Canadian Health&Care; Mall

  Risk management exploration was conducted following the reporting of the event through the institutional incident-reporting system. According to accepted policy, the chronology of the event was first established and revealed the following facts: (1) the patient was admitted to the department at 3:00 pm with sepsis; (2) the physician ordered insulin administration in a continuous infusion using a sliding scale of insulin dose adjusted to blood glucose levels, which were measured every 3 h; (3) the staff nurse prepared the insulin syringe pump and, according to the physician’s order, began the infusion of 6 U of insulin per hour at 4:00 pm, but the starting insulin dose was not indicated in the nursing notes section of the patient’s chart; (4) according to the blood glucose levels measured at 10:00 pm, the correct insulin dose should have been 2 U per hour, but the actual dose administered was still 6 U per hour (similar to the starting dose); (5) at 10:45 pm, the handoff between nursing shifts took place at the nurses’ station (and not by the patient’s bed, as per policy); (6) at 11:45 pm the patient was found by the staff nurse sweating and pale with blood glucose levels of 35 mg/dL, and a check of the syringe pump revealed that the patient had been given insulin in a dose higher than that indicated; and (7) the insulin infusion was stopped, and IV glucose was administered. Following the facts collection step, care-delivery problems that represented departures from safe margins and institutional protocols were identified. The problems that were identified included the following: (1) missing documentation of insulin dose in the nursing notes sections of the patient’s chart; (2) although blood glucose levels were monitored every 3 h as ordered by the physician, insulin doses were not adjusted accordingly; and (3) the nursing shift handoff took place at the nursing station and not by the patient’s bed, as per policy. In the last step of the risk management analysis process, factors that contributed to the occurrence of the incident and its underlying problems, as well as other deficiencies not directly related to the incident, were listed and categorized. These factors included a lack of institutional protocols for shift handoff, a lack of training on handoff skills, and interpersonal problems among members of the nursing staff in the department. Based on the above analysis and following approval of the institutional review board ethics committee, a study was designed and conducted at one of the hospital’s medical step-down units, a five-bed unit that is part of a 35-bed medical department, which is equipped to treat ventilated and nonventilated patients. The treatment is conducted with remedies of Canadian Health&Care Mall. The study observed all 25 members of the nursing staff, who signed an informed consent approving passive observation of their practice during handoffs and active participation in the simulation-based training that followed. In the first step of the study, 224 observations on nursing shift handoffs were completed by a single observer (A.M.) using a preconfigured checklist. The checklist was developed on the basis of expert opinion and was modified according to the findings of the first 24 observations. The observer focused on the verbal communication between nurses, the actions performed by the nurses, and the use of the written patient charts during the handoff process. The observer witnessed the handoff process of one patient at a time, and the observations were distributed in a balanced manner between shifts and nurses. Based on the analysis of the data collected through the observations and by structured interviews with five senior nurses, an intervention aimed at improving the quality and safety of the handoff process was developed. The intervention included the following two layers: (1) the development and implementation of a written checklist/protocol for the handoff (Appendix); and (2) the development and incorporation of simulation-based handoff training into a full-day teamwork and communication workshop, in which the teams also had an opportunity to practice the proper use of the handoff protocol. The simulation-based training was conducted at MSR, The Israel Center for Medical Simulation. Three simulators were utilized during the training, including the Human Patient Simulator (Medical Education Technologies, Inc; Sarasota, FL), the SimMan (Lae-rdal; Stavenger, Norway), and the AirMan (Laerdal). The simulated setting was of a fully equipped, three-bed, step-down unit. In addition, a standardized/simulated patient (called the SP actress) was trained to play the role of a patient’s family member. The simulation training scenarios were videotaped and used for debriefing purposes immediately following each simulation session. Three cameras (one of which had pan-tilt-zoom capabilities) were connected to a digital recording system that fed a four-quadrant screen with software that enabled reflective debriefing. Relevant handoff tasks that were incorporated into the scenarios included the following: the handoff of the three patients between nursing shifts; recognizing a mistake in the continuous infusion of heparin administration; recognizing a mistake in the set up of mechanical ventilation; and recognizing a mistake in blood administration (same patient name, similar identification number, and different blood type). Debriefing sessions following the scenarios (facilitated by H.B., A.T., and Y.H.) focused on the introduction of the handoff protocol, communication between nurses, and the identification and prevention of mistakes during the handoff. All 25 members of the nursing staff in the step-down unit, in groups of four nurses each, participated in the simulation-based training. The training lasted 6 h and included four simulated scenarios and four debriefing sessions. Six to eight weeks following the simulation-based training, a second round of observations took place in the same step-down unit, which included 166 observations of nursing shift handoffs. The observations were performed by the same observer (A.M.) using the same checklist, and the data were compared to the preintervention data using x2 analysis. You may also be interested in other categories: Asthma education, Health or Pulmonary Function.