Here's how one hospital is helping everyone on staff learn from each unintended error. The end result is improving reporting and ultimately its safety culture.
In traditional hospital safety initiatives, errors are reported to leadership through a formal reporting tool, and leaders determine which errors merit private discussion with the employee or larger discussion with the team. In 2015, using a different approach, a group of PICU nurses at Dell Children's Medical Center of Central Texas began publishing a monthly bulletin that included "good catches" (near-miss events), as well as reports of formally and informally reported patient care and medication errors.
The strategy behind this bulletin is 100 percent of errors present teachable opportunities for 100 percent of staff members. The bulletin, edited monthly by the medical director, is now distributed to all PICU medical and nursing staff. This model of open, blinded reporting of all errors has increased reporting and improved the culture safety in the ICU. At the 2017 Quality and Safety in Children's Health Conference, the team at Dell Children's shared how this works.
A new approach
Using the bulletin moves the team beyond traditional error response. "With traditional approaches, the assumption is it's the person who made the error that's the problem," says Michael Auth, M.D., D.O., PICU medical director. "This also discourages people from reporting things. We all walk away feeling shamed, and maybe the only person who learns something is the nurse who made the mistake."
Monica Smith, RN, ICU nurse at Dell Children's, began publishing the ICU Safety Bulletin in 2015. Each monthly email includes good catches and every error that occurred that month. As she compiles the errors, she removes staff and patient information and sends the edited description to the staff members who were involved to ensure it's a fair representation of what happened.
Next, reviewers validate the information and add any follow-up education that staff should know about. "Then we take another look at the email and peel off any blaming language or tone we feel when we read it," says Smith. By mid-month, the email is sent to list of 200 staff members, including all ICU nurses, float nurses, doctors, respiratory therapists, pharmacists and quality analysts.
The bulletin follows the same format each month. "All events are shared in the spirit of improvement and awareness, and then there's the bad news sandwich," Smith says. "It starts with the good catches and ends with positive behavior, but in the middle is a list of everything that went wrong: medication errors, patient care adverse events, falls, or events we found out from another unit that our unit stands to learn from."
She says this works because every error deserves attention from everyone on the team. "It also helps eliminate chatter that happens with events because they are anonymous, and helps reduce the negative emotions and shame that happens when you make an event," she says. "We give the same amount of screen time to every bad thing that happened on the unit. This in turn leads to increased reporting."
Now in its third year of publication, the bulletin has become a valuable resource for staff. "We get constant feedback that staff are compelled to change by anecdotal experiences, not aggregate data," Smith says. A hospital-wide safety bulletin is in the works, and other units are launching their own versions, too.
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