curry college nursing department workarounds as identified by senior preceptored students qsen...
TRANSCRIPT
Slide 1Cathleen C. Santos, MSN, RN
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Curry College: QSEN Strategies
1: Ask faculty to add “level of evidence” on all PowerPoint slides illustrating clinical studies application in classroom teaching (EBP).
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WWW.CURRY.EDU
3: Adopt prepared institutional (BIDMC) resources, such as adverse event flow sheets, as teaching tools in selected nursing courses (S, QI).
4: Design and use student cards/tags for medication rights, SBAR, Rapid Response Team triggers (S).
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WWW.CURRY.EDU
6: Revise the Critical Objectives for Clinical Evaluation adapting an institutional systems focus with the assistance of the practice partner (S, PCC).
7: Develop clinical assignments to assist students in identification of potential unsafe nursing practices including “work arounds”(S).
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WWW.CURRY.EDU
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AHRQ Glossary:
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Introduced:
4. Please list 3 examples of workarounds
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Cold classrooms – faculty/students wear layers
Scheduling classrooms – several administrators
Late withdrawals – calls Registrar directing
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Second-order problem solving viewed as time consuming
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Patricia Folcarelli, PhD, RN Director of Professional Practice
Beth Israel Deaconess Medical Center (BIDMC)
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Educational Retreat Content 10-02-07
Patient Safety Series Film: “When Things Go Wrong: Voices of Patients and Families”
Swiss cheese model (Reason, 1991)
Blunt end and sharp end
Hindsight bias
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Accountability Determination Model
Team Structure and Climate
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National Quality Forum – “Never Events”
Communicating in the Aftermath of an Adverse Event
Process for Reporting and Analyses - Adverse Event
Transparency - Adverse Event
QSEN - standing department agenda item
> 50% faculty attended multidisciplinary QI/RCA
clinical conferences hosted by BIDMC
Developed an appreciation for Transparency
Revised Critical Objectives for Clinical Evaluation
Tucker, A. L. and Edmondson, A. C. (2003).
*
Lucian L. Leape, M.D.
*
1. AHRQ Glossary of Safety and Quality-Related Terms
2. Have you discussed workarounds with your preceptor
3. Were you able to identify any occurring on your unit
4. Please list 3 examples of workarounds
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Failure to observe precautions
Hourly checks not performed but documented
Failure to confirm code cart security
*
Failure to use Pyxis system as intended
Withdrawing medication prior rating pain level
Failure to confirm patient ID against MAR
Leaving medications at bedside
*
Conflict noted between optimal/actual clinical nursing behaviors
*
PowerPoint /Lecture/ Blackboard Documents
Interactive classroom RCA exercises
AHRQ Glossary of Safety and Quality-Related Terms
Senior externship seminar discussions re: WA
*
Clinical Response Sheets:
Quality Improvement – clinical setting
Seminar/Clinical discussions
Duplicate QSEN efforts with other agencies
*
*
NSG 2041 Adult Health I Sophomore
NSG 2051 Maternal-Newborn Junior
*
Access to BIDMC multidisciplinary QI/RCA meetings
“We Hit the Home Run”
Lucian L. Leape – guest speaker
Harvard School of Public Health
*
*
Curry College: QSEN Strategies
1: Ask faculty to add “level of evidence” on all PowerPoint slides illustrating clinical studies application in classroom teaching (EBP).
*
WWW.CURRY.EDU
3: Adopt prepared institutional (BIDMC) resources, such as adverse event flow sheets, as teaching tools in selected nursing courses (S, QI).
4: Design and use student cards/tags for medication rights, SBAR, Rapid Response Team triggers (S).
*
WWW.CURRY.EDU
6: Revise the Critical Objectives for Clinical Evaluation adapting an institutional systems focus with the assistance of the practice partner (S, PCC).
7: Develop clinical assignments to assist students in identification of potential unsafe nursing practices including “work arounds”(S).
*
WWW.CURRY.EDU
*
*
AHRQ Glossary:
*
Introduced:
4. Please list 3 examples of workarounds
*
Cold classrooms – faculty/students wear layers
Scheduling classrooms – several administrators
Late withdrawals – calls Registrar directing
*
Second-order problem solving viewed as time consuming
*
Patricia Folcarelli, PhD, RN Director of Professional Practice
Beth Israel Deaconess Medical Center (BIDMC)
*
Educational Retreat Content 10-02-07
Patient Safety Series Film: “When Things Go Wrong: Voices of Patients and Families”
Swiss cheese model (Reason, 1991)
Blunt end and sharp end
Hindsight bias
*
Accountability Determination Model
Team Structure and Climate
*
National Quality Forum – “Never Events”
Communicating in the Aftermath of an Adverse Event
Process for Reporting and Analyses - Adverse Event
Transparency - Adverse Event
QSEN - standing department agenda item
> 50% faculty attended multidisciplinary QI/RCA
clinical conferences hosted by BIDMC
Developed an appreciation for Transparency
Revised Critical Objectives for Clinical Evaluation
Tucker, A. L. and Edmondson, A. C. (2003).
*
Lucian L. Leape, M.D.
*
1. AHRQ Glossary of Safety and Quality-Related Terms
2. Have you discussed workarounds with your preceptor
3. Were you able to identify any occurring on your unit
4. Please list 3 examples of workarounds
*
*
Failure to observe precautions
Hourly checks not performed but documented
Failure to confirm code cart security
*
Failure to use Pyxis system as intended
Withdrawing medication prior rating pain level
Failure to confirm patient ID against MAR
Leaving medications at bedside
*
Conflict noted between optimal/actual clinical nursing behaviors
*
PowerPoint /Lecture/ Blackboard Documents
Interactive classroom RCA exercises
AHRQ Glossary of Safety and Quality-Related Terms
Senior externship seminar discussions re: WA
*
Clinical Response Sheets:
Quality Improvement – clinical setting
Seminar/Clinical discussions
Duplicate QSEN efforts with other agencies
*
*
NSG 2041 Adult Health I Sophomore
NSG 2051 Maternal-Newborn Junior
*
Access to BIDMC multidisciplinary QI/RCA meetings
“We Hit the Home Run”
Lucian L. Leape – guest speaker
Harvard School of Public Health
*