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The patient safety movement was galvanized by the Institute of Medicine (IOM) re-port, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson,2000).This report fundamentally changed how providers, policy makers, and the pub-lic view healthcare safety and focused national attention on the mistakes and errorsoccurring in a deficient system that permits 44,000 to 98,000 needless patient deathseach year due to medical error (Kohn et al., 2000). Although certainly one of the mosthighly recognized initiatives, the IOM report was not the first attempt to addresshealthcare safety concerns. White (2004) noted that the earliest safety and quality ef-forts can be traced to 1955, although this work was not specific to patient safety ini-tiatives but rather to patient outcomes, complications, and strategies for establishingmeasures to monitor outcomes.

Approximately 40 years later, in the mid-1990s, interest in medical errors and pa-tient safety peaked with the convening of the first Annenberg Conference on PatientSafety, the establishment of the National Patient Safety Foundation (NPSF), andPresident Clinton’s formation of the Advisory Commission on Consumer Protectionand Quality in the Health Care Industry. In 1996, the Joint Commission launchedits Sentinel Event Policy for the voluntary reporting of sentinel events. By 2000, con-tinued momentum in the patient safety and quality movement led the Agency forHealth Care Policy and Research (AHCPR) to change its name to the Agency for Healthcare Research and Quality (AHRQ) and become a funding powerhousefor research focused on patient safety, error reduction, strategic planning specific topatient safety, and technology utilization in the interest of enhancing quality of care(White, 2004).

Patient Safety: PreventingUnintended Consequences

and Reducing ErrorsPatti Rager Zuzelo, EdD, RN, MSN, ACNS-BC*

C H A P T E R N I N E

* Dr. Zuzelo would like to acknowledge the contributions of JoAnne Phillips, MSN, RN,CCRN, CCNS. Her first edition chapter, The Patient Safety CNS: A New Role for anEstablished Systems Expert, is incorporated into this revised chapter.

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© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.

Within this same period of time, the Business Roundtable established the LeapfrogGroup, an organization with the mission of triggering “giant leaps forward in thesafety, quality, and affordability of health care by supporting informed healthcare de-cisions by those who use and pay for health care; and promoting high-value healthcare through incentives and rewards (Leapfrog Group, 2007).

CNSs have been involved in workplace safety initiatives throughout this trajectoryand are uniquely positioned to serve as patient safety experts across a variety of care set-tings. As patient safety is indistinguishable from quality care (Aspden, Corrigan, Wol-cott, & Erickson, 2004), the CNS’s goal of delivering quality patient care is in concertwith, and contributes to, creating and sustaining an environment of safety.This chapterintroduces CNSs to current patient safety perspectives and opportunities while sharingsuggestions for Web sites, tools, and resources that may be used to create and sustain aculture of safety through the integration of evidence-based practice with patient safetypractices, as defined by the Agency for Health Research and Quality (AHRQ) (2001).

Human Error and Types of ErrorMost practicing nurses are well aware of the high rates of errors and near misses thatoccur on a daily basis across the healthcare system.The number of actual errors and pre-vented errors is staggering. Appreciating the various types of errors and their triggersmay assist CNSs in planning and implementing targeted strategies that minimize errorlikelihood and improve patient outcomes. Reason’s work (1990) on human error pro-vides interesting theoretical and practice perspectives on basic error mechanisms, typesand consequences of errors, and techniques for assessing and reducing the risks of errors.

Human error theory (HET) (Reason, 1990) suggests that organization failures incomplex systems cause accidents. Reason (1990) asserts that the term error denotes anintentional act. Other error types depend upon two kinds of failure—slips and lapses—and mistakes. Errors may be active or latent. Latent errors lie dormant for a long periodof time until they align with enough other factors to breech the system’s defenses.

The alignment of latent failures and a variety of triggering events is referred to asthe dynamics of accident causation, or the Swiss cheese model of accident causation(Figure 9-1).The figure illustrates a trajectory of accident opportunity that penetratesseveral defensive systems and is the result of complex interactions between latent fail-ures and triggering events. In this model, latent failures at the managerial levels com-bine with psychological precursors, and unsafe acts within a context of local triggeringevents lead to an accident opportunity. When these factors and influences align, acci-dents are more likely to occur, characterized by the holes of a Swiss cheese wedgealigning to allow for unimpeded passage through the cheese wedge. A few examplesof organizational failures include lack of administrative commitment to safety, blurredsafety responsibilities, and poor training (Wolf, 2007).

Reason (1990) points out that very few unsafe acts actually result in damage or in-jury, even in systems that are unprotected. Findings from a focus group study explor-ing the influence of technologies on registered nurses’ work illustrate the many waysthat nurses work around and bypass technology-related rules and routines in efforts

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to meet patient care needs, save time, or minimize frustrations. Rarely do these sys-tem breeches lead to patient harm (Zuzelo, Gettis, Hansall, & Thomas, 2008). How-ever, when mistakes do occur, they may be catastrophic.

Reason (1990) pessimistically observes that while engineered safety devices offerbarriers against most single errors, human and mechanical, there are no guaranteedtechnological defenses against the accumulation of latent failures that provide oppor-tunities for errors within organizations, including high-risk healthcare systems (seeExemplar 9-1). Reducing the likelihood of errors by minimizing latent failures, scru-tinizing and improving systems, and rapidly evaluating the effectiveness of processchanges are requisite activities to promote safety and certainly fall within the purviewof CNS practice.

Accident causation theory is very relevant to CNS practice and is applicable to largehealthcare organizations as well as to specific types of clinical care areas. As an exam-ple, critical care poses great risk for patients related to (1) increased patient acuity,(2) high frequency of invasive interventions, (3) high medication volume, (4) need for

Human Error and Types of Error 293

Local triggersIntrinsic defectsAtypical conditions

Latent failures at themanagerial levels

Trajectory of accidentopportunity

Defense-in-depthPsychologicalPrecursors

UnsafeActs

Figure 9-1 The dynamics of accident causation.The diagram shows a trajectory of acci-dent opportunity penetrating several defensive sysems. This results from a complex inter-action between latent failures and a variety of local triggering events. It is clear from thisfigure, however, that the chances of such a trajectory of opportunity finding loopholes in allof the defenses at any one time is very small.Source: James Reason (1990). Human error. © Cambridge University Press, 1990. Reprinted with permis-sion of Cambridge Univerity Press.

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speedy decision-making processes and associated intervention, and (5) other factors,including patient characteristics. In one study, researchers found that critical care pa-tients experienced 1.7 errors per day, 29% with the potential to cause significant harmor death (Pronovost, Thompson, Holzmueller, Lubomski, & Morlock, 2005). Acrossthe United States, that data extrapolates to 85,000 errors every day, of which 24,650are potentially life threatening. Nursing homes and ambulatory care settings are alsonot immune from error. In fact, because the number of outpatient visits each year far


Exemplar 9-1

The Unsafe Act: Case of the Infusion PumpTim Bradley, RN, is a new intensive care unit nurse with 1 year experience. One evening,Tim is presented with a newly admitted, critically ill patient requiring intravenous antibi-otics, high-volume fluid resuscitation, and vasopressor and inotropic support therapy totreat progressive shock.The patient is deteriorating, and Tim is rapidly responding to eachailing system.

This particular shift, there had been a registered nurse sick call. This individual was notreplaced.The remaining nurses were very busy providing care to unstable patients. As a re-sult, Tim was independently handling his patient’s care needs.

Tim’s patient was prescribed dopamine 400 mg/250 ml @ 7 micrograms/kilogram/minute. The patient weighed 80 kilograms.

Unit policy required high-risk medication infusions via Smart Pump devices capable ofidentifying and preventing adverse drug events (ADE) when used as designed. Tim wasfamiliar with the correct use of the Smart Pump infusion devices and had been correctlyin-serviced; however, during his orientation, his preceptor had also encouraged Tim to by-pass the pump technology. Tim’s colleagues shared with him a variety of ways to avoid“dealing with the drug library and all those alerts!”The rationale was to “save time” by “by-passing” the information required when setting up the infusion device alerts.

Tim was in a hurry. His patient required many medications. Tim felt rushed and pres-sured. When he saw the dopamine infusion order, he decided to hang the medicationwithout the use of the Guardrails alerts. His intent was to go back after hanging the re-maining medications and set up the dopamine infusion as per policy.

Tim calculated the dopamine infusion rate. He set the infusion pump as per his calcula-tion. Tim did not realize that he had mistakenly calculated an infusion rate of 70 micro-grams/kilograms/minute. Within a short period of time, the patient exhibited tachycardiaand ventricular irritability with increased blood pressure significantly above the desired meanarterial pressure. Scared that he had made an error, Tim immediately rechecked thedopamine dosage and quickly discovered his error.The patient did not suffer apparent unto-ward effects once the dose was corrected; however, certainly the ADE could have been fatal.

This exemplar provides an overview of an unsafe act that violated an established rulebecause the rule violation was perceived as a routine, common act. Nurses had violated thisparticular rule on many occasions but the preconditions of nurse inexperience, high acuity,and inadequate supports in combination with established workarounds or shortcuts con-tributed to the actual adverse drug event.

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exceeds the number of inpatient visits, the opportunity for error in that setting is alsoconsiderable (Aspden et al., 2004).

The frequencies and costs of patient safety incidents (PSI) that occurred in the hos-pitalized Medicare population are staggering. From 2004 to 2006, patient safety inci-dents (PSIs) cost the Medicare program $8.8 billion and resulted in 238,337potentially preventable deaths (HealthGrades, 2006). HealthGrades analyzed 41 mil-lion Medicare patient records and identified that those patients treated at top-performing hospitals had approximately a 43% lower chance of experiencing one ormore medical errors than if treated at the poorest-performing hospitals.

While HealthGrades found that the overall death rate among Medicare benefici-aries that developed one or more patient safety incidents had decreased by almost 5%during the 2-year period, four indicators had increased when compared to a 2004baseline. These indicators included postoperative respiratory failure, postoperativepulmonary embolism or deep vein thrombosis, postoperative sepsis, and postoperativeabdominal wound separation/splitting. These key areas are included in the currentfocus of regulatory (e.g., Joint Commission and Centers for Medicare and MedicaidServices [CMS]) (CMS and Joint Commission, 2008) and recommending (e.g., In-stitute for Healthcare Improvement [IHI]) agencies.

Since the release of the IOM report (Kohn et al., 2000), there has been an abun-dant volume of published patient safety-focused literature. Multiple recommendingand regulatory agencies offer guidelines and mandates. Many organizations provideevidence-based practice guidelines to assist clinicians in providing standardized evi-dence-based care.

The volume of materials and ever-changing safety standards and best practices maybe overwhelming to CNSs, particularly those who are new to putting patient safetyprinciples into practice. The CNS is absolutely pivotal in assessing the clinical envi-ronment for accident and error opportunities, collaborating with appropriate teammembers to proactively improve systems or to meaningfully react to occurrences, andrapidly evaluating the outcomes of systems changes. Actively engaging in this workrequires a preliminary review of the definitions of terms commonly used in patientsafety projects and publications (Table 9-1). The CNS concentrating on a patientsafety role integrates all the skill and competencies described in role-based CNS con-ceptualizations (Hamric, 1989; Oncology Nursing Society, 2003) and influence-basedmodels (American Association of Critical-Care Nurses [AACN], 2002; National As-sociation of Clinical Nurse Specialists [NACNS], 2004).

Creating a Just Culture for Patient SafetyCulture is a shared set of beliefs and values about how people work individually andtogether as teams (Phillips, 2005). It delineates a shared set of values and beliefs thatinfluences communication, social relations, and actions (Friersen, Farquhar, &Hughes, 2006). Achieving and sustaining a culture of safety requires an understand-ing of the values and beliefs within a particular organization. The safety culture of anorganization is the product of individual and group values, attitudes, perceptions,

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competencies, and patterns of behavior that combine to determine the commitmentto, and the style and proficiency of, an organization’s health and safety management(AHRQ, 2001).

The notion of a “just culture” is relatively recent and denotes a culture where peoplecan report mistakes, errors, accidents, or waste without negative repercussions(AHRQ, 2008a). In a just culture, individuals remain accountable for their actions butthey are not held responsible for flawed systems that permit earnest, trained people toerr. Sharing and disclosure are prominent features of a just culture because efficienciesand quality improvement processes depend on the frontline staff to drive improve-ments, and such drive requires a sense of safety. Staff must feel empowered to point outerrors, defects, and systems failures that could cause patient harm (AHRQ, 2008a). Ajust culture is not an “anything goes” culture. In other words, individuals may be heldpersonally accountable for intended actions that are unsafe and violate rules. But, inhighly protected systems with established defense systems, such unsafe acts are morelikely in a highly specific, often atypical, set of circumstances (Reason, 1990).

Organizations with a positive safety culture have characteristics in common. Theseorganizations have leaders who support bidirectional communications founded onmutual trust, with the ability for all employees to speak up and raise concerns, as wellas the willingness to listen when others have a concern. In addition, there are shared


Table 9-1 DEFINITIONS OF KEY TERMS IN PATIENT SAFETY

Term Definition

Error

Near miss

Patient safety

Incident

Adverse event

Source: Aspden et al., 2004; Pronovost et al., 2005.

Mistakes made in the process of care that result in, or havethe potential to result in, harm to the patient.An act of commission or omission that could have harmedthe patient, but did not do so as a result of chance (IOM).The absence of the potential for, or occurrence of, healthcare-associated injury to patients. Created by avoiding medicalerrors as well as taking action to prevent medical errors fromcausing injury. Mistakes include failure of a planned action tobe completed as intended or the use of a wrong plan toachieve an aim. These can be the result of an action that istaken (error of commission) or an action that is not taken(error of omission).Unexpected or unanticipated events or circumstances notconsistent with the routine care of a particular patient, whichcould have, or did, lead to an unintended or unnecessaryharm to a person, or a complaint, loss, or damage.An injury resulting from a medical intervention.

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perceptions of the importance of safety, coupled with a systems approach to analysis ofsafety issues (Friersen et al., 2006; Helmreich, 2005). Patient safety permeates the cul-ture, and there is an emphasis on continuous improvement (Friersen et al., 2006).Highly reliable organizations (HROs) tend to be exceptionally consistent and are par-ticularly good at avoiding error (AHRQ, 2008b). HROs are characterized by severalorganizing concepts: (1) sensitivity to operations with staff maintaining an ongoingorganizational awareness; (2) reluctance to simplify; (3) preoccupation with failure;(4) deference to expertise; and (5) resilience (AHRQ, 2008b).

Progress toward creating a culture of patient safety requires honest, routine error re-porting. Errors and near misses are reported in organizations in which staff feels safereporting errors. In organizations with a culture of patient safety, the emphasis is onwhy the error occurred, versus who made the error (see Figure 9-2). Leaders use errorsto help staff evaluate processes and learn how to prevent a recurrence of an error,rather than to blame.Two strategies encouraged by the Joint Commission that can as-sist with error analysis are failure mode and effects analysis (FMEA) and root causeanalysis strategies (RCA) (De Rosier & Stalhandske, 2006; Duwe, Fuchs, & Hansen-Flashen, 2005).

What strategies can the CNS use to assess the culture of safety within the practiceenvironment? AHRQ has tools posted on its Web site that can be downloaded free ofcharge to facilitate assessment of the safety culture within a hospital or nursing home.The tools are designed to provide institutions with the opportunity to assess their pa-tient safety cultures, track changes in safety over time, and evaluate the influence ofpatient safety interventions (AHRQ, 2008c).

Results of the AHRQ survey will assist the CNS and other members of the lead-ership team to assess the perception of patient safety within their organizations,whether errors are reported and discussed in an appropriate forum, and whetherthere is an atmosphere of continuous learning based on the principles of patientsafety. Each healthcare institution can use the completed survey data to calculatetheir percentage of positive responses on each item. Those data can be submitted toAHRQ for entry into a national database. The AHRQ Hospital Survey on PatientSafety Culture allows comparisons between the submitting hospital and other simi-lar hospitals. This report enables each hospital to compare itself to the benchmarkhospitals (AHRQ, 2008c).

Safety culture assessments are useful tools for measuring organizational conditionsthat lead to adverse events and patient harm in hospitals. The assessment is the start-ing point from which action planning begins and patient safety changes evolve (Sora& Nieva, 2003). Reassessments serve as barometers to measure the success of im-provement interventions. Once the cultural assessment is complete, the CNS can usethe data to integrate evidence-based guidelines into everyday practice for patient care.

Creating a Safe EnvironmentArmed with the culture assessment findings, the CNS must continue to examine thepractice environment with an eye on safety. Through assessment and analysis of the

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practice environment, the CNS begins to understand potential root causes of errorswithin that environment. The majority of medical errors do not occur as the result ofone person’s actions, but are the result of faulty systems, processes, and conditions thatlead people to make mistakes or fail to prevent them (Phillips, 2005).


ASSESS - ERR™Medication System WorksheetPatient MR#

(if error reached patient)Date of error:

Drug(s) involved in error:

Non-formulary drug(s)?Drug sample(s)?Drug(s) packaged in unit dose/unit of use?Drug(s) dispensed from pharmacy?Error within 24 hours of admission, transfer, or after discharge?Did the error reach the patient?Source of IV solution:

Date information obtained:

Incident #✓ if no callback identified:Patient age:

Brief description of the event: (what, when, and why)

❑ Yes❑ Yes❑ Yes❑ Yes❑ Yes❑ Yes❑ Pharmacy IV admixture

❑ No❑ No❑ No❑ No❑ No❑ No

❑ Nursing IV admixture❑ Manufacturer premixed solution

❑ Testing ❑ Additional observation ❑ Gave antidote ❑ Care escalated (transferred, etc.) ❑ Additional LOS ❑ Other

Possible causes Y/N CommentsCritical patient information missing?(age, weight, allergies, BS, lab values, pregnancy, patientidentity, location, renal/liver impairment, diagnoses, etc.)

Critical drug information missing?(outdated/absent references, inadequate computer screening,inaccessible pharmacist, uncontrolled drug formulary, etc.)

Miscommunication of drug order?(illegible, ambiguous, incomplete, misheard, ormisunderstood orders, intimidation/faulty interaction, etc.)Drug name, label, packaging problem?(look/sound-alike names, look-alike packaging,unclear/absent labeling, faulty drug identification, etc.)

Drug stoage or delivery problem?(slow turn around time, inaccurate delivery, doses missing orexpired, multiple concentrations, placed in wrong bin,etc.)

Drug delivery device problem?(poor device design, misprogramming, free-flow, mixed uplines, IV administration of oral syringe contents, etc.)

Environmental, staffing, or workflow problems?(lighting, noise, clutter, interruptions, staffing deficiencies,workload, inefficient workflow, employee safety, etc.)

Lack of staff education?(competency validation, new or unfamiliar drugs/devices,orientation process, feedback about errors/prevention, etc.)

Patient education problem?(lack of information,noncompliance, not encouraged to askquestions, lack of investigating patient inquiries, etc.)

Lack of quality control or independent check systems?(equipment quality control checks, independent checks forhigh alert drugs/high risk patient population drugs etc.)

Did the patient require any of the following actions after the error that you would not have done if the event had not occurred?

Patient outcome:

@2006 Institute for Safe Medication Practices

Figure 9-2 Assess-ERR Medication Safety System Worksheet.Source: © 2006, Institute for Safe Medication Practices. Reprinted with permission.

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AHRQ has identified factors that contribute to errors: communication, inadequateflow of information, human problems, patient-related issues, organizational transferof knowledge, staffing patterns and work flow, technical failures, and inadequate poli-cies and procedures (AHRQ, 2003). Table 9-2 presents each of these factors with anexample of how they apply to bedside practice.

When assessing the role each factor plays in contributing to errors within the prac-tice environment, the CNS must also assess how staff has adapted its practice to workaround systematic obstructions to completing work. Nurses have unparalleled skill atdeveloping workarounds. In other words, what can the nurse do to solve the issue forthe patient today?

Although this strategy does garner short-term success, it creates long-term prob-lems. As a simple example, if a nurse does not have a patient’s medications and solvesthis problem by borrowing medications from another patient, this exemplifies first-order problem solving (Tucker & Edmondson, 2002). The nurse has met the needs ofthe patient in the immediate period by securing the needed medications. But, ofcourse, the medications are now no longer available for the patient for whom theywere intended.

In examining this simple issue, numerous other issues arise: What about the patientwhose medications were taken (his or her dose is now missing)? What if it is a slightlydifferent dose? What will keep this situation from arising tomorrow? Bedside nurses’role supports first-order problem solving. Nurses at the point-of-care do not have theresources (mainly time) to do second-order problem solving (Tucker & Edmondson,2002).

The role of the CNS in this scenario is critical. Second-order problem solving in-volves a system analysis of why the error occurred—what part of the system failed thenurse and the patient (Tucker & Edmondson, 2002). To have more than a temporaryfix, the root cause of the problem must be uncovered. It is often easier to work aroundproblems, especially when the staff nurses believe that they have reported this issuepreviously and no action has been taken. The CNS must partner with the staff nurseto investigate the concern and to craft a reasonable, efficient solution to the clinicalproblem. Partnering facilitates staff buy-in, because the nurses helped to broker thesolution. The CNS must make it easier for staff to do the right thing while making itmore difficult to do a workaround.

One essential support to sustaining a culture of safety is the creation of a healthywork environment (HWE). The attributes of a healthy work environment are symbi-otic with a culture of patient safety. The American Association of Critical-CareNurses’ (AACN) Healthy Work Environment standards demonstrate a commitmentto creating a positive work environment that facilitates safety (Barden, 2005). Eachstandard is clarified by essential (absolutely required, fundamental), standard (author-itative statement), and critical elements (structures, processes, programs, and behav-iors required for a standard to be achieved).

The first healthy work environment standard is skilled communication; nursesmust be as proficient in communication skills as they are in clinical skills.The conceptof communication is complex, encompassing verbal, written, and nonverbal skills. Inreviewing sentinel events, the Joint Commission has identified team communication


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Table 9-2 FACTORS THAT CONTRIBUTE TO ERRORS

Factor Description Examples of Interventions for CNS

Communication Verbal/nonverbal,written (e.g., in e-mail communication).Between any mem-bers of the team:nurse, physician,family, support staff,therapists.NPSG #2: “Improvethe effectiveness ofcommunicationamong caregivers”( Joint Commission,2006).

1. Conduct briefings: Role-model efficient and effectivebidirectional communicationwith all team members. Whenpreparing to perform a proce-dure, review each step beforebeginning to prevent miscom-munication.

2. Be assertive: Create an envi-ronment where any member ofthe team feels comfortable invoicing their concern. Utilizethe SBAR strategy to commu-nicate a message that is clearand concise.

3. Develop situational awareness:Place signs outside the patient’sdoor, be sure all staff are awareof patients who are “at risk” forfalls or other clinical issues.

4. Understand the differencebetween the novice and theexpert in making decisions:Decisions are made based onpast experience, and becausethe novice has little past expe-rience, he or she may rely moreon the CNS to support his orher decision-making process.

5. Conduct debriefings: After asignificant clinical event, re-view with the staff the pre-event situation, the event, andthe response to the event. Lis-ten to the staff ’s perception ofwhat happened. The CNS maybe able to use the informationto plan future education.

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Table 9-2 (continued)


Communication(continued)

Inadequate flow of information

Human problems

Members of the teammay not have the in-formation they needto appropriately carefor the patient.NPSG #2, to“Improve the effec-tiveness of communi-cation,” includes arequirement for astandardized handoffof communications( Joint Commission,2006).How standards ofcare, policies, andprocedures arefollowed.Other factors thatplay a role: fatigue,stress, distractions,interruptions, and

6. SBAR strategy: Develop atemplate for the use of theSBAR strategy, including a fewkey clinical characteristics. Forexample, if caring for a thoracicpopulation, always include anassessment of breath soundsand pattern of breathing.

1. Examine the handoff processwithin the practice environ-ment; include nurses, physi-cians, pharmacists, etc.

2. Partner with other members ofthe team to create a handofftool that would enable clear,concise communication.

1. CNS plays a key role in the design, development, imple-mentation, and evaluation ofpolicies.

2. Partner with the nurse managerand bedside nurses to establishthe standards of care within thepractice environment.

3. Evaluate the practice environ-ment for factors that may influence care.

4. Develop a peer-review processto enable the staff to hold eachother accountable for caredelivered.

(continues)

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Patient-related issues

Organizational transfer of knowledge

Staffing patterns/workflow

multitasking.Incomplete assess-ment, which mayinclude allergies, orduplicate or missingmedications.NPSG #8 requires ac-curate and completereconciliation of med-ications across thecontinuum of care.Patient identifica-tion, utilizing twounique identifiers(NPSG #1) ( JointCommission, 2006).Formal transfer ofknowledge occursduring orientation,education, and com-petency assessments.Informal.

Supplies: disjointed,missing, not easilyavailable to the nurse.Assignmentsgeographicallyundesirable.

1. Monitor patient identification:As you make rounds on eachpatient, ask the patient if thestaff have been checking his orher identification.

2. Ensure that there is a clearprocess if the identification isincorrect.

3. Partner with bedside nurses,pharmacists, physicians, andnursing leadership to establisha process for medicationreconciliation.

1. In collaboration with other ex-perts, design, develop, andevaluate clinical competenciesas they relate to the care of adefined population.

2. Develop a tool for a brief ori-entation to your practice areafor staff who are pulled, poolnurses, or agency staff. Includeemergency equipment, sup-plies, medications, a short les-son on how to contact thephysicians; anything that isimportant about your patientpopulation.

1. Review work by Ebright andcolleagues who have studiedthe flow of “nurse work”(Ebright, 2004).

2. Start with one simple project:What does a nurse need toperform safe, aseptic intra-

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as a top contributor to sentinel events ( Joint Commission, 2006). Healthcare organi-zations are obligated to help staff develop excellent communication skills. Skilledcommunicators focus on finding solutions and desirable outcomes, advancing col-laborative relationships, listening as intently as they speak, and demonstrating mutual



Staffing patterns/workflow(continued)

Technical failures

Inadequate policies and procedures

Source: AHRQ, 2003; Phillips, 2005.

Frequent interruptions/distractions.Mechanical devicescan malfunction.

Policies that are toolong, too wordy, outof date, or not easilyaccessible will not beutilized.

venous line care? If the care isdone at the patient’s bedside,the supplies should be at thebedside, not in the supplyroom.

3. Discuss with the staff changesin where/how medications are prepared to decrease, andeventually eliminate interruptions/distractionswhen preparing medications.

1. Ensure that contact numbersfor experts (in house or fromthe companies) are easily acces-sible, particularly for life-sus-taining equipment; for example,ventricular assist devices.

2. Plan and execute drills for allequipment that is low volume,high risk (continuous renal re-placement machines, postcar-diac arrest hypothermia devices).

1. Participate in policy reviewand revision, with an eye forpracticality (e.g., if the policy is28 pages single spaced, it is notlikely to be used).

2. Promote electronic availabilityof nursing policies and medi-cation information (e.g.,online policy manuals or medi-cation manuals).

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respect (Barden, 2005). The CNS must role model expert communication techniquesand offer constructive feedback to staff nurses as they develop their communicationskill sets.

One strategy that has been effective in facilitating clear, direct communicationamong caregivers is the SBAR strategy. SBAR is an acronym for situation, background,assessment, and recommendation (Leonard, Graham, & Bonacum, 2004). SBAR is a sit-uational briefing model characterized by appropriate assertion, critical language, andawareness and education. It is a vital model designed to address the different commu-nication styles used and valued by nurses, physicians, and other clinicians (Table 9-3).


Table 9-3 SBAR

30–60 Second Communication

Situation

Background

Assessment

Recommendation

Source: Leonard et al., 2004; Phillips, 2005.

What is happening with the patient?Example:“Hello, Dr. Jones, this is Susan, I am calling from 2West. I am taking care of Mr. Green in room 212,a patient of Dr. Johnson’s who went to the OR today for a colectomy. He has been back from the PACU for 4 hours. I have just reassessed him.”What is the important clinical information?“Over the past 4 hours, his BP has dropped from120/78 to 90/58, his heart rate has increased from 70 to100, his respiratory rate is 24, and his urine output was80 mL/hour for the first 2 hours and has dropped to 30mL each hour for the past 2 hours.He is receiving IV fluids, D5.45NS + 20 meq KCL at125 mL/hour.His postop labs were unremarkable, his hemoglobinwas 10.2.His estimated blood loss was 450 mL.”What do you think the problem is?“I think he is dry.”What do you think he needs? If you think the patientneeds to be seen by the physician or nurse practi-tioner, do not be afraid to say so.“I think he needs more fluid.”

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The CNS can assist staff with developing a template for communicating withphysicians and other team members using the SBAR strategy and incorporating theconsistent use of particular elements that relate to the specific patient population. Forexample, if caring for a neuroscience population, the assessment of the GlasgowComa Score (GCS) would always be included in every communication. Additionalstrategies to improve communication include conducting briefings, being assertive,developing situational awareness, understanding the differences in expert and novicedecision making, and conducting debriefings (Volker & Clark, 2004). Communica-tion successes will develop over time and will occur only with practice, repetition, andconstructive feedback to staff.

The second healthy work environment standard is true collaboration: Nurses mustbe relentless in pursuing and fostering true collaboration.True collaboration can buildon the relationships fostered through skilled communication. It is a relationshipgrounded in respect and trust. Nurse–physician collaboration is one of the threestrongest predictors of nurse empowerment. One of the critical elements of true col-laboration is that “every team member contributes to the achievement of commongoals by giving power and respect to each person’s voice, integrating individual differ-ences, resolving competing interests, and safeguarding the essential contribution eachmust make in order to achieve optimal outcomes” (Barden, 2005, p. 21). Authenticcollaboration is revealed through relationships with other nurse leaders, physicians,and administrators.

The third standard is effective decision making: Nurses must be valued and com-mitted partners in making policy, directing and evaluating clinical care, and leadingorganizational operations (Barden, 2005). Nurses have primary responsibility for pa-tient safety, but only 8% of physicians recognize the nurse as part of the decision-making team (Cook, Hoas, Guttmannova, & Joyner, 2004). Effective decision making bridges the autonomy–accountability gap by empowering nurses to be the decision-making authority in the care of their patient.

The fourth healthy work environment standard addresses appropriate staffing:Staffing must ensure the effective match between patient needs and nurse competen-cies (Barden, 2005). Some CNSs may play a functional role in staffing by either beingaccountable to make sure enough staff is present or filling in when staffing is short.One clear role for the CNS in any staffing pattern is to collaborate with the nursemanager and staff nurses to look at the nurse work flow and the relationship tostaffing. Are there staff members uninvolved in patient care for parts of the day thatcould have time schedules flexed? Are there times when the CNS must partner withthe manager to assert that the staff has reached a critical workload point and cannottake any more patients? This standard builds on the first, second, and third standards,wherein all the skills can combine to provide excellent communication, collaboration,and decision making to solve complex staffing issues.

Meaningful recognition is the fifth standard: Nurses must be recognized and mustrecognize others for the value each brings to the work of the organization (Barden,

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2005). Recognition was important to 75% of the nurses in the healthy work environ-ment study. A formalized process for recognition is essential for it to be effective. TheCNS must be knowledgeable about recognition programs nationally (as with profes-sional organizations), regionally (as with local chapters or statewide awards), or withinthe organization. The CNS must lead the recognition initiative to ensure that excel-lence in clinical practice, communication, patient–family relationships, and other keyperformance measures are recognized.

The final standard is authentic leadership: Nurse leaders must fully embrace theimperative of a healthy work environment, authentically live it, and engage others inthe achievements (Barden, 2005). Authentic leaders are supported by their organiza-tion in developing skills and competency in skilled communication, true collabora-tion, effective decision making, meaningful recognition, and authentic leadership.Establishing and sustaining a practice environment that is supported by the conceptsin the healthy work environment standards contributes to a hospital culture rich insafety, which contributes to an environment of patient safety.

Safety and Quality OrganizationsThe complexity of regulatory agencies and recommending organizations withinhealth care is extraordinary. The CNS is frequently held accountable for compliancewith multitudes of guidelines, competencies, rules, and regulations. In developingclinical programs for improvement, which may be in response to a regulatory require-ment, the CNS must partner with the bedside nurse to collaborate with numerousdisciplines to establish compliance strategies for each regulation or guideline.

Joint Commission accreditation is a nationwide seal of approval indicating that or-ganizations meet high performance standards. The Joint Commission and JointCommission International were designated in 1995 as the World Health Organiza-tion (WHO) Collaborating Centre for Patient Safety Solutions (WHO Collaborat-ing Centre for Patient Safety Solutions, 2008).

There are numerous regulatory and recommending agencies that address health-care safety and quality; many of their recommendations overlap and are quite similargiven their shared evidence base. Key organizations include, but are not limited to, theCenter for Medicare and Medicaid (CMS), Institute for Healthcare Improvement(IHI), AHRQ, National Patient Safety Goals (NPSG), Joint Commission, and Na-tional Quality Foundation (NQF).

Tools of the TradeThe World Wide Web has dramatically influenced patient care delivery. The role ofthe CNS in patient safety is inextricably linked to the use of electronically availabletools in the form of assessment tools, guidelines, and other references, many of whichcan be downloaded without charge. Professional organizations, not-for-profit (NFP)recommending organizations, governmental agencies, regulatory bodies, and evidence-based practice Web sites offer many useful resources (refer to Tables 9-4 through 9-8).


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Tools of the Trade 307Ta

ble

9-4

EXA

MP

LES

OF

WEB

SIT

ES W

ITH

PA

TIEN

T SA

FET

Y IN

FOR

MA

TIO

N (P

SI):

PR

OFE

SSIO

NA

L O

RG

AN

IZA

TIO

NS

Web

Sit

eCo

nten

tsCN

S B

enef

its

http

://w

ww

.aac

n.or

g/W

D/H

WE

/D

ocs/

HW

ESt

anda

rds.

pdf

Am

eric

an A

ssocia

tion

ofC

riti

cal

Car

e Nur

ses (

AA

CN

)A

cces

sed:

Dec

embe

r 9,2

008

http

://w

ww

.ons

.org

/pub

licat

ions

/po

sitio

ns/p

atie

ntsa

fety

.sht

ml

Onc

olog

y N

ursin

g So

ciety

(ON

S)A

cces

sed:

Dec

embe

r 9,2

008

http

://w

ww

.aor

n.or

g/ab

outa

orn/

who

wea

re/p

atie

ntsa

fety

first

Asso

ciati

on o

fper

iOpe

rati

ve R

egist

ered

N

urse

s (A

OR

N)

Acc

esse

d:D

ecem

ber 9

,200

8

Hea

lthy

wor

k en

viro

nmen

t sta

ndar

ds:

Six

key

fact

ors i

n cr

eatin

g an

d su

stai

ning

ahe

alth

y w

ork

envi

ronm

ent (

HW

E).

Ava

ilabl

eto

dow

nloa

d th

e fu

ll do

cum

ent o

r the

exe

cutiv

esu

mm

ary.

Prac

tice

Ale

rts:

Ele

ven

succ

inct

,dyn

amic

evi

denc

e-ba

sed

guid

elin

es d

esig

ned

to c

lose

the

rese

arch

–pr

actic

e ga

p an

d fa

cilit

ate

stan

dard

ized

pr

actic

e.

Posi

tion

stat

emen

t on

patie

nt sa

fety

Iden

tifyi

ng,c

olle

ctin

g,an

d de

velo

ping

clin

ical

and

educ

atio

nal r

esou

rces

to im

prov

e pa

tient

safe

ty in

the

surg

ical

sett

ing.

In a

dditi

on:

•G

ener

al re

sour

ces—

links

to n

umer

ous

patie

nt sa

fety

site

s•

AO

RN

reso

urce

s and

jour

nal a

rtic

lere

fere

nces

Prov

ides

evi

denc

e-ba

sed

guid

elin

esth

at su

ppor

t the

six

key

fact

ors i

ncr

eatin

g a

HW

E.T

he C

NS

can

op-

erat

iona

lize

thes

e gu

idel

ines

tom

eet t

he n

eeds

of t

he p

ract

ice

envi

ronm

ent.

Onc

olog

y nu

rses

can

use

this

stat

e-m

ent t

o fo

rmul

ate

thei

r ow

n po

si-

tion

stat

emen

t on

patie

nt sa

fety

.

Res

ourc

es o

n th

is si

te a

pply

to p

eri-

oper

ativ

e,po

stop

erat

ive

and

proc

e-du

ral s

taff

.The

se re

sour

ces c

an b

eus

ed to

dev

elop

edu

catio

n pr

o-gr

ams,

orie

ntat

ion

prog

ram

s,an

dpa

tient

safe

ty p

rogr

ams.

(con

tinu

es)

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 307



Tab

le 9

-4(c

on

tin

ued

)

Web

Sit

eCo

nten

tsCN

S B

enef

its

•L

ist o

f pat

ient

safe

ty jo

urna

ls an

d ne

wsle

tter

s•

Patie

nt sa

fety

boo

ks a

nd m

edia

•Jo

int C

omm

issi

on p

atie

nt sa

fety

pra

ctic

eson

line

•Jo

urna

l sca

n•

Posi

tion

stat

emen

t on

patie

nt sa

fety

•N

urse

con

sulta

tion

oppo

rtun

ities

•C

orre

ct si

tes s

urge

ry to

olki

t•

Nat

iona

l Tim

e-O

ut D

ay

Site

is d

esig

ned

to p

rom

ote

safe

ane

sthe

sia

patie

nt c

are

by e

duca

ting

the

publ

ic.C

on-

tain

s nee

d-to

-kno

w in

form

atio

n fo

r ane

sthe

-si

a pa

tient

s:•

“Pat

ient

Can

dor E

ssen

tial f

or S

afe

Ane

sthe

siaC

are”

;the

full

stor

y di

scus

ses t

he im

port

ance

of fu

ll di

sclo

sure

to th

e an

esth

esia

pro

vide

r.•

“New

Ane

sthe

sia

Stan

dard

s for

Off

ice

Sur-

geri

es”;

refle

cts t

he A

AN

A n

ew st

rict

stan

-da

rds f

or o

ffic

e su

rger

ies.

•“C

onsc

ious

Sed

atio

n”;d

iscu

sses

whi

ch ty

pes

of su

rger

y an

d pr

oced

ures

can

be

done

with

cons

ciou

s sed

atio

n.

Thi

s site

con

tain

s ext

ensi

ve re

-so

urce

s for

pat

ient

edu

catio

n,w

hich

coul

d be

inco

rpor

ated

into

a p

re-o

ped

ucat

ion

prog

ram

.

http

://w

ww

.ane

sthe

siap

atie

ntsa

fety

.co

mA

mer

ican

Asso

ciati

on o

fNur

seA

nest

heti

sts (

AA

NA

)A

cces

sed:

Dec

embe

r 9,2

008

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 308



ble

9-4

(co

nti

nu

ed)

Web

Sit

eCo

nten

tsCN

S B

enef

its

Lin

k to

“Ane

sthe

sia

and

Your

Chi

ld,”

prov

ides

a st

ory

and

a co

lori

ng b

ook

for c

hild

ren

who

are

abou

t to

have

ane

sthe

sia

to a

llay

fear

s.

Site

con

tain

s res

ourc

es fo

r bot

h th

e nu

rse

and

the

patie

nt/f

amily

.•

Lin

k to

ask

a c

linic

al p

ract

ice

ques

tion

and

num

erou

s org

aniz

atio

nal c

omm

ittee

s,su

chas

edu

catio

n an

d ev

iden

ce-b

ased

pra

ctic

e•

Nur

sing

Cor

e C

urri

culu

m fo

r Per

iane

sthe

sia

Nur

ses

•Fo

r pat

ient

s,an

ext

ensi

ve se

ctio

n on

wha

t to

expe

ct fr

om th

e pr

e-ad

mis

sion

inte

rvie

wth

roug

h di

scha

rge

The

Rol

e of

the

Nur

se E

xecu

tive

in P

atie

ntSa

fety

:1.

Lea

d cu

ltura

l cha

nge

2.Pr

ovid

e sh

ared

lead

ersh

ip3.

Bui

ld e

xter

nal p

artn

ersh

ips

4.D

evel

op le

ader

ship

com

pete

ncie

s

The

pre

-adm

issi

on in

terv

iew

can

begi

n th

e pr

oces

s of m

edic

atio

nre

conc

iliat

ion,

to c

ompl

y w

ith th

eJo

int C

omm

issi

on N

atio

nal P

atie

ntSa

fety

Goa

l on

med

icat

ion

reco

n-ci

liatio

n.

The

CN

S ca

n pa

rtne

r with

the

nurs

e ex

ecut

ive

to le

ad c

ultu

ral

chan

ge a

cros

s dis

cipl

ines

,as w

ell a

sde

velo

p an

d dr

ive

patie

nt sa

fety

ini-

tiativ

es a

cros

s the

org

aniz

atio

n.

http

://w

ww

.asp

an.o

rgA

mer

ican

Socie

ty o

fPer

iane

sthe

-sia

Nur

ses (

ASP

AN

)A

cces

sed:

July

23,

2006

http

://w

ww

.aon

e.or

g/ao

ne/

pdf/

Rol

e%20

of%

20th

e%20

Nur

se%

20E

xecu

tive%

20in

%20

Patie

nt%

20Sa

fety

%20

Too

lkit_

July

2007

.pdf

Am

erica

n A

ssocia

tion

ofN

urse

Exe

cu-

tive

s (A

ON

E)

Acc

esse

d:D

ecem

ber 9

,200

8

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 309



Tab

le 9

-5EX

AM

PLE

S O

F W

EB S

ITES

WIT

H P

SI:N

OT-

FOR

-PR

OFI

T “R

ECO

MM

END

ING

”O

RG

AN

IZA

TIO

NS

Web

Sit

eCo

nten

tsCN

S B

enef

its

http

s://

ww

w.e

cri.o

rg/P

ages

/de

faul

t.asp

xE

CR

I Ins

titu

teA

cces

sed:

Dec

embe

r 9,2

008

http

://w

ww

.ism

p.or

gIn

stit

ute f

or S

afe M

edica

tion

P

ract

ices (

ISM

P)A

cces

sed:

Dec

embe

r 9,2

008

Des

igna

ted

by A

HR

Q/W

orld

Hea

lth O

rgan

i-za

tion

as a

n ev

iden

ce-b

ased

pra

ctic

e ce

nter

.A

dmin

iste

rs:N

atio

nal Q

ualit

y M

easu

res

Cle

arin

g H

ouse

;Nat

iona

l Gui

delin

esC

lear

ingh

ouse

Com

plet

e lis

t of t

echn

olog

y as

sess

men

ts a

ndev

iden

ce-b

ased

repo

rts

A “c

onsu

mer

repo

rts”

for m

edic

al d

evic

esM

DSR

—m

edic

al d

evic

e in

cide

nt a

nd h

azar

din

form

atio

nP

ublis

hes H

ealth

Dev

icesj

ourn

al

Ext

ensi

ve re

sour

ces f

or st

aff a

nd p

atie

nts:

•E

duca

tion:

new

slet

ters

,edu

catio

nal p

ro-

gram

s,se

lf-as

sess

men

ts,p

atie

nt sa

fety

vid

eo

•M

edic

atio

n sa

fety

tool

s and

reso

urce

s:hi

gh-

aler

t med

icat

ion

list,

conf

used

dru

g lis

t,er

ror-

pron

e ab

brev

iatio

n lis

t,do

-not

-cru

sh li

st•

“Pat

hway

s for

Med

icat

ion

Safe

ty”;

an e

xten

-si

ve p

rogr

am fo

r med

icat

ion

safe

ty th

at c

anbe

dow

nloa

ded

for f

ree

•U

SP—

ISM

P M

edic

atio

n E

rror

repo

rtin

gsy

stem

The

CN

S pl

ays a

key

role

in p

rod-

uct s

elec

tion.

The

tech

nolo

gy a

s-se

ssm

ent o

n th

e E

CR

I Web

site

can

assi

st in

ass

essi

ng th

e sa

fety

of a

tech

nolo

gy,a

s wel

l as o

ffer

ing

ano

nbia

sed

com

pari

son

of d

iffer

ent

prod

ucts

that

pro

vide

the

sam

ete

chno

logy

.The

CN

S ca

n al

so se

ekou

t gui

delin

es fo

r a b

road

rang

e of

clin

ical

issu

es.

Man

y to

ols w

ill a

ssis

t with

com

pli-

ance

with

Join

t Com

mis

sion

NP

SGto

:•

Impr

ove

the

safe

ty o

f usi

ng m

edic

a-tio

ns

•A

ccur

atel

y an

d co

mpl

etel

y re

conc

ilem

edic

atio

ns a

cros

s the

con

tinuu

mof

car

e“P

athw

ays f

or M

edic

atio

n Sa

fety

”w

ill g

uide

the

CN

S in

cre

atin

g a

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 310



ble

9-5

(co

nti

nu

ed)

Web

Sit

eCo

nten

tsCN

S B

enef

its

•L

inks

to n

umer

ous p

atie

nt sa

fety

site

s•

Asse

ss-E

RR

Med

icati

on S

yste

m W

orks

heet

tofa

cilit

ate

med

icat

ion

use

syst

em e

valu

atio

ns(F

igur

e 9-

2)

Nat

iona

l Pat

ient

Saf

ety

Foun

datio

n:•

Cre

ate

a co

re b

ody

of k

now

ledg

e•

Dev

elop

a c

ultu

re re

cept

ive

to sa

fety

•R

aise

pub

lic a

war

enes

s•

Fost

er c

omm

unic

atio

ns

Spon

sors

edu

catio

nal p

rogr

ams,

patie

nt sa

fety

fello

wsh

ips;

educ

atio

nal v

ideo

s,ne

wsl

ette

rs

Res

ourc

es a

re a

vaila

ble

for p

atie

nts,

fam

ilies

,an

d ca

regi

vers

med

icat

ion

safe

ty p

rogr

am a

s a c

ol-

labo

rativ

e w

ith p

harm

acy.

Mon

thly

new

slet

ter c

onta

ins i

nfor

-m

atio

n to

impr

ove

med

icat

ion

ad-

min

istr

atio

n pr

oces

s.

“Whe

n th

ings

go

wro

ng…

”is a

docu

men

t fro

m th

e H

arva

rd H

os-

pita

ls to

teac

h ph

ysic

ians

and

nur

ses

wha

t to

do if

som

ethi

ng g

oes

wro

ng.T

he C

NS

can

use

this

inco

llabo

rativ

e fo

rum

s for

phy

sici

ans

and

nurs

es to

dis

cuss

pla

ns o

n ho

wto

resp

ond

whe

n an

adv

erse

eve

ntoc

curs

.

http

://w

ww

.nps

f.org

Nat

iona

l Pat

ient

Saf

ety

Foun

dati

on

(NPS

F)

Acc

esse

d:D

ecem

ber 9

,200

8

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 311



Tab

le 9

-6EX

AM

PLE

S O

F W

EB S

ITES

WIT

H P

SI:G

OV

ERN

MEN

T A

GEN

CIE

S

Web

Sit

eCo

nten

tsCN

S B

enef

its

http

://w

ww

.ahr

q.go

v/cl

inic

/pts

afet

y/pd

f/pt

safe

ty.p

dfA

genc

y fo

r Hea

lthca

re R

esea

rch

and

Qua

lity

(AH

RQ

)A

cces

sed:

Dec

embe

r 9,2

008

http

://w

ww

.ahr

q.go

v/qu

al/

patie

ntsa

fety

cultu

re/h

osps

urvi

ndex

.ht

mA

genc

y fo

r Hea

lthca

re R

esea

rch

and

Qua

lity

(AH

RQ

)A

cces

sed:

May

6,2

009

http

://w

ww

.psn

et.a

hrq.

gov

AH

RQ

Pat

ient

Saf

ety

Net

wor

kA

cces

sed:

Dec

embe

r 9,2

008

“Mak

ing

Hea

lthca

re S

afer

:Cri

tical

ana

lysi

s of

Patie

nt S

afet

y Pr

actic

es (2

001)

.”T

he a

im o

fth

is e

xten

sive

doc

umen

t was

to c

olle

ct a

nd re

-vi

ew e

xist

ing

evid

ence

on

prac

tices

rele

vant

toim

prov

ing

patie

nt sa

fety

.Ele

ven

prac

tices

wer

eid

entif

ied

and

rate

d m

ost h

ighl

y in

term

s of

stre

ngth

of e

vide

nce.

Hos

pita

l Sur

vey

on P

atie

nt S

afet

y C

ultu

re(2

004)

:how

to a

dmin

iste

r the

surv

ey,h

ow to

anal

yze

and

inte

rpre

t the

resu

lts

Thi

s res

ourc

e is

ava

ilabl

e as

an

e-m

ail f

rom

the

AH

RQ

,whi

ch p

rovi

des a

con

tinuo

usly

up-

date

d,an

nota

ted,

and

care

fully

sele

cted

col

lec-

tion

of p

atie

nt sa

fety

new

s,lit

erat

ure,

tool

s,an

dre

sour

ces.

Als

o co

ntai

ns th

e “p

atie

nt sa

fety

clas

sics

,”in

clud

ing

the

mos

t inf

luen

tial,

fre-

quen

tly c

ited

artic

les,

book

s,an

d re

sour

ces i

npa

tient

safe

ty.

The

se e

leve

n pr

actic

es c

an b

e in

te-

grat

ed in

to a

uni

t-ba

sed

patie

ntsa

fety

pro

gram

.

The

CN

S ca

n us

e th

is to

ol to

beg

inan

env

iron

men

tal a

sses

smen

t of t

hepa

tient

safe

ty c

ultu

re o

f the

pra

ctic

ear

ea.

Sinc

e th

is is

aut

omat

ical

ly se

ntfr

om th

e A

HR

Q,i

t kee

ps th

e C

NS

abre

ast o

f all

the

key

rece

nt p

atie

ntsa

fety

lite

ratu

re.

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 312



ble

9-6

(co

nti

nu

ed)

Web

Sit

eCo

nten

tsCN

S B

enef

its

Med

ical

err

ors a

nd p

atie

nt sa

fety

:•

Onl

ine

jour

nals

•41

pat

ient

safe

ty d

ocum

ents

for s

taff

and

patie

nts

•Pa

tient

Saf

ety

Tas

k Fo

rce

info

rmat

ion

•T

he F

eder

al Q

ualit

y In

tera

genc

y C

oord

ina-

tion

Qul

C T

ask

Forc

e:en

sure

s tha

t all

fed-

eral

age

ncie

s tha

t pur

chas

e,pr

ovid

e,st

udy,

orre

gula

te h

ealth

care

serv

ices

are

wor

king

in a

coor

dina

ted

way

tow

ard

the

com

mon

goa

l of

impr

ovin

g th

e qu

alit

y of

car

e•

Con

fere

nces

and

wor

ksho

ps

Nur

sing

act

iviti

es a

ssoc

iate

d w

ith th

e A

HR

Q:

•N

ursi

ng re

sear

ch•

Res

earc

h fu

ndin

g •

Too

ls a

nd re

sour

ces;

for e

xam

ple,

palli

ativ

ew

ound

car

e at

the

end

of li

fe•

Lis

t of 1

6 lin

ks fo

r nur

sing

reso

urce

s•

Kee

ping

pat

ient

s saf

e:T

rans

form

ing

the

wor

k en

viro

nmen

t for

nur

ses

Tea

mw

ork

is a

n es

sent

ial c

ompo

-ne

nt in

pat

ient

safe

ty.T

his s

ite c

on-

tain

s a li

nk to

:AH

RQ

’s M

edic

alT

eam

wor

k an

d Pa

tient

Saf

ety:

Com

pete

ncie

s on

know

ledg

e,sk

ill,

and

attit

udes

.The

CN

S ca

n us

eth

ose

com

pete

ncie

s to

stru

ctur

e a

team

app

roac

h to

a n

umbe

r of c

lini-

cal i

nitia

tives

;the

dev

elop

men

t of a

rapi

d re

spon

se te

am is

a g

ood

ex-

ampl

e.In

add

ition

to a

cces

s to

the

onlin

e jo

urna

ls,t

he in

form

atio

nco

ntai

ned

in th

e pa

tient

safe

ty d

oc-

umen

ts is

ext

ensi

ve.

In a

sses

sing

a c

linic

al is

sue,

this

site

prov

ides

link

s to

the

AH

RQ

Evi

-de

nce-

Bas

ed P

ract

ice

Cen

ter,

Na-

tiona

l Gui

delin

es C

lear

ingh

ouse

,N

atio

nal Q

ualit

y M

easu

res C

lear

-in

ghou

se,a

nd o

ther

s.T

he C

NS

can

utili

ze a

ll th

ese

links

to b

egin

est

ab-

lishi

ng a

foun

datio

n of

evi

denc

e fo

ran

y cl

inic

al is

sue.

http

://w

ww

.ahr

q.go

v/qu

al/

erro

rsix

.htm

Age

ncy

for H

ealth

care

Res

earc

h an

d Q

ualit

y (A

HR

Q)

Acc

esse

d:D

ecem

ber 9

,200

8

http

://w

ww

.ahr

q.go

v/ab

out/

nurs

ing

Age

ncy

for H

ealth

care

Res

earc

h an

dQ

ualit

y (A

HR

Q)

Acc

esse

d:D

ecem

ber 9

,200

8

(con

tinu

es)

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 313



Tab

le 9

-6(c

on

tin

ued

)

Web

Sit

eCo

nten

tsCN

S B

enef

its

Cas

e st

udie

s are

pre

sent

ed fr

om se

vera

l dis

ci-

plin

es,w

ith re

view

s by

cont

ent e

xper

ts in

that

disc

iplin

e

Ext

ensi

ve W

eb si

te,s

pons

ored

by

the

Vet

eran

’sA

dmin

istr

atio

n,de

sign

ed fo

r pat

ient

s and

staf

f:

•C

ultu

re c

hang

e•

Patie

nt sa

fety

for p

atie

nts

•A

lert

s and

adv

isor

y ex

ampl

e:pa

per o

n an

ti-co

agul

atio

n vu

lner

abili

ty•

FME

A (f

ailu

re m

ode

and

effe

cts

anal

ysis

)/R

CA

(roo

t cau

se a

naly

sis)

pro

cess

:E

xten

sive

dis

cuss

ion

on F

ME

A a

s it r

elat

esto

hea

lth c

are

•P

ublic

atio

ns in

clud

e “To

pics

in P

atie

nt S

afet

y”•

Patie

nt sa

fety

reso

urce

s,in

clud

ing

info

rma-

tion

on th

e Pa

tient

Saf

ety

Rep

ortin

g Sy

stem

(PSR

S) a

nd h

uman

fact

ors r

esou

rces

•T

oolk

its o

n fa

lls,h

and

hygi

ene,

and

ensu

ring

corr

ect p

atie

nt su

rger

y

Cas

e ex

ampl

es m

ay b

e us

ed to

rein

-fo

rce

the

impo

rtan

ce o

f the

NP

GS.

Rec

ent s

elec

t cas

es il

lust

rate

mis

take

nid

entit

y an

d a

case

of t

rans

ition

failu

re.

Thi

s Web

site

con

tain

s vol

umes

of

use

ful i

nfor

mat

ion

the

CN

S m

ay u

se to

add

ress

the

patie

ntsa

fety

cul

ture

with

in th

e pr

actic

een

viro

nmen

t:•

PSA

T•

Use

of t

he R

CA

pro

cess

to e

valu

ate

fact

ors i

nvol

ved

in a

n er

ror

•H

and

hygi

ene

prog

ram

•Fa

lls p

reve

ntio

n pr

ogra

m•

Patie

nt sa

fety

wor

ksho

p cu

rric

ulum

http

://w

ww

.web

mm

.ahr

q.go

vA

HR

Q M

&M

:Mor

bidi

ty a

ndM

orta

lity

Rou

nds o

n th

e Web

Acc

esse

d:D

ecem

ber 9

,200

8

http

://w

ww

.pat

ient

safe

ty.g

ovN

atio

nal C

ente

r for

Pat

ient

Saf

ety

Acc

esse

d:D

ecem

ber 9

,200

8

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 314



ble

9-6

(co

nti

nu

ed)

Web

Sit

eCo

nten

tsCN

S B

enef

its

•Pa

tient

Saf

ety

Ass

essm

ent T

ool (

PSA

T)

that

exa

min

es si

x el

emen

ts o

f pat

ient

safe

ty:

man

agem

ent a

nd le

ader

ship

,pat

ient

safe

tym

anag

emen

t pro

gram

,Joi

nt C

om-

mis

sion

com

plia

nce,

proc

urem

ent a

nd e

quip

-m

ent m

anag

emen

t,re

calls

and

VA

ale

rts/

ad-

viso

ries

,pat

ient

safe

ty p

olic

ies,

tool

s,an

d ai

ds

Prod

uct r

ecal

lsPr

oduc

t saf

ety

New

s for

hea

lth e

duca

tors

and

stud

ents

Onl

ine

data

base

s:M

aude

,MD

R (m

edic

al d

evic

e re

port

ing)

,M

edw

atch

Haz

ard

sum

mar

ies:

e.g.

,ant

icoa

gula

tion

vuln

erab

ility

Gui

delin

es fo

r com

plet

ing

a he

alth

care

failu

rem

odes

and

eff

ect a

naly

sis

Gui

delin

es fo

r ens

urin

g co

rrec

t sur

gery

The

CN

S pl

ays a

key

role

in p

rod-

uct s

elec

tion

and

eval

uatio

n of

new

prod

ucts

.Whe

n th

e C

NS

has b

een

aske

d to

run

a tr

ial o

f a p

artic

ular

piec

e of

tech

nolo

gy o

r equ

ipm

ent,

the

FDA

dat

abas

e ca

n pr

ovid

e in

-fo

rmat

ion

on w

heth

er th

at p

artic

u-la

r tec

hnol

ogy/

bran

d ha

s bee

nre

port

ed to

the

FDA

as h

avin

g be

endy

sfun

ctio

nal o

r cau

sed

inju

ry to

apa

tient

or s

taff

mem

ber.

In le

adin

g an

initi

ativ

e on

han

dhy

gien

e,th

is W

eb si

te h

as a

Pow

er-

Poin

t pre

sent

atio

n,po

ster

s,ot

her

med

ia m

ater

ials

,and

num

erou

s

http

://w

ww

.fda.

gov

Food

and

Dru

g A

dmin

istra

tion

(FD

A)

Acc

esse

d:D

ecem

ber 9

,200

8

http

://w

ww

.va.

gov/

ncps

/sa

fety

topi

cs.h

tml

Nat

iona

l Cen

ter f

or P

atie

nt S

afet

y(N

CPS

)A

cces

sed:

Dec

embe

r 9,2

008

(con

tinu

es)

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 315



Tab

le 9

-6(c

on

tin

ued

)

Web

Sit

eCo

nten

tsCN

S B

enef

its

Falls

tool

kit

An

exte

nsiv

e ha

nd h

ygie

ne p

rogr

amPa

tient

Saf

ety

Ass

essm

ent T

ool

AH

RQ

and

Am

eric

an M

edic

al A

ssoc

iatio

nna

tiona

l gui

delin

es c

lear

ing

hous

e

tool

s for

the

CN

S to

use

in th

is in

i-tia

tive,

from

cal

cula

ting

the

amou

ntof

wat

erle

ss so

ap to

the

time

it ta

kes

to c

lean

han

ds w

ith th

e w

ater

less

soap

.

CN

Ss c

halle

nged

with

a n

ew p

a-tie

nt p

opul

atio

n sh

ould

star

t by

goin

g to

the

evid

ence

to se

e w

hat

has a

lread

y be

en p

ublis

hed.

Gui

de-

lines

on

this

site

are

evi

denc

e ba

sed.

http

://w

ww

.gui

delin

es.g

ovA

HR

Q a

nd A

mer

ican

Med

ical

Asso

ciati

onA

cces

sed:

Dec

embe

r 9,2

008

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 316



ble

9-7

EXA

MP

LES

OF

WEB

SIT

ES W

ITH

PSI

:REG

ULA

TOR

Y A

GEN

CIE

S

Web

Sit

eCo

nten

tsCN

S B

enef

its

http

://w

ww

.ccf

orpa

tient

safe

ty.o

rgW

HO

Col

labo

rati

ng C

entr

e for

Pa

tien

t Saf

ety

Solu

tion

sA

cces

sed:

Dec

embe

r 9,2

008

Patie

nt S

afet

y Pr

actic

esR

esou

rces

,pat

ient

safe

ty to

ols,

case

s stu

dies

•T

ools

/res

ourc

es in

clud

ing

a lin

k to

app

roxi

-m

atel

y 40

pat

ient

safe

ty W

eb si

tes

•A

war

ds

•C

ase

stud

ies

•Pa

tient

safe

ty g

ood

prac

tices

•A

rtic

les/

new

slet

ter

Faci

litat

es fi

ndin

g pa

tient

safe

ty g

oals

and

prac

tices

by

usin

g dr

op-d

own

men

us•

Cau

ses o

f adv

erse

eve

nts/

type

s of e

vent

s•

U.S

.nat

iona

l pat

ient

safe

ty g

oals

/in

tern

atio

nal p

atie

nt sa

fety

goa

lsPa

tient

safe

ty li

nk,n

ewsl

ette

rL

inks

to p

atie

nt sa

fety

pra

ctic

es,p

rodu

cts a

ndse

rvic

es,a

nd re

sour

ces.

Arc

hive

s ava

ilabl

eon

line

Off

icia

l new

slet

ter:

Col

labo

rati

ons

(qua

rter

ly;e

lect

roni

c)

The

CN

S ob

serv

es th

at th

e cu

lture

of sa

fety

is n

ot in

grai

ned

in th

epr

actic

e ar

ea.T

here

is a

sam

ple

out-

line

for a

pat

ient

safe

ty p

rogr

am.

In in

vest

igat

ing

a se

ntin

el e

vent

via

the

root

cau

se a

naly

sis m

echa

nism

,th

is si

te w

alks

the

CN

S th

roug

h th

eca

uses

of a

dver

se e

vent

s and

type

sof

adv

erse

eve

nts t

hat m

ight

be

unco

vere

d.So

lutio

n se

ts fo

r loo

k-al

ike,

soun

d-al

ike

med

icat

ion

nam

es,p

atie

ntid

entif

icat

ion,

com

mun

icat

ion

dur-

ing

hand

-off

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d pe

rfor

man

ce o

fco

rrec

t pro

cedu

re a

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rect

bod

ysi

te.

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 317



Tab

le 9

-8EX

AM

PLE

S O

F W

EB S

ITES

FO

R E

VID

ENC

E-B

ASE

D P

RA

CTI

CE

Web

Sit

eCo

nten

tsCN

S B

enef

its

http

://w

ww

.ohs

u.ed

u/ep

cO

rego

n E

vide

nced

-Bas

ed P

ract

ice C

ente

rA

cces

sed:

Dec

embe

r 9,2

008

http

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ww

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nabr

iggs

.edu

.au/

abou

t/ho

me.

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na B

rigg

s Ins

titu

teA

cces

sed:

Dec

embe

r 9,2

008

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SU is

an

evid

ence

d-ba

sed

prac

tice

cent

erth

at c

ondu

cts s

yste

mat

ic re

view

of h

ealth

care

topi

cs fo

r fed

eral

and

stat

e ag

enci

es a

nd p

riva

tefo

unda

tions

.The

se re

view

s rep

ort t

he e

vide

nce

from

clin

ical

rese

arch

stud

ies a

nd th

e qu

alit

y of

that

evi

denc

e fo

r use

by

polic

y m

aker

s in

deci

-si

ons o

n gu

idel

ines

Inte

rnat

iona

l Res

earc

h an

d D

evel

opm

ent U

nit,

whi

ch p

rovi

des a

col

labo

rativ

e ap

proa

ch to

the

eval

uatio

n of

evi

denc

e de

rive

d fr

om a

div

erse

rang

e of

sour

ces,

incl

udin

g ex

peri

ence

,exp

er-

tise,

and

all f

orm

s of r

igor

ous r

esea

rch

The

CN

S is

the

lead

er in

the

intr

o-du

ctio

n of

the

conc

epts

of e

vide

nced

-ba

sed

prac

tice.

Eith

er o

f the

se W

ebsi

tes p

rovi

des g

uida

nce

on “w

here

tost

art”

in in

trod

ucin

g ev

iden

ce-b

ased

prac

tice

at th

e be

dsid

e.

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 318


Educating New and Experienced Nurses:Electronic Resources for the CNSPatient safety as a discipline is a relatively new phenomenon. Many nurses, as well asother healthcare providers, did not explore the science of safety and error reduction orthe relationship of culture to patient safety during formal nursing education experi-ences. Nurses may be inclined to consider patient safety as closely aligned with thetraditional five rights of medication administration. These five “rights” include rightpatient, right drug, right dose, right route, and right time. Many nurses will recalllearning these rights by rote as students, and new orientees were often drilled aboutthese rules during clinical experiences involving medication or treatment deliveries.Nurses may continue to view these five rights as the gold standard of error prevention;however, these five rights are best viewed as the desired outcomes of safe medicationpractices (Federico, 2007).They do not offer strategies for nurses interested in achiev-ing these goals other than a rather bewildering perception that error is the result of in-dividual performance and good nurses do not make mistakes (Federico, 2007). Giventhat nurses do not come to work intending to commit errors, opportunities for errorand accident reduction must be more broadly based than relying on drilled processes.

CNSs interested in using creative, evidence-based resources for educating new-to-practice nurses as well as more experienced staff without much formal exposure tohealth safety and quality topics will appreciate the opportunities available throughQuality and Safety Education for Nurses (2007), a comprehensive resource funded bythe Robert Wood Johnson Foundation (see Exemplar 9-2).

Educating New and Experienced Nurses: Electronic Resources for the CNS 319

Exemplar 9-2

Promoting Safety by Influencing New-to-Practice NursesGeralyn Altmiller, EdD, MSN, APRN

Quality improvement and patient safety initiatives are much broader and more evidence-based than suggested by simplistic and systematized rules historically emphasized in basicnursing education. Recognizing the need for change, the Robert Wood Johnson Founda-tion spawned a national movement to change the way that nurses are prepared for patientcare delivery by funding the Quality and Safety in Nursing Education (QSEN) grantthrough the University of North Carolina, Chapel Hill (2005). The grant provided 15pilot schools across the nation with the opportunity to integrate practices for quality im-provement and patient safety standards into their nursing curricula. As this national move-ment to improve preparation in prelicensure education of all nurses grows, recentlygraduated nurses are entering the workforce with varying degrees of competency in ad-dressing patient safety concerns.

The CNS has a particularly important role in bridging the gap between prelicensurenursing education and the first work position of new-to-practice nurses. Providing re-

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 319



sources and opportunities that connect practitioners to nationally accepted standards andby supporting and developing safety initiatives, CNSs model the transformation of nurs-ing practice into a higher quality, safer endeavor.

The Institute for Healthcare Improvement (IHI) Web site (n.d.) contains a wealth ofresources to assist the CNS as she or he supports those new to the profession of nursing.One such resource is Transforming Care at the Bedside (TCAB) (IHI, 2003), an initiativedeveloped to connect nursing education to the vision of improving bedside care for thepatient. Using the easily downloadable TCAB storyboard (IHI, 2008b), the CNS canconnect the newly graduated nurse to the new skill sets being implemented across the na-tion to provide patient-centered care. The storyboard promotes personal accountabilityand situational awareness as tools to avoid codes, reduce readmission rates, prevent falls,and improve patient satisfaction.

At the same Web site, CNSs may access the 5 Million Lives Campaign (IHI, 2008a).This initiative works toward preventing 5 million incidents of medical harm by askinghealthcare institutions to adhere to 12 safety-focused interventions. By clicking the Ma-terials tab, the CNS has access to free slide presentations that demonstrate strategies forimplementing the 12 interventions, along with blueprints for educational presentations tostaff, updates on the latest prevention interventions, and related articles.

An important role of the CNS is to introduce the new language of safety and qualitycare improvement to the new-to-practice nurse or to the uninitiated seasoned profes-sional. Value-added nursing care, which is the care that directly contributes to an improvedoutcome for the patient (such as rounding on the unit), or workarounds, the term thatidentifies routes to circumvent the established work system (obtaining meds from anotherpatient’s drawer rather than the pharmacy), may be terms more commonly used in thework environment but missing from some aspects of nursing education at present, therebycreating a communication barrier for the new graduate RN. To bridge that gap, theAgency for Healthcare Research and Quality (AHRQ) provides a Glossary (n.d.) of cur-rent terms as a resource on its Web site.

Many times new-to-practice nurses are uncomfortable communicating with othermembers of the healthcare team, particularly when they believe a patient concern is notbeing attended to. Improving communication skills can be facilitated by the CNS usinghelpful tools available through the AHRQ such as TeamSTEPPS (AHRQ, 2005). TheTeamSTEPPS site contains free slide show downloads for presentations as well as shortvignettes in high-resolution video that are designed to familiarize healthcare workers withcurrent trends in communication techniques and risk-reduction practices. On the Website, there are many examples of safe communication practices that can be used to increasethe attention of other healthcare team members such as CUS (I’m Concerned, Uncom-fortable, Safety) or DESC (Describe the situation, Express feelings about the situation,Suggest other alternative actions, Consequences of current actions are stated).

The Joint Commission is an organization that is frequently discussed in healthcare set-tings but many new-to-practice nurses do not have a clear understanding of what the JointCommission does or how it functions within the healthcare setting. It is a national organ-ization that accredits healthcare facilities. In doing so, hospitals are graded based on theirability to demonstrate that they follow the standards set by the Joint Commission to main-tain a highly reliable practice setting. Not only does this accreditation assure the public

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Educating New and Experienced Nurses: Electronic Resources for the CNS 321

that the hospital is meeting standards, but it provides a measure that insurance companiesuse to determine their willingness to refer members to that facility. The CNS promotescompliance of the standards when she or he helps staff members understand the value ofaccreditation and the pivotal role of nurses in the process.

Familiarizing new-to-practice nurses with the Joint Commission Web site (n.d.) pro-motes a sense of personal accountability for system improvement to ensure patient safety.The Patient Safety tab provides concrete information regarding the current National Pa-tient Safety Goals, abbreviations that are not acceptable due to high error potential, andextensive materials that can be used to demonstrate and promote patient safety practices.The Sentinel Event tab provides a root cause analysis framework that presents a step-by-step walk through the process. Using this resource, the CNS demonstrates to the new graduate that there are usually multiple factors that contribute to error. The rootcause analysis specifically identifies those factors and frequently reveals that error is at-tributed to systems failure. The CNS empowers the new-to-practice nurse when that in-dividual recognizes that reporting an adverse event can lead to quality improvementbecause only then can the root cause be identified and the system or process be correctedto reduce risk.

In addition, the Joint Commission Sentinel Event tab highlights current alerts. Mostnotable is the alert that workplace intimidation and aggression is a threat to patient safety.The Joint Commission has mandated that all healthcare systems address hostile work en-vironment behavior by January 2009 as a risk-reduction strategy. Many times, new-to-practice nurses are the most vulnerable to intimidation by peers in the workplace as theyhave known knowledge deficits. Intimidation interferes with their acquisition of knowl-edge and skill development. Cognitive rehearsal of shielding responses (Griffin, 2004) hasbeen an effective strategy that the CNS can teach new-to-practice nurses. It enables themto recognize that the intimidating behavior is a result of stress and frustration and not apersonal affront, thereby allowing the new graduate to respond in an intellectual mannerrather than respond emotionally.

The unfolding case study is a learning strategy that has been promoted by QSEN(2007) to increase critical thinking in undergraduate nursing education.This approach canbe used by the CNS to promote critical thinking in new-to-practice nurses by stimulatingreal-world decision making. The CNS can access descriptions of actual workplace adverseevents on the AHRQ’s Patient Safety Network (n.d.) by clicking the Patient SafetyPrimers tab. Based on these descriptions, the CNS can develop unfolding case scenariosthat cultivate critical thinking and decision-making skills. The CNS can utilize the un-folding case study method as a strategy to inform new-to-practice nurses of the availableresources at the institution that should be utilized to achieve a positive outcome for pa-tients in similar situations.

Lastly, the CNS functions as a bridge between research and practice. Many new-to-practice nurses have a familiarity with evidence-based practice but are not sure how it isimplemented in the clinical setting.The Cochrane Collaboration (n.d.) is an internationaldatabase that the CNS can access to retrieve the latest information regarding appropriateinterventions. AHRQ’s National Guideline Clearinghouse (2008) provides recommenda-tions and rating schemes of the strength of evidence for specific diseases and health prob-

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lems. The CNS can promote the use of these sites with new-to-practice nurses as a meansto determine the appropriate care required for their patients.

There are many resources available to the CNS working with new-to-practice nursesthat will support a smooth transition from the prelicensure educational setting to the workenvironment.The CNS needs to recognize the significant role he or she plays in the trans-formation that occurs when a nurse enters the workforce and is confronted with the chal-lenges to provide high-quality, safe patient care in a rapid-paced, constantly evolvingprofession. A toolkit of resources (see Table 9-9) is an invaluable asset.

Table 9-9 TOOLKIT OF INTERNET RESOURCES FOR THE CNS WORKING WITH NEW-TO-PRACTICE NURSES

Resource Web Site Address

AHRQ: GlossaryAHRQ: National Guideline ClearinghouseAHRQ: Patient Safety NetworkAHRQ: TeamSTEPPS

The Cochrane CollaborationIHI: Transforming Care at the Bedside

IHI: Transforming Care at the Bedside Storyboard

IHI: 5 Million Lives Campaign

QSEN Teaching Strategies

The Joint Commission

http://www.webmm.ahrq.gov/glossary.aspxhttp://www.guideline.gov/compare/synthesis.aspxhttp://psnet.ahrq.govhttp://dodpatientsafety.usuhs.mil/index.php?name=News&file=article&sid=31http://www.cochrane.orghttp://www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.htmhttp://www.ihi.org/NR/rdonlyres/F81270CD-B8BC-47D5-B2A6-BDA550096AA9/4252/TCABStoryboardFall2006FINAL.pdfhttp://www.ihi.org/IHI/Programs/Campaignhttp://qsen.org/teachingstrategies/search_strategies#resultshttp://www.jointcommission.org

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Case Study: Development and Implementationof a Rapid Response Team

The majority of hospitalized patients experience antecedent physiologic abnormali-ties prior to cardiopulmonary arrests. When these abnormalities occur outside an in-tensive care unit, they are often unrecognized or are not responded to in a timely,appropriate manner by the hospital care team. This may be partially due to a reducedawareness of the importance of these physiologic abnormalities in the spectrum ofdisease or perhaps due to competing clinical responsibilities on the part of the physi-cian or nurse practitioner. This scenario becomes increasingly complex in academicmedical centers, as the most junior-level physicians typically perform the triage, clin-ical management, and communication around these critical events.

A rapid response team (or medical emergency team) is a team of critical care clini-cians who can respond to the bedside of a deteriorating patient before a catastrophicevent (e.g., cardiac or respiratory arrest) occurs. The goal of the team is to reduce thenumber of cardiac arrests and unanticipated intubations outside the ICU throughclinical staff members’ heightened awareness to signs of physiologic deterioration andthrough the development of a mobile team that can provide immediate critical care tothe bedside.

The IHI Save 100,000 Lives campaign had designated the development of a rapidresponse team as one of the six interventions to decrease unanticipated mortality. Thesubsequent 5 Million Lives campaign, launched in December 2006, continues to ad-vocate for rapid response teams and the other five original interventions while alsoadding new interventions selected to reduce harm (IHI, 2008a). IHI provides manyuseful, effective, and cost-efficient resources for CNSs interested in beginning pro-grams designed to improve healthcare safety. It is an “absolute must” Web site thatshould be easily accessible to CNSs and professional staff.

Kleinpell and Gawlinski (2005) have developed a nine-step process to guide theCNS in planning and implementing an outcomes-driven initiative. Table 9-10 de-scribes an example of a process to establish a rapid response team, one of the recom-mendations of the IHI Save 100,000 Lives campaign and continued with the 5 Million Lives campaign. The model can be used to develop other safety-relatedinterventions, such as programs to decrease central line infections and ventilator-associated pneumonia (IHI, 2008b).

Skill breadth, competence, and familiarity with multiple roles uniquely positionsthe CNS to play a pivotal role in patient safety. The CNS is able to integrate knowl-edge of patient safety with evidence-based practice to improve outcomes (Phillips,2005). The role of the CNS in patient safety will continue to expand exponentially;thus, the introduction of the CNS into the world of patient safety is just the begin-ning of a successful journey toward creating a culture of safety, integrated withevidenced-based practice to produce the highest quality of care possible.

Case Study: Development and Implementation of a Rapid Response Team 323

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Tab

le 9

-10

DEV

ELO

PIN

G A

RA

PID

RES

PO

NSE

TEA

M

Step

s in

the

Pro

cess

Inte

rven

tion

s

Fin

d/Id

enti

fy o

utco

me

vari

able

s tha

tth

e C

NS

can

impa

ct.

CN

S Sk

ills/

Rol

es:

Col

labo

rato

r,cl

inic

al le

ader

,res

earc

h(H

amri

c,19

89)

Org

aniz

e a

team

:Who

are

the

key

stak

ehol

ders

?C

NS

Skill

s:C

hang

e ag

ent,

colla

bora

tor,

role

mod

el(H

amri

c,19

89)

Cla

rify

cur

rent

kno

wle

dge

of th

epr

acti

ce is

sue

to b

e re

solv

ed.

CN

S Sk

ills/

Rol

es:

Res

earc

h,co

llabo

rato

r,pa

tient

advo

cate

,cha

nge

agen

t(H

amri

c,19

89)

1.D

ecre

ase

code

s/ai

rway

em

erge

ncie

s out

side

the

ICU

.2.

Dec

reas

e un

plan

ned

tran

sfer

s to

the

ICU

.3.

Impr

ove

nurs

e/ca

regi

ver s

atis

fact

ion

by p

rovi

ding

a su

ppor

t sys

tem

for t

hest

aff t

o ca

ll w

hen

thei

r pat

ient

is in

dis

tres

s.

1.E

ngag

e se

nior

lead

ersh

ip:p

hysi

cian

s,nu

rsin

g,ad

min

istr

atio

n.2.

Oth

er st

akeh

olde

rs:n

ursi

ng,h

ouse

staf

f and

trai

ning

dire

ctor

s,re

spir

ator

yth

erap

y,ph

arm

acy.

1.Pr

epar

atio

n ph

ase

incl

udes

acc

urat

e co

llect

ion

of b

asel

ine

leve

ls o

f ser

ious

adve

rse

even

ts a

nd c

ardi

ac a

rres

ts.

2.W

hat p

erce

nt o

f cod

es o

r air

way

em

erge

ncie

s occ

ur o

utsi

de th

e IC

U?

3.W

hat p

erce

nt o

f cod

es o

r air

way

em

erge

ncie

s are

acc

ompa

nied

by

clin

ical

ante

cede

nts?

4.W

ere

the

clin

ical

ant

eced

ents

reco

gniz

ed?

5.W

hat i

s the

und

erst

andi

ng o

f the

staf

f of e

arly

det

ectio

n of

phy

siol

ogic

dete

rior

atio

n?6.

Wha

t com

mun

icat

ion

stra

tegi

es a

re u

tiliz

ed to

acc

urat

ely

and

conc

isel

y ge

tth

e m

essa

ge a

cros

s?7.

SBA

R (s

ituat

ion,

back

grou

nd,a

sses

smen

t,re

com

men

datio

n).

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 324


Case Study: Development and Implementation of a Rapid Response Team 325Ta

ble

9-1

0(c

on

tin

ued

)

Step

s in

the

Pro

cess

Inte

rven

tion

s

Und

erst

and

sour

ces o

f var

iati

on.

CN

S Sk

ills/

Rol

es:

Res

earc

h,co

nsul

tant

,edu

cato

r,pa

tient

advo

cate

(Ham

ric,

1989

)

Sele

ct p

ract

ices

and

stra

tegi

es fo

rim

prov

emen

t.C

NS

Skill

s/R

oles

:C

linic

al le

ader

,edu

cato

r,ch

ange

age

nt(H

amri

c,19

89)

Pla

n fo

r im

plem

enta

tion

.C

NS

Skill

s/R

oles

:C

linic

al le

ader

,rol

e m

odel

,edu

cato

r,co

nsul

tant

(Ham

ric,

1989

)

1.W

hen

clin

ical

det

erio

ratio

n is

reco

gniz

ed,h

ow is

that

clin

ical

pre

sent

atio

nre

spon

ded

to b

y th

e nu

rse?

Hou

se st

aff?

2.W

hat b

arri

ers p

reve

nt th

e be

dsid

e pr

actit

ione

r fro

m c

allin

g fo

r hel

p (c

allin

gth

e at

tend

ing

phys

icia

n) w

hen

his o

r her

gut

inst

inct

sugg

ests

it is

the

righ

tth

ing

to d

o?

1.E

stab

lish

a tr

igge

r too

l to

prov

ide

the

staf

f with

a c

oncr

ete

refe

renc

e fo

r whe

nto

cal

l the

team

.Inc

lude

at l

east

one

cav

eat t

hat r

elat

es to

that

“gut

feel

ing.

”2.

Des

ign

the

team

bas

ed o

n cu

rren

tly a

vaila

ble

pers

onne

l.T

eam

con

stru

ctio

nva

ries

from

hos

pita

l to

hosp

ital.

Tea

ms a

re a

s sim

ple

as th

e IC

U c

harg

e nu

rse

and

resp

irat

ory

ther

apis

t to

as c

ompl

ex a

s an

eigh

t-m

embe

r tea

m le

d by

an

inte

nsiv

ist.

3.D

evel

op p

roto

cols

for p

ract

ice

if ne

eded

.4.

Def

ine

team

role

dur

ing

activ

atio

n.5.

Prov

ide

team

lead

ersh

ip.

6.A

sses

s,in

terv

ene,

stab

ilize

,arb

itrat

e to

app

ropr

iate

leve

l of c

are.

7.C

omm

unic

ate,

com

mun

icat

e,co

mm

unic

ate!

8.E

stab

lish

a fe

edba

ck m

echa

nism

for t

he re

spon

se te

am to

feed

back

info

rma-

tion

to th

e te

ams t

hat m

ade

the

calls

.

1.D

evel

op e

duca

tiona

l cur

ricu

lum

.2.

Bed

side

pra

ctiti

oner

s.3.

Res

pond

ing

team

.

(con

tinu

es)

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 325



Tab

le 9

-10

(co

nti

nu

ed)

Step

s in

the

Pro

cess

Inte

rven

tion

s

Pla

n fo

r im

plem

enta

tion

.(c

ontin

ued)

Do

the

inte

rven

tion

s acc

ordi

ng to

the

plan

.C

NS

Skill

s/R

oles

:R

esea

rch,

educ

atio

n,ch

ange

age

nt,r

ole

mod

el,e

xper

t pra

ctiti

oner

(Ham

ric,

1989

)

4.P

hysi

cian

s,nu

rses

,the

rapi

sts,

tech

nici

ans,

virt

ually

any

one

who

com

es in

cont

act w

ith th

e pa

tient

,pag

e op

erat

ors.

5.D

ata

man

agem

ent.

6.D

ocum

enta

tion

whi

le o

n th

e sc

ene.

7.W

hy te

am w

as c

alle

d,w

ho c

alle

d,in

terv

entio

ns,o

utco

mes

,com

mun

icat

ion

with

att

endi

ng p

hysi

cian

.8.

Log

and

ana

lyze

cal

ls a

nd “m

isse

d op

port

uniti

es.”

9.P

ublic

rela

tions

(nee

d at

leas

t fiv

e ve

nues

to g

et th

e w

ord

out)

.10

.Po

ster

s,fly

ers.

11.

Gra

nd ro

unds

for n

ursi

ng,m

edic

ine,

any

depa

rtm

ent.

12.

Pres

ent a

t dep

artm

enta

l mee

tings

.13

.D

iscu

ss a

t uni

t-ba

sed

mee

tings

.14

.“R

oads

how

,”or

trav

elin

g in

serv

ice,

brin

ging

the

info

rmat

ion

to th

e st

aff o

n th

eflo

ors.

1.O

pera

tiona

lize

team

as p

lann

ed.

2.P

hase

I or

pilo

t for

a d

efin

ed p

erio

d of

tim

e.3.

Ana

lyze

eac

h ca

ll to

iden

tify

area

s of o

ppor

tuni

ty.

4.C

linic

al re

view

:Why

wer

e ca

lls p

lace

d? W

hat h

appe

ned

at th

e be

dsid

e?5.

Ope

ratio

nal r

evie

w:D

id e

very

thin

g go

as p

lann

ed? D

id th

e te

am sh

ow u

p?

Did

the

equi

pmen

t wor

k? D

id y

ou n

eed

som

ethi

ng th

at y

ou d

idn’

t hav

e?

Did

you

nee

d so

meo

ne w

ho w

as n

ot a

vaila

ble?

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 326


Sour

ce:K

lein

pell

and

Gaw

linsk

i,20

05;P

hilli

ps,2

005.

Case Study: Development and Implementation of a Rapid Response Team 327Ta

ble

9-1

0(c

on

tin

ued

)

Step

s in

the

Pro

cess

Inte

rven

tion

s

Che

ck/a

naly

ze/r

evie

w d

ata

CN

S Sk

ills/

Rol

es:

Col

labo

rato

r,re

sear

cher

(Ham

ric,

1989

)

Put

impr

ovem

ent i

nto

effe

ct,h

old

gain

s,an

d es

tabl

ish

less

ons l

earn

ed.

CN

S Sk

ills/

Rol

es:

Cha

nge

agen

t,co

llabo

rato

r,cl

inic

alle

ader

,rol

e m

odel

,pat

ient

adv

ocat

e(H

amri

c,19

89)

1.R

evie

w d

ata

from

eac

h ev

ent f

or c

linic

al a

nd o

pera

tiona

l eff

icie

ncie

s.2.

Com

pare

pre

inte

rven

tion/

post

inte

rven

tion

data

for c

hang

es in

rate

s of c

odes

outs

ide

the

ICU

,una

ntic

ipat

ed tr

ansf

ers t

o th

e IC

U,a

nd u

nant

icip

ated

mor

talit

y.

1.E

valu

ate

proc

ess a

nd m

ake

appr

opri

ate

chan

ges t

o tr

igge

r too

l,do

cum

enta

-tio

n to

ol,t

eam

not

ifica

tion

proc

ess,

or te

am a

ctiv

ities

at t

he b

edsi

de.

2.C

ontin

ue to

revi

ew d

ata

to e

stab

lish

succ

ess o

f pro

gram

.3.

Invo

lve

staf

f in

satis

fact

ion

surv

ey to

asc

erta

in th

e ef

fect

on

nurs

ing

satis

fact

ion.

61141_CH09_291_332.qxd 7/30/09 11:42 AM Page 327



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dards of professional performance for the acute and critical care clinical nurse specialist. AlisoViejo, CA: Author.

American Association of Critical-Care Nurses (AACN). (2005). AACN standards for es-tablishing and sustaining healthy work environments. A journey to excellence. Retrieved July7, 2006, from http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandards.pdf

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