Safety Culture Survey Results - Patient hand offs and non-punitive response to errors

ICU team participates in change of shift whiteboard report
ICU team participates in change of shift whiteboard report

As part of Brigham and Women’s Faulkner Hospital’s commitment to patient safety, last year we partnered with Pascal Metrics to conduct a survey-based assessment of our hospital patient safety culture. The information gathered is of great importance because an organization’s beliefs and attitudes about patient safety provide an indication of the likelihood of errors and adverse events. Based on staff feedback, it was clear that staff felt there were areas for improvement at BWFH. Departments throughout the hospital have been working to meet with staff and better understand the feedback from the survey. Below you’ll read about two important patient safety topics that were concerns during the survey: patient hand offs and non-punitive response to errors.

Patient Hand Offs

No one person can work all the time. In the hospital setting, staff changes are necessary for physicians, nurses and support staff. But what does a change of shift mean for the patient who is staying overnight or even longer? Unfortunately, it can mean critical information regarding their care may not get communicated fully from one shift to the next.

From the kitchen to the bedside to the Pharmacy, every change of shift or hand off between staff within a shift has the potential to impact patient care.

In the Food and Nutrition Department, a dietitian might have nutrition or meal information regarding a patient that is discussed verbally and doesn’t get documented in the medical record. When the next dietitian works with the patient, that key information is lost. “We realized that while the daily Partners eCare report lists necessary clinical information, some pertinent information related to food and nutrition may not be included in the medical record. The dietitians will now make notes on that report to communicate different nuances about the patient for the next dietitian that will be covering that patient,” says Director of Food and Nutrition Susan Langill, RD, LDN. The team also has a whiteboard in the diet office where they can leave notes for one another, for the call center and for the tray passers.

In the ICU, a similar system is being used. “We implemented a change of shift whiteboard report during which both oncoming and off-going shifts congregate at the whiteboard and give a brief update on every patient in the ICU,” says ICU Nurse Director Pat Marinelli, MSN, RN, NP. The team even has icons that they can stick on the whiteboard to improve cues for the staff. For example, they use a small car to mean the patient is traveling off the floor. This helps the staff as a whole get a picture of all patients in the ICU rather than just focus on the two to which they are assigned. In terms of direct provider to provider hand offs, discussion revealed that there were issues related to inexperience using the new I-PASS format. To help, education was provided at an ICU Competency Day regarding the use of the I-PASS format.

Similarly, the Pharmacy staff expressed concern over hand offs from the night shift to the day shift. Director of Pharmacy Services Joseph O’Day, MBA, RPh, decided to implement more formal communication between the shifts. Staff now document their hand offs by cosigning a log book. The book creates accountability and allows for tracking implementation of the new process.

Non-Punitive Response to Error

As humans, we all make mistakes. In a hospital setting, a simple human error can have very serious consequences for the patient. That’s why staff at all levels at BWFH are encouraged to report errors or near miss events into the patient safety reporting system, RL Solutions. In doing so, system issues can be addressed and changes can be made to close gaps in safe patient care. The system is not intended to record mistakes for the purpose of disciplining staff. However, the Safety Culture Survey results indicated that staff were worried that the system would be used in a disciplinary manner and some are scared to admit they’ve made a mistake for fear of punishment.

At BWFH, we work hard to foster a Just Culture. This means the working environment should be a place where you can openly talk about errors and system problems without fear of punishment. In the kitchen, ICU, Pharmacy and other work areas, steps are being taken to make sure staff understand the concept of Just Culture and non-punitive response to error.

“It’s been helpful for me to go through Just Culture training,” says Langill. By gaining a better understanding of the concept, she’s able to better communicate with her staff the importance of safety incident reporting. A main source of anxiety among her staff is passing the wrong tray to the patient. Tray passers are expected to use two patient identifiers when delivering meals, but sometimes the patient is out of their bed or asleep when the tray passer arrives. After taking Just Culture training, Langill has changed her approach in these situations. “We now talk about the road blocks to being able to do two patient identifiers and how we can overcome them.”

Marinelli says, “My staff expressed concern that advances in technology creates electronic records that are being stored about their performance and will be used as tools to discipline them.” Audits of documentation within the new Partners eCare record were perceived to be punitive rather than the basis for education. To better understand this, Marinelli invited Director of Patient Safety, Quality, Infection Control and Accreditation Christi Barney to meet with staff about safety incident reporting. Marinelli has also committed to focusing on positives before addressing concerns with her staff. “I am trying to start off with positive things. Do congratulations. We’ve had ‘fall free’ parties. There are a lot of changes happening here but it is easy to get focused on what is not working well,” she says.

In the Pharmacy, O’Day is working to improve communication with staff around medication errors. “It’s something we talk about all the time at Pharmacy and Therapeutics Committee meetings. But we don’t talk about them enough with the staff,” he admits. Going forward, O’Day is including a medication safety discussion at every staff meeting and documenting these discussions in his staff meeting minutes. And when it comes to reporting medication errors, he tells his staff not to cover them up. Reporting takes courage, but it’s necessary.

In the coming months, additional departments will review their discussions of the Safety Culture Survey data and local work on addressing issues raised by their survey results. In addition to other work group plans to address hand off communication and non-punitive response to error, groups are working on communication between departments and teamwork within departments.

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