Nurses Make the LEAP: Improving Patient
Safety at Hospital X
Jeanne Poindexter, BSN, MSA, CPHRM, CPHQ
VCU Patient Safety Fellowship
To improve critical thinking in nurses in Hospital
X by giving insight into what critical thinking is,
providing instruction, feedback and practice to
improve clinical decision-making while
describing the relationship between the quality
(safety) of patient care and the critical thinking
and judgment ability of the nurses providing that
• IOM: To Err is Human: Building a Safer
Health System - 1999
• IOM: Crossing the Quality Chasm: A new
Health System for the 21st
Century - 2000
• Board of Directors Retreat – Fall 2000
• Multidisciplinary design group
• Physician champion
• Facility-wide focus on reduction of
• Medication Safety Plan
• Plan for Patient Safety
– Encourages recognition & acknowledgement of risk
to patient safety & medical errors
– Initiates actions to reduce these risks
– Encourages internal reporting
– Focuses on processes and systems
– Minimizes blame or retribution for involvement
– Encourages organizational learning and supports
sharing of knowledge
– Challenges leaders to be responsible for fostering safe
Focus on Key Areas
• Culture and reporting
• Medication practices
• Staff skill & knowledge
• Created P&P related to:
– Nursing practice
– Peer review
– Medication practices
– Monitoring, reporting, & measuring
• Created tools for communication,
educational sessions, other materials
What was missing?
Before any of this would work, we
had to improve error detection,
analysis, and increase reporting of
errors, near misses, and other safety
issues and then reporting results or
actions taken back to staff.
How did we do this?
• Hospital-wide education
• Implementation of computerized occurrence
• Standardization of event codes
• Risk management and CQI team reports
• Newsletter spotlights, staff meetings
• Poster presentations, etc.
Scope of Problem
• Hospital X
– Analysis of occurrence reports
– Claims analysis
– Patient complaints
– Intensive investigation of sentinel events and
What was our goal?
• To increase the effectiveness of health care
team collaboration by improving
communication and improve quality of care
provided thereby reducing risk exposure
• IOM reports, QuIC
• Critical thinking—Benner, NLN, Nurse
• Reporting of errors—Medicare,
underreporting, near miss reporting,
• Organizational culture—Beyond Blame,
• Patient satisfaction with healthcare—The
Commonwealth Fund Survey
– Critical thinking
– Professional development
– Improved quality of care
– Increased competence
– Decrease patient events
– Decrease claims
– Decrease patient complaints
Table 1 Patient Safety Activities
Objective Action Tasks
To form a “culture of
Fully implement computerized occurrence reporting system.
Adapt reporting system and change policy to include “near misses”, patient safety concerns, patient
Conduct intensive analysis of patient events and near misses to identify underlying systems issues.
Provide feedback on sentinel event alerts, response to issues and lessons learned.
Re-structure Patient Safety Committee to be more inclusive and organizational structure for reporting.
Provide patient safety education for all new and existing employees.
“LEAP” –ongoing recognition of safety and quality innovations.
Create non-punitive environment and open discussion of errors.
Leadership leads the way with commitment to informing the patient of errors and providing public
education.To provide for staff
Rejuvenate and revise preceptor and mentor programs to allow for education and guidance through
orientation and beyond.
Support education and quality activities with Education coordinator and Outcomes Manager.
Provide continuing education through regularly scheduled in-services, staff meetings, closed claim and
case study reviews, poster presentations and newsletter articles.
Supplement educational activities with critical thinking vignettes via electronic mailings, “grand rounds”,
and development of cognitive aids.
Provide quick reference materials – handbook targeting high priority or problem prone patient safety
Identified patient safety coordinator, developed role and responsibilities.
Revised role and membership of Patient Safety Committee.
Developed Nurse Practice Council and charter.
Medical Care Evaluation Committee-- Restructure medical staff peer review.
Developed policy and procedure and implemented process for Nurse Peer Review.
Developed clinical protocols for at-risk patient populations.
Preparing for implementation of electronic Medication Administration Record with go-live date in Oct
De-centralized pharmacy staff.
Developed or revised policies and procedures for high-risk medications and procedures.
• No quick fix
• Multidimensional solution to complex problem
• Start at the top
• Leadership commitment—manpower, resources
• Modeling—non-punitive attitudes, patient-
• Proactive vs. reactive; prevention vs.
• Active participation
Improved reporting, what’s next?
• Creating a culture of safety
– Report near misses, concerns, complaints
– Intensive analysis
– Provide FEEDBACK
– Patient Safety Committee & Nurse Practice
– House-wide safety education
– LEAP Risk & Quality join forces
– Non-punitive, open discussion
– Informing the patient
BOARD OF TRUSTEES
MEDICAL EXECUTIVE COMMITTEE
QUALITY COUNCIL MEDICAL STAFF DEPARTMENTS
JOHN RANDOLPH MEDICAL CENTER
4/03Q U A L I T Y A N D S A F E T Y M A N A G E M E N T R E P O R T I N G
C O R E M E A S U R E S C U S T O M E R S E R V I C E
R E S U S C I T A T I O N
O U T C O M E S
P E R C
N D N Q I M R R E V I E W
C O M M I T T E E
U T I L I Z A T I O N
R E V I E W
P A I N T E A M
M O R T A L I T Y I C U / C C U
C O M P L I C A T I O N S N U R S E P E E R
R E V I E W
N R M I
N U R S E P R A C T I C E C O U N C I L
F A L L S M E D I C A T I O N S A F E T Y
R E S T R A I N T S I O P
M E D I C A L A L A R M S I N F E C T I O N
C O N T R O L
P A T I E N T
O C C U R R E N C E S
E X E C U T I V E
S A F E T Y
R C A / S E N T I N E L
E V E N T S
F M E C A
S T A F F I N G
E F F E C T I V E N E S S
S T A F F O P I N I O N S
H I G H R I S K
P O P U L A T I O N C A R E
P A T I E N T S A F E T Y C O M M I T T E E
M R R E V I E W
C O M M I T T E E
P I T E A M S
R E G U L A T O R Y &
C O M P L I A N C E A U D I T
R E S U L T S
R I S K M A N A G E M E N T R E P O R T
Q U A L I T Y C O U N C IL
M E D I C A L C A R E E V A L U A T I O N
M E D I C A L S T A F F D E P A R T M E N T S
M E D I C A L E X E C U T I V E C O M M I T T E E
B O A R D O F D I R E C T O R S
What’s after culture?
• Staff competence
– Preceptor & mentor programs
– Educational activities—regularly from
educational services, risk and quality
– Closed claim reviews, case study, critical
thinking vignettes, cognitive aids
– Quick reference materials—handbook of
problem prone patient safety issues
Last but not least…
• Infrastructure, processes and systems
– Patient safety coordinator
– Revised Patient Safety Committee
– Developed Nurse Practice Council, Nurse Peer Review
– Restructured Medical Staff peer review—Medical Care
– Clinical protocols
– Preparing for E-MAR
– De-centralized pharmacy staff
– Review and revision of policies for high risk medications
– Leadership involvement
• All nurses practicing at Hospital X in
patient care areas. Nurses vary according to
experience, position/status, and educational
• Evaluation study
• What is the effect of a multifaceted program
to teach critical thinking to staff nurses on
patient safety as evidenced by risk exposure
and patient satisfaction?
Measurement & Sampling
• Measurement – patient occurrences, patient
complaints, malpractice claims
• Baseline data Jan-Dec 2001
• Retrospective analysis by location and risk
• Note: the number and value of claims will
most likely change over time to reflect
reserve changes, final losses, and is limited
in some cases as claims are reported later in
the reporting period.
• Events reported to RM
• 1999 = 511
• 2000 = 930
• 2001 = 1213
• 2002 = 1421
• Reflects > 17% in reporting 2001-2002 and
is sustained with 341 reports 1st
• Medication events + Falls = 57% in 2001,
44% at present.
High Frequency Areas?
• Med/Surg – 100% incurred loss 2000
• Med/Surg Units – 74% of reports 2001
• Claims also increased in 2001 by more than
20% in M/S
• Percentage of claims in M/S decreased by
6.41% to date
• Treatment Injuries, Monitoring Related
Events, Falls = 82% events in 1999, 25%
2002-2003 to date.
• 39% decrease in Monitoring Related claims
• Improvement in reporting 17%
• Improvement in reduction of errors 15%
• Improvement in reduction of claims 67%
• Improvement in reduction of complaints 10%
• New question? Can we sustain in light of
nursing shortage, turnover, use of agency
personnel, regulatory and budgetary pressures,
We have to keep leaping over
the potholes or we could end up
on the bottom.
• Based on assumption that lower the adverse event
rate, higher the quality of care
• Will not identify cause and effect relationships
• Assumption that adverse events/quality of care is
directly impacted by critical thinking ability of
• Assumption that programs designed will have
effect on that ability
• Does not control other independent variables (staff
mix or care hours, turnover, changes in leadership,
acuity, reporting habits, education/experience etc.
• Prone to false relational patterns
• Inferences about relationship arbitrary and
• Little or no reliability or validity
• Encourages shotgun approach to research
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