pain and pain assessment, and knowledge of the standard of care for pain management enhances the nurse’s ability to advocate for and assure effective pain management for each patient. When advocating for the patient, it is crucial that the nurse utilizes and references current evidence-based pain management standards and guidelines.
Hospital staff conduct every now and then mock disaster plan training to get them ready for a possible real one.
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As a patient advocate, the nurse takes all reasonable means to alleviate the patient’s pain and suffering. In addition, the nurse consults and collaborates with specially trained experts in pain management, such as senior nurses, clinicians, pharmacists, physiotherapists, and others to assure an effective interdisciplinary treatment plan to address each patient’s pain through the organization’s chain of command.
The nurse also has an obligation to advocate for all patients in the aggregate. When an organization’s policies, procedures and practices are insufficient to provide consistent effective pain management, the nurse works through appropriate committees and channels to insure that patients’ pain management needs are addressed. This advocacy role is particularly critical for populations known to be at risk for under-management of their pain.
Categories of pain include but are not limited to:
a) Acute Pain: A normal, predicated physiologic response to an adverse clinical, thermal or mechanical stimulus. It is generally time-limited and responsive to opioid and non-opioid therapy. Acute pain responses may vary between patients and between pain episodes within an individual patient. Acute pain episodes may be present in patients with chronic pain.
b) Chronic Pain: Malignant or nonmalignant pain that exists beyond its expected time frame for healing or where healing may not have occurred. It is persistent pain that is not amenable to routine pain control methods. Chronic pain is often present with no physiologic signs, which may lull the clinician into falsely believing the patient is not in pain. Chronic pain may result in a look of sadness, depression, or fatigue causing the clinician to misinterpret the picture and not identify that the patient may also be experiencing pain. Patients with chronic pain may have episodes of acute pain related to treatment, procedures, disease progression or reoccurrence.
c) Breakthrough Pain: An acute exacerbation of pain that breaks through an existing analgesic regime.
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Pain management is the use of pharmacological and non-pharmacological interventions to control the patient’s identified pain. Pain management extends beyond pain relief, encompassing the patient’s quality of life, ability to work productively, to enjoy recreation, to function normally in the family and society, and to die with dignity.Unrelieved pain can negatively affect an individual’s psychological state as well as his or her physical well-being. To provide safe and effective care, health care organizations must assess pain in all patients. This requires an initial screen of all patients to determine pain and a more comprehensive assessment when warranted by a patient’s response and condition. Specific populations, including the elderly, infants/children, and patients who are known or suspected substance abusers, require special pain management considerations. Unfortunately, pain tends to be undertreated. Patients can be reluctant to communicate about their pain, and providers can underestimate the level of an individual’s pain.
An individual’s report of pain is typically the primary source regarding the presence of pain. In addition, when appropriate, staff—such as nurses—should consider consulting family members to help determine the frequency and severity of pain.
Pain assessments should be appropriate for the patient’s age and take into account the pain’s intensity, character, origin, location, onset, frequency, and duration. Organizations may want to have a rating scale to measure pain intensity and use that same rating scale across the organization if possible. This will allow a continuity of pain reporting throughout the system. Depending on an organization’s population, a numeric, verbal, or visual scale may be most appropriate. Nurses should familiarize themselves with their organization’s pain scale and know how to use it. When a patient has screened positively for pain, a more comprehensive assessment should be conducted.
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0-10 Numeric Pain Rating Scale
0No
pain
42 6 91 5 83 7 10Moderate
painWorst
possible pain
VAS – Visual Analog Scale:This is a simple measurement tool, the left anchor of scale shows no pain and right anchor
shows worst pain(RNAO, 2007)
Universal Pain Assessment Tool – FACES Wong-Baker (2007):This tool helps to assess pain according to patient’s needs.
7. Reducing Pressure Ulcers:
Pressure ulcers - also called pressure sores or bedsores - are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.
The use of clinical practice guidelines can effectively identify patients at risk for pressure ulcers and define early interventions for prevention of ulcers. An effective plan for preventing pressure ulcers includes recognizing at-risk individuals and the specific factors that place them at risk. A systematic risk assessment tool, such as the Braden Scale or Norton Scale, can help improve assessment and identification of at-risk patients. Each patient should have a specific and customized prevention program. Nurses should be familiar with any assessment tools used by the organization, as well as how to inspect and clean the skin, properly position and transfer the patient, and address any nutritional needs.
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An assessment tool for predicting the risk of PRESSURE ULCERS, based on the total of scores given in the categories sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Pressure Ulcer Staging1
Stage CharacteristicsI Pressure-related changes of intact skin compared
with the adjacent or opposite areas:• Color (nonblanchable redness in lightly pigmented
skin; red, blue, or purple hues in darkly pigmented skin)There may also be changes in
• Temperature (increased warmth or coolness)• Consistency (firm or boggy feel)• Sensation (pain)
II Partial-thickness skin loss into but not deeper than the dermis, including abrasions, intact or ruptured blisters, and other shallow defectsNo exposure of subcutis or deeper structures
III Full-thickness skin loss down to subcutaneous fat or, in areas without underlying fat (eg, nose, malleolus), to fascia, perichondrium, or periosteumNo exposure of muscle, tendon, cartilage, or boneSometimes devitalized tissue, undermining, or tunneling but that does not hide deeper injury
IV Full-thickness skin loss with exposure of muscle, tendon, bone, or adjacent structures (eg, joint spaces)Potentially extensive destruction and increased risk of osteomyelitis
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Grade IV pressure ulcer
The Norton Scale for Predicting Pressure Sore Risk2
Criterion ScorePhysical condition
4 = Good3 = Fair2 = Poor1 = Very bad
Mental condition
4 = Alert3 = Apathetic2 = Confused1 = Stupor
Activity 4 = Ambulant3 = Walk with help2 = Chair bound1 = Bed bound
Mobility 4 = Full3 = Slightly impaired2 = Very limited1 = Immobile
Incontinent 4 = Not3 = Occasionally2 = Usually/Urine1 = Doubly
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Calculated as the sum of the scores in all 5 areas. A score < 14 indicates a high risk of pressure ulcer
development
Prevention of Pressure Ulcers3
Bedsores are easier to prevent than to treat, but that doesn’t mean the process is easy or uncomplicated. And wounds may still develop with consistent, appropriate preventive care. Develop a strategy that’s appropriate whether it’s personal care with at-home assistance or professional care in a hospital or residential setting.
Position changes are key to pressure sore prevention. These changes need to be frequent, repositioning needs to avoid stress on the skin, and body positions need to minimize the risk of pressure on vulnerable areas. Other strategies include skin care, regular skin inspections and good nutrition.
Repositioning in a wheelchair:Repositioning in a wheelchair includes the following
recommendations: • Frequency. People using a wheelchair should change position as
much as possible on their own every 15 minutes and should have assistance with changes in position every hour.
• Self-care. If patient has enough strength in the upper body, can do wheelchair push-ups — raising the body off the seat by pushing on the arms of the chair.
• Specialized wheelchairs. Pressure-release wheelchairs, which tilt to redistribute pressure, provide some assistance in repositioning and pressure relief.
• Cushions. Various cushions — including foam, gel, and water- or air-filled cushions — can relieve pressure and help ensure that the body is appropriately positioned in the chair. A physical therapist can advise on the appropriate placement of cushions and their role in regular repositioning.
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Repositioning in a bed:Repositioningforapersonconfinedtoabed
includes the following: • Frequency. Repositioning should occur every
two hours.• Repositioning devices. People with enough
upper body strength may be able to reposition themselves with the assistance of a device such as a trapeze bar. Using bed linens to help lift and reposition a person can reduce friction and shearing.
• Special mattresses and support surfaces. Special cushions, foam mattress pads, air-filled mattresses and water-filled mattresses can help a person lie in an appropriate position, relieve pressure and protect vulnerable areas from damage.
• Bed elevation. Hospital beds that can be elevated at the head should be raised no more than 30 degrees to prevent shearing.
• Protecting bony areas. Bony areas can be protected with proper positioning and cushioning. Rather than lying directly on a hip, it’s best to lie at an angle with cushions supporting the back or front. Cushions should also be used to relieve pressure against and between the knees and ankles. Heels can be cushioned or «floated» with cushions below the calves.
Skin care:Protecting and monitoring the condition of
the skin is important for preventing pressure sores and identifying stage I sores before they worsen. • Bathing. Skin should be cleaned with mild
soap and warm water and gently patted dry. Or a no-rinse cleanser can be used.
• Protecting skin. Skin that is vulnerable to excess moisture can be protected with talcum powder. Dry skin should have lotion applied.
• Inspecting skin. Daily skin inspection is important for identifying vulnerable areas of skin or early signs of pressure sores.
Air-filled mattress overlay on top of bed mattress to
relieve pressure.
Gel heel and ankle protector.
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• Managing incontinence. Urinary or bowel incontinence should be managed to prevent moisture and bacterial exposure to skin. Care may include frequently scheduled assistance with urinating, frequent diaper changes, protective lotions on healthy skin, urinary catheters or rectal tubes.
Nutrition: Dietitian can recommend dietary changes that can help improve the patient’s health.
• Diet. May need to increase the amount of calories, protein, vitamins and minerals in the diet. Dietician may also prescribe dietary supplements, such as vitamin C and zinc.
• Fluids. Adequate hydration is important for maintaining healthy skin. Care team can advise on how much fluid to drink and signs of poor hydration, such as decreased urine output, darker urine, dry or sticky mouth, thirst, dry skin, or constipation.
• Feeding assistance. Some people with limited mobility or significant weakness may need assistance with eating in order to get adequate nutrition.
Other strategies: Other strategies that can help decrease the risk of pressures sores include:
• Cessation of smoking. • Activity: Limited mobility is a key factor in causing pressure
sores. However, daily exercise that is appropriately matched to a person’s abilities is an important step in maintaining healthy skin. A physical therapist can recommend an appropriate exercise program that improves circulation, builds up vital muscle tissue, stimulates appetite and strengthens the body overall.
Reference:1. Adapted from the National Pressure Ulcer Advisory Panel (2007).
Available at www.npuap.org.2. Adapted from Norton, D: Calculating the risk: Reflections on the
Norton Scale. Decubitus 1989;2:243. Mayo Foundation for Medical Education and Research, March 2011
Gel Heel Cup: useful pad for protecting
against pressure sores.
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8. Emergency Department Overcrowding:
Overcrowding and its associated problems have been highlighted since the late 1980s.1 The problem reflects an international trend, with commentary from Ireland2, New Zealand3, United States4, Canada5, and Australia6
Overcrowding occurs when an emergency department (ED) has more patients than it has staffed treatment beds, and wait times are longer than reasonable. A common problem in cold climates during the influenza season, overcrowding can also be the result of a plane or train crash, natural disasters such as floods or tornadoes, or an explosion in a nearby factory or plant. It represents a host of patient safety risks, including:• treatment delays,• higher error rates due to the high volume of high-complexity cases,• poorer outcomes due to delayed treatment,• patients who leave without being seen by a clinician, and • higher readmission rates due to premature discharge.
The most frequently cited cause for ED overcrowding is a systems issue—a lack of available inpatient beds. Other contributing factors include a growing number of more critically ill patients and an inappropriate use of emergency room services. Managing patient flow should be an organization wide initiative in which nurses are active participants. Critical processes that affect the movement of patients at each stage of the health care experience (admissions, assessment, treatment, and discharge) should be evaluated and modified to allow for large influxes of patients. Support services, such as diagnostics, patient transportation, and communication, need contingency plans for times when extra staff and supplies are required. Nurses are critical in evaluating, modifying, and creating plans to address these issues.
Credit Valley Hospital’s emergency department, Canada, has been using a retrofitted ambulance bay (ambulance
garage) for patients waiting for a bed in the hospital.7
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When an ED has reached or surpassed its capacity, it diverts ambulances, which results in more new patients arriving at other hospitals in the area. Policies and procedures for ambulance diversions need to be developed in collaboration with emergency medical services agencies, health care associations, public agencies, and other organizations. Communitywide diversion plans are necessary to ensure that patients receive care in the timeliest way possible. Individual hospitals need policies that set criteria for when to divert ambulances and define how long a diversion can last, the types of patients and conditions that are considered “off limits,” the capacity limitations that trigger a diversion, and how many regional hospitals can divert at the same time. Again, nurses should play a critical role in the development of these plans and policies.
To help address and overcome staffing shortages, organizations should focus not only on recruitment but also retention, fostering a collaborative, team-based culture that emphasizes mutual respect and high-quality communication among nurses, clinicians, and other staff. Nurses who work in retention-focused organizations have a sense of ownership and control of their jobs and are involved in evaluating and revising processes to simplify systems and prevent errors. Getting involved in developing processes and systems not only promotes a sense of ownership; it is also practical, because the people who know a process best are those who use it every day.
References:1. Ardagh, M. and Richardson, S. 2004. Emergency department
overcrowding – can we fix it? The New Zealand Medical Journal,117(1189):125-128
2. Ireland. Department of Health and Children. 2005. Press Statement. Statement by an Tanaiste on the Health and Safety Authority’s inspection of Accident & Emergency Departments:http://www.dohc.ie/press/releases/2005
3. Richardson, L.D. Asplin, B.R. and Lowe, R.A. Emergency department crowding as a health policy issue: past development, future directions. Annals of Emergency Medicine 2002;40:388-393
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4. Trzeciak, S. and Rivers, E.P. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emergency Medical Journal 2003; 20:402-405
5. Canadian Association of Emergency Physicians, National Emergency Nurses Affiliation. Joint Statement on Emergency Department Overcrowding. Journal Canadian Association of Emergency Physicians 2001;3:81-86
6. Fatovich, D.M.. Emergency medicine. BMJ 2002; 324: 958-9627. http://www.mississauga.com/news/news/article/898791. Accessed
10.10.2011
9. Patient Education:
Data indicate that providing patients with a solid knowledge base has a significant impact on outcomes. Higher levels of knowledge and a greater degree of self-management were associated with significant improvements in functioning and well-being.
The importance of education and teaching as vital components of the nursing process has been recognized since the early days of the profession1.
Assessing Patient Educational NeedsThe nursing process provides a method for
individualizing patient care and education for each patient and event. The first step in this process is a nursing assessment: the process of collecting data to identify the needs and problems of an individual patient and family. In the assessment process, the nurse collects information from various sources, validates this information, sorts and categorizes data, and summarizes or interprets it. The end product--a nursing diagnosis of educational need--is a judgment based on sound data and information2.
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Many healthcare professionals have the misconception that assessment is a prolonged, time intensive process. However, in many cases nurses perform assessments instinctively on a day to-day basis. Consider this scenario: You are caring for a patient who presents for her first hemodialysis session of the week. The patient is pale. You know she has been receiving Epoetin alfa and intravenous iron, and that her hemoglobin (Hb) has been averaging about 11.6 g/dL. You also remember from the patient’s chart that she has a history of gastrointestinal bleeding. You talk with the patient, and ask her how she is feeling. She reports that she has not been feeling particularly well the past few days, and did not have the energy to go out to dinner with her friends last night. An additional probing question reveals that the patient’s stools have been tar-colored for the past several days. An assessment of laboratory values reveals that her Hb has fallen to 10.5 g/dL.
In this brief scenario, the nurse has applied the principles of assessment by integrating physical symptoms, a brief interview with the patient, and knowledge of the patient’s history and laboratory data to detect a clinical challenge.
In addition, several potential knowledge deficits were uncovered, including how bleeding can affect Hb levels and quality of life, the need to ensure that the patient recognizes the implications of a change in stool color in the future, and the need to immediately notify the health care team when such a change Occurs.
A formal assessment of educational needs typically includes analysis of data from a variety of sources, including the patient’s history, the medical chart, and the family. Once educational opportunities have been identified, it is important to prioritize the most vital learning needs that are required to modify behavior and improve outcomes. Theories on adult education consistently state that adults will devote energy to learn something in proportion to how they perceive it will help them perform tasks or deal with problems that they are currently confronting. As a result, it is vital that any educational topic that is identified is
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conceptualized in a framework that highlights the patient’s needs rather than the interests of the healthcare team.3-5 For example, if the needs assessment finds that the patient does not understand the ramifications of anemia, a nurse who is interested in physiology may want to provide an overview of red blood cell physiology--a topic that many patients may find uninteresting or not particularly applicable to their personal situation. In contrast, a nurse who knows that a patient is very interested in improving his/her quality of life will be more likely to motivate patient interest if the educational session focuses on how to improve quality of life by avoiding anemia.
Planning a Patient Educational SessionSuccessful patient education is dependent on a well-designed plan that
includes a clear statement of the goals and objectives of the educational process. Goals are the desired outcomes of learning, while objectives detail the behaviors that will be performed to achieve the goal. Setting goals and objectives ensures that learning interventions will be tailored to the patient’s individual needs. Conversely, when goals and objectives are not stated, the impact of teaching will not be optimized. A common unintended result of the latter approach is that the patient and family are provided with information, but they fail to understand how” to use the information in their own environment and circumstances2.
The plan should also account for individual patient characteristics
that may affect the learning process, such as age, gender, race/ethnicity, culture, religious orientation, socioeconomic status, vision or hearing problems, and language/ dialect.6 The reading level of individual patients is also an important consideration, especially if written materials are being distributed. It is desirable to develop a plan that accounts for the individual characteristics of each patient. Patients will often be reluctant to admit that they have reading problems. A quick and easy general assessment of the reading level can be done in a few minutes using the Rapid Estimate of Adult Literacy in Medicine (REALM).7 Ideally this test should be completed in private to avoid potential embarrassment for the patient.
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Six Steps to Enhance Understanding Among Patients with Low Health Literacy8
1- Slow down, and take time to assess the patients’ health literacy skills.2- Use “living room” language instead of medical terminology.3- Show or draw pictures to enhance understanding and subsequent
recall.4- Limit information given at each interaction, and repeat instructions.5- Use a “teach back” or “show me” approach to confirm understanding.
This approach involves having physicians take responsibility for adequate teaching by asking patients to demonstrate what they have been told (e.g., repeat how to take their medication) to ensure that education has been adequate.
6- Be respectful, caring, and sensitive, thereby empowering patients to participate in their own health care.
There are potential obstacles to patient education that should also be acknowledged and accounted for in the plan. Potential staff-related barriers, for example, include personnel scheduling/experience, limited nursing staffing, and educational resources that may be inappropriate for or incomprehensible to some patients. Potential patient-related considerations include differences in learning styles, anxiety, physical-discomfort, financial concerns, or an inability to understand the information being presented. The patient’s emotional state should also be assessed as an indicator of the patient’s readiness to learn. For example, the patient may be in a state of denial or depression, presenting a barrier to learning. It is important for nurses to be flexible and willing to adapt to individual patient characteristics and situations4,5.
Keepinmindthatpeopletendtorememberonly:● 10% of what they read● 20% of what they hear● 30% of what they read & hear● 50% of what they hear and see● 70% of what they say● 90% of what they say and do
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Implementing the PlanIn view of the importance of patient education and the many factors
that may hinder the teaching-learning process, it is important for nurses to use the most effective teaching strategies possible. The keys to successful patient-focused education are to keep it simple and make it understandable, while at the same time drawing the learner into the process. The intended outcome of education is to empower patients to advocate for themselves by becoming active participants. If education is successful, the patient will be able to use the new knowledge and skills to help maximize comfort and quality of life5. A few simple guidelines can help nurses succeed in this endeavor.
Choose an Appropriate Teaching MethodEducation can be delivered in many ways: Choose the method that is
appropriate for the content and for the learning style of the patient and family. Whenever possible, use a variety of media that will appeal to the patient’s learning style (e.g., lecture, still pictures, motion pictures, television, audio recordings, text)5.
SetRealisticObjectivesLimit educational objectives to no more than four of the most important
items. If additional objectives are necessary, schedule separate sessions. Objectives should be clear, concise, and meaningful to the individual4.
Eliminate Medical Jargon Whenever PossibleMedical jargon is routinely used by medical professionals, and
it is sometimes easy to forget that words and phrases we hear every day can be baffling to patients about indication, dosage, side effects, and prognosis following therapy.5 A more patient-focused method of addressing these issues is to discuss specific issues that are important to patients, for example: “What medication am I taking for anemia? “How much of the medication will I receive?” “What problems can it cause? “How will this medication help me?” “Why is it important that I not miss a dose?”
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Limit Education to Short Teaching SessionsShort educational sessions (15 minutes or less) are preferred, and
should include breaks, repetition of important information, and ongoing assessments of knowledge as determined by questions and patient demonstration6.
To Change Health Behaviors, Focus on Behaviors and Skills
Nurses should focus on action items for the patient and changing behavior that will lead to positive outcomes for patients. Patients may not need to know all the facts and principles that apply to the behavior; positive outcomes may be sufficient to cause behavioral changes.3,4 For example, for patients who typically miss dialysis sessions and experience a consequential decline in quality of life, the realization that they will feel better if they attend every dialysis session and receive appropriate medications may be sufficient to make the patient want to modify their behavior--regardless of whether they fully understand the drug’s mechanism of action. Similarly, a well-designed educational program can help to empower patients by involving them in the process of improving their own outcomes. For example, knowledge can be imparted so that patients recognize and report conditions that they may notice before the healthcare team that could potentially aggravate anemia and necessitate a modification in the Epoetin alfa prescription. (Examples include fatigue, impotence, and lowered exercise tolerance.)
Present Context FirstThe context is what the patient already knows; everyone learns better
with a foundation for new knowledge. It is important to move from basic to more complex information to give the patient a positive sense of understanding and accomplishment.3,4 For example, patients who do not understand anything about anemia or red blood cells may be lost if they are immediately confronted by information that expounds on
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the quality of life effects associated with differing Hb levels. Instead, consider putting anemia into a context that the patient is familiar with--for example, start with a discussion of the importance of having energy to perform daily tasks and how the body needs oxygen to supply that energy before talking about topics that the patient may find unfamiliar.
Partition Complex InformationDivide instructions into small, logical pieces. Health-related
information can be overwhelming, and patients often are bombarded with information at a time when their ability to comprehend and retain it is impaired. As a result, a number of short educational sessions can often be much more effective than one lengthy session3,4.
Make Learning InteractiveInteractive learning greatly increases interest and recall. Clinical
studies have shown that interaction causes a protein change in the brain that stimulates information retention mid long term memory. Encouraging interaction will assist in drawing the learner into the learning experience. Also, whenever possible, consider including a family member and/or caregiver in the educational session3,4.
Capitalize on Educational Opportunities When Patients Are Ready to Learn
Patient’s readiness to learn can be affected by how sick they feel or their ability to accept information at a given time. A patient who is just starting dialysis, for example, may have a limited ability to absorb information about why it is important to adhere to a host of treatments, therapies, and life style alterations. Similarly, the patient’s emotional or physical state may also interfere with the educational process. Anxiety, physical discomfort, financial concerns, or an inability to understand the information being presented may make the learning experience unpleasant and ineffective.3-5 In contrast, a patient who just experienced a decrease in quality of life because Hb level fell below 11 g/dL may be very receptive to information on what can be done to help improve Hb outcomes.
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These guidelines offer a frame work for the design of health instruction in any medium and for any audience. This will help the learner understand what the nurse is teaching and accept the information being presented as useful and meaningful.
Evaluating and Continuing the Educational ProcessNurses should continually assess whether behavioral objectives are
being achieved. The evaluation process should include: (a) measurement of the extent to which the patient has met the learning objectives, (b) indication of any need to clarify, correct, or review information, (c) notation of objectives that are not clear, (d) documentation of shortcomings in the process, (specifically ill content, format, activities, and media), and (e) identification of barriers that have prevented learning from occurring3-5.
If the evaluation reveals that a desired behavioral change has
occurred, then the behavior should be reinforced with ongoing educational reminders. When providing reinforcement, remember that educational interludes need not be formally scheduled to be effective. For example, praise for patients who continually achieve a Hb of 11 to 12 g/dL--especially when they are working with the nephrology team by pointing out a change in their condition that could affect anemia--helps foster a trusting relationship between the nurse and patient, keeps important information uppermost in the patient’s mind, and encourages patient empowerment. Conversely, if objectives have not been met, it may be necessary to return to the assessment phase, reassess learning needs, and establish a new teaching plan (possibly with an alternative implementation approach). It is also important to document teaching and the patient response to the medical record so that other staff members can follow through on teaching topics.
References:1. Kovner, A.R., & Jones, S. (2002). Health Care Delivery in the United
States. New York: Springer Publishing Company. 3-1062. Rankin, S.H., & Stallings, K.D. (2001). Patient Education: Principles
and Practice. Philadelphia, PA: Lippincott Company. 8-39
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3. Rankin, S.H., & Stallings, K.D. (2001). Patient Education: Principles and Practice. Philadelphia, PA: Lippincott Company. 8-39
4. Redman, B.K. (2004). Advances in Patient Education. New York: Springer Publishing Company. 45-128
5. Wick, G.S., & Robbins, K.C. (1998). Patient education. In: Parker, J., ed. Contemporary Nephrology Nursing. Pitman, NY: Anthony J Jannetti, Inc. 837-851
6. Giger, J., & Davidhizar, N. (2004). Transcultural Nursing. Assessment and Intervention. New York, Mosby Year Book, Inc.
7. Murphy, P.W., & Davis, T.C. (1997). When low literacy blocks compliance. RN, 60, 58-64
8. Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med 2002;34:387
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Principles of Quality and Patient Safety
is indispensable
CHALLENGES TO NURSES INVOLVEMENT IN QUALITY IMPROVEMENT
However, determining the best use of resources, including nurses, will likely become more challenging for hospitals. Some areas of the country are currently faced with a shortage of nurses, and others are expected to see shortages develop, some of which are likely to be significant. As a result, hospitals will face growing tensions and trade-offs when allocating nursing resources among the many competing priorities of direct patient care, quality improvement and other important activities. While quality improvement is not solely the domain of nurses, they are integral to these activities because of their day-to-day patient care responsibilities. Within this evolving environment, hospitals will need to guard against diminishing the involvement of nurses in quality improvement activities where they are likely to have the greatest influence and impact.
Hospitalsarereportingseveralchallengesrelatedspecificallyto nurses’ involvement in quality improvement, including: ● Having adequate nursing staff when resources are scarce; ● Engaging nurses at all levels—from bedside to management; ● Facing growing demands to participate in more, often duplicative,
quality improvement activities; ● Dealing with the high level of administrative burden associated with
these activities; and ● Confronting traditional nursing education that does not always
adequately prepare nurses for their evolving role in today’s contemporary hospital setting.
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Consequently, hospitals’ pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.
Challenges in nursing● scarcity of nursing resources● difficulty engaging nurses at all levels—from bedside to management● growing demands to participate in more, often duplicative, quality
improvement activities● the burdensome nature of data collection and reporting● shortcomings of traditional nursing education in preparing nurses
for their evolving role in today’s contemporary hospital setting.
Scarcity of NursesThe scarcity of nurses is a major challenge for hospitals because it
impacts not only their ability to provide nursing coverage for patient care, but also to provide adequate nursing resources for other key activities, such as quality improvement. Many hospitals reported being significantly affected by a nursing shortage, which some believed would only worsen, particularly as more nurses move or age out of the workforce and demand continues to exceed supply. It was noted also that there is a limit to how much work, including quality improvement, can be added to nurses who are already short staffed. Chronic shortage of nurses will restrict nurses to their care role and will make it hard to keep quality improvement efforts on track.
When hospitals are unable to employ an adequate number of nurses for patient care, they often are forced to use agency or temporary nurses. It is exceedingly difficult to get these nurses engaged and invested in quality improvement because they may be at your hospital one day but at another the next day. Hospital leaders understands that with heavy reliance on agency or temporary staff, hospitals will have a hard time making people available to participate in quality improvement activities and will have a hard time seeing improvement because they will not going to have the consistency they need.
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Similar to the challenges with the use of agency or temporary nurses, staffing composition—the mix of full-time and part-time nurses—may also influence hospitals’ ability to engage nurses in quality improvement. As a hospital CEO discussed, it is easier to make change with full-time staff “because they are here more often and you are in front of them more often. It is that much more difficult with part-time folks because you don’t have the face time with them.” Sometimes, however, part-time staff present what one CNO described as “a double-edged sword.” That is, while some part-time staff just want to work part-time and not be engaged in activities other than bedside nursing, others want to be more engaged, particularly in activities like quality improvement. The part-time status of nurses provides greater flexibility for the hospital because they can increase patient care staffing and participation in quality improvement without having to hire someone new.
The staffing requirements associated with quality improvement often force hospitals to balance quality improvement activities with many other competing priorities. While there is the belief that quality improvement can ultimately lead to greater efficiencies, the activity itself is often very resource intensive. Though many assert there is a business case for quality—that engaging in quality improvement activities will be cost neutral or reduce costs in the long-run—few hospitals have been able to demonstrate such savings and consider quality improvement activities an added expense. However, some hospital respondents expressed the belief that as quality improvement activities become better integrated into the day-to-day work of nurses (and other staff), “the right thing to do will also be the easiest thing to do.” That is, to the extent that quality improvement reduces, if not prevents, complications, cost savings are likely to be realized from less nursing labor needed to fix problems.
Engaging All Nurses, not Just Nursing LeadershipAnother dilemma hospitals face is that they want their best nurses
at the bedside caring for patients and these same nurses leading their quality improvement activities. This poses an even greater quandary when nurses are in scarce supply. Trying to balance nurses’ work at the bedside with their involvement in quality improvement activities has
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sometimes resulted in nurses receiving mixed messages about their role in quality improvement. It also can diminish the importance of quality improvement or give the impression that the related work is more of a burden than an opportunity.
Although a goal of many hospitals is to substantively engage all nurses in quality improvement activities, there is considerable variation in the degree to which they are able to accomplish this. A disproportionate share of the responsibility falls to nursing management. Quality improvement initiatives are reportedly much more successful in cases where they have developed from the ground up and bedside staff—nurses and others.
Growing DemandsHospitals also face ever-growing demands to participate in
more quality improvement activities, many of which are viewed as duplicative. The lack of standardization in quality measurement and reporting intensifies the challenge. With nurses assuming many of the added responsibilities, balancing various responsibilities becomes even more challenging.
High Administrative BurdenThe administrative burden associated with quality improvement is
reportedly so high that it often precludes nurses from having a more substantive role. With all the time spent on data collection and analysis, it’s hard to find the time to develop and implement changes. However, enhanced information technology systems and more automated processes could relieve much of the labor-intensive work—such as manual chart reviews—that is often required for data collection and reporting, freeing nurses to do more engaging and rewarding quality improvement work.
An additional benefit of better information technology systems is to provide nurses with more “real-time” data. This would be particularly beneficial in increasing nurses’ commitment to quality improvement because they would see in a timely manner that their work was making
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a difference. But while more sophisticated information technology may ease some of the administrative burden of quality improvement, it may also create a potential pitfall of hospitals wanting to collect data on significantly more measures than they do currently, which would in fact, have a counter effect.
Dissonance with Traditional Nursing EducationTo optimize the role of nurses in quality improvement, it is important
for nursing education programs to strengthen curricula to emphasize the concepts and skills needed to participate in quality improvement activities. Everyone needs to see their role as improving patient care and patient service. I think it will only get easier if the nursing schools make this philosophy part of the training process. Also, there is a need for effective continuing education programs for nurses in this area. That is, to better prepare nurses to be more adept at translating their observations of problems at the beside into an effective improvement effort. Within the realm of nursing education, there is not the strength or emphasis on patient safety and understanding change as there should be. In many cases, caregivers are approached with ideas that they have not necessarily been exposed to. Through academic experience, they should have the opportunity to hear about change models and understand some of the basics of the need for good information in making decisions. Data are all around nurses and they are using data for clinical decisions. We need them to understand how to use data to change practice and improve quality.
References:1. Hoangmai HP, Coughlan J, O’Malley AS. The Impact of Quality-
Reporting Programs on Hospital operations. Health Affairs 2006; 25; 1412-22
2. Rosenthal, M.B. Nonpayment for Performance? Medicare’s New Reimbursement Rule, NEJM 2007; 357: 1573-1575
3. Kuehn, B.M.,“No End in Sight to Nursing Shortage: Bottleneck at Nursing Schools a Key Factor,” JAMA 2007; 298: 1623-1625.
For the sake of patient care and safety, health care providers work as one unit.
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APPENDIX I
DISASTER RESPONSE PLAN
The following information is an overview of the DISASTER RESPONSE PLAN.
The DISASTER RESPONSE PLAN is a hospital-wide document and should be available in all departments.
It is the responsibility of head of departments to ensure that every member of their staff has read and signed for The DISASTER RESPONSE PLAN and everyone›s role has been explained to him/her.
1.0.1 IntroductionA ‘DISASTER’ IS AN ACCIDENT WHICH GENERATES
MORE CASUALTIES THAN CAN BE DEALT WITH BY ON DUTY STAFF AND AVAILABLE RESOURCES. Therefore during periods when reduced staff are on duty, for example at night time, fewer casualties are needed to create a ‘disaster’ situation. This plan may be needed therefore, for incidents generating as few as 10/20 casualties, or as many as tens or even hundreds of casualties.
It however can be assumed that the following would be the main disaster risks in the area, and therefore make an assessment of what medical problems would present in association with these. These are:● Large Road Traffic Accidents : mainly trauma / burns● Aircraft Crashes : trauma, burns, smoke inhalation● Exploding Munitions : trauma / burns● Fires : burns, smoke inhalation● Industrial Accidents : burns, trauma, smoke inhalation● Infectious disease epidemics
The Hospital may be called on for assistance by other local hospitals depending on the extent of the disaster.
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This procedure details the hospital’s response in 2 ways:Section (i) This applies when casualties are brought to the hospital and no external response is required.Section (ii) When the Disaster requires resources to be deployed from the hospital to an external Disaster site.
1.0.2 When to use the Disaster PlanThe most likely Disaster situation is where a small number of
casualties (10/20) present to and temporarily overwhelm the ER.
Even with small numbers, if staff are in any doubt the disaster plan should be initiated. When deciding whether to use the disaster document packs, remember that the casualties appearing may just be the first wave from a large disaster.
The likelihood is that no warning will be received that a disaster has occurred. It is highly probable that the first casualties will be brought in by civilians.
If notified by telephone, the call should be put through to the ER and taken by the most Senior Doctor / Nurse.
The following information should be taken:● Name and phone number of the caller● Location and nature of the disaster● Number of Casualties (if known)● Time of the call
Inform the Ambulance Control Room immediately (extension: …….)
N.B. Any Disaster Emergency call received by the telephone exchange must be directed to ER.
Any disaster call information received by E.R. should be given immediately to the Ambulance Dispatch Room and vice versa.
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1.0.3 NotificationofaDisasterStaff at the hospital will probably not know a disaster has happened
until the first casualties arrive at the ER. They may be brought by ambulance or by the public. Any warning received may be very inaccurate. A disaster could happen day or night.
If a call is received by the switchboard it should be put through to the ER
If there is time, the ER Clinician on duty must contact a senior member of staff to discuss what action to take. However if there is not time for this, or if senior staff can not be contacted, the ER Clinician together with the ER Staff available must make the decision to activate the Disaster Plan.
The decisions to be made at this early stage are whether to use the disaster document packs and how many staff should be called.
This plan uses the principles of a flexible staff call out system, i.e. the number of staff called should be commensurate for the size and circumstances of the disaster. Off-duty staff will probably be needed unless it is a small Disaster during the day time.
1.0.4 Activation of the ResponseSpecification for overall management control of the disaster response
is included in action card number 2.
The Disaster Plan is activated from the ER. If possible the ER Clinician should contact a Senior Primary Care Doctor for consultation or initiate Disaster Alert (First Group). A member of staff from this group will then, in consultation with ER staff, senior Doctors – decide on any further disaster call out.
The Disaster plan will primarily be controlled from the designated Control Room and action cards for appropriate areas should be implemented.
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There are three ways the ER receiving the casualties can call staff to help them:
i) Activate the Disaster Bleep Network by dialling a code number on the phone. A disaster message can be sent to many bleeps simultaneously. The codes are kept in the controlled drug cupboard in ER.
ii) Use the PA System to call staff in the hospital, e.g. “This is the ER; we have a disaster situation. There has been a bus crash involving 30 people. The first casualties are now arriving in ER. All available medical and nursing staff please come immediately to the hospital cafeteria in the main hospital”.
iii) Phone the other ER and ask them to phone/bleep all the staff who will be needed individually (using the on-call board and the usual staff phone/bleep lists). Essential medical and nursing staff should be contacted first, followed by x-ray, administration, laboratory, etc. once key individuals have been contacted they can initiate their own internal “cascade” call out.
1.0.4.1 Complete sets of action cards will be kept in the Control Room and ER. Each area will have Specialist action cards to be implemented in the event of a disaster.
It is important that these action cards are followed as directed to prevent confusion in a Disaster situation. Once the Disaster Plan has been activated relevant staff should report to the location specified in their individual action card.
1.0.5 Where to reportStaff may be on or off duty when the disaster plan is activated. If
off duty proceed to the hospital by any means possible and report to the designated waiting areas unless the action card shows otherwise. The designated waiting area for all non action card staff is the hospital cafeteria located adjacent to the ER.
On arrival an identified staff member will take the names of medical and nursing staff.N.B. The identified person will be designated by the ER Controller.
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1.0.6 Disaster Control RoomThe key role of the control room is to coordinate and control the
Disaster response The designated control room is at the ……..
On notification of a Disaster, designated Control team personnel will report to the control room
Other key roles of the control room are to maintain communication between the Disaster site, the hospital and any other areas which may be involved.
Designated control room personnel will coordinate the Disaster response using the allocated action card
The hospital controller will designate 3 additional controllers.
1.0.7 Triage and TreatmentTriage is the sorting of patients into different groups according to
priority of treatment.
In a disaster situation, Triage is used to select those patients who will benefit most from treatment.
Disaster triage at the Hospital is done in four groups as follows:GREEN: Minor injuries, walking woundedRED: Those with life threatening injuries who will most
benefit from the treatment available e.g. airway obstruction, shock
YELLOW: a) Those with less serious injuries e.g. fractured femur b) Those with such injuries that they will probably die e.g. massive head traumaBLACK: Dead
Triage will be carried out by a Senior Doctor or Nurse at the E.R. Entrance and Casualties distributed accordingly.
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1.0.8 Disaster Document PacksDisaster document packs are located in the ERi) They comprise of Triage tag (stating one of the four groups
previously mentioned)ii) A bag (for valuables and clothes)iii) Individual sets of patients notes. (The patients triaged will be
given a disaster number on arrival).iv) An Identification Wristband.
All patients where possible will be identified on arrival. Those who can not, will be identified by an allocated Emergency number.
1.0.9 Disaster Stand DownThe Disaster response will be stood down using the tannoy system.
The hospital controller will initiate the Stand Down procedure following consultation with senior clinicians, and site medical team where relevant.Stand Down is communicated: i) Via Tannoy Systemii) Telephone notification to ERiii) Telephone notification to Executive Director
Once the Disaster has been stood down all staff may return to their own areas as appropriate.
Employees should feel free to report errors and instances of improper care, as well as suggest innovations, regardless of their
position within an organization.
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APPENDIX II
LIST OF HIGH-ALERT MEDICATIONS
Adrenergic Agonists, IV (e.g, Epinephrine, Phenylephrine, Norepinephrine)Adrenergic Antagonists, IV (e.g, Propranolol, Metopronol, Labetalol)Anesthetic Agents, General, Inhaled & IV (e.g, Propofol, Ketamine)Antiarrhythmic, IV (e.g, Lidocaine, Amiodarone)Antithrombotic Agents (Anticoagulants) including Warfarin, Low-molecular-weight Heparin, IV Unfractionated Heparin, Factor Xa inhibitors (Fondaparinux), Direct Thrombin Inhibitors (e.g, argatropan, Lipidurin, Bivalirudin), Thrombolytics (e.g, Alteplase, Reteplase, Tenecteplase), and Glycoproteins IIb/IIIa inhibitors (e.g, Eptifibatide)Cardioplegic SolutionsChemotherapeutic agents, Parenteral & OralDextrose, hypertonic, 20% or greaterDialysis Solutions, Peritoneal & HemodialysisEpidural or Intrathecal MedicationsHypoglycemic, OralInotropic medications, IV (e.g, Digoxin, Milrinone)Liposomal Forms of Drugs (e,g Liposomal Amphotericin B) Moderate Sedation Agents, IV (e.g, Midazolam)Moderate Sedation agents, IV, Oral, for children (e.g, Chloral hydrate)Narcotics?Opiates, IV, Transdermal, & Oral (including liquid concentrates, immediate and sustained release formulations)Neuromuscular Blocking Agents (e.g, Succinylcholine, Rocuronium, Vecuronium)Radiocontrast agents, IVTotal Parenteral Nutrition SolutionsColchicine InjectionEpoprostenol (Flolan), IVInsulin, Subcutaneous & IVMagnesium Sulfate InjectionMethotrexate, oral, non-oncologic useOpium TinctureOxytocin, IVNitroprusside Sodium for injectionPotassium Chloride for injection concentratePotassium Phosphates InjectionPromethazine, IVSodium Chloride for Injection, hypertonic (greater than 0.9% concentration)
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APPENDIX III
DO NOT USE LIST
Do Not Use Potential Problem Use InsteadU (unit) Mistaken for “0” (zero), the Number
“4” (four) or “cc”Write “unit”
IU (International Unit)
Mistaken for IV (intravenous)or the number 10 (ten)
Write “International
Unit”Q.D., QD, q.d., qd
(daily)Q.O.D., QOD, qod(every other day)
Mistaken for each otherPeriod after the Q mistaken for “I” and
the “O” mistaken for “I”
Write “daily”Write “every other day”
Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
Decimal point is missed Write X mgWrite 0.X mg
MSMSO4 AND MgSO4
Can mean morphine sulfate ormagnesium sulfate
Confused for one another
Write “morphine
sulfate”Write
“magnesium sulfate”
> (greater than)< (less than)
Misinterpreted as the number“7” (seven) or the letter “L”Confused for one another
Write “greater than”
Write “less than”
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CONCLUSION
In promoting quality and patient safety, the nurses are exceptionally valuable members of the healthcare providers and in a unique position to care for patients as they are working on the front lines of care, saving lives, promoting health and contributing to reducing costs. We regard nurses as the central pillar of the healthcare establishment. From our experience, nurses are the most suitable healthcare professionals to implement principles of quality and patient safety at the bedside. They are critical to the delivery of high-quality, efficient care and, as members of the interdisciplinary teams, they are cooperative, dynamic, and dependable in applying healthcare quality and patient safety standards in the workplace.
It is the duty of healthcare leadership to adopt a positive policy of investing in nurses’ education, training, and well-being. Nurses should be represented and involved in the policy making and implementation of the quality plan of the healthcare facility. On regular basis, they should be encouraged to attend and participate in a well-designed quality training program. Assistance, direction, and incentives must always be available to them, and their progress during implementation is monitored and audited so that corrective actions are applied to sustain the improvement in the care provided to patients.
In this book, we tried to present an outline of quality concepts and patient safety principles to the nurses for implementation in their daily duties. The aim is to continuously achieve high standard of patient care in a continuously improving safety environment.
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Acknowledgement
We would like to thank all readers who spent time to read this book and please send your comment or suggestion to my email: [email protected] or post to P.O. Box 3877 Abha 61481, Kingdom of Saudi Arabia.
للمؤلف د. علي بن سعيد محمد القحطانيجمادى األولى 1434هـ املوافق أبريل 2013م
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