Tag Archives: tjc

Who ya gonna call? Myth Busters!!

MYTH: There is no real payoff in engaging  patients and families.

FACT:  Health care organizations can reap many benefits fromMythBUSted
“activated” patients and families – those who have the knowledge, skills and confidence to manage their own care.

How does engaging patients help?   1) It may increase quality of life by reducing falls, helping patients learn to manage chronic conditions. 2) It can reduce Underuse or Overuse of health services. 3) It may increases reimbursement through improved HCAHPS scores.  And YOU may be more satisfied at work!

TWO EXAMPLES of positive results yielded from partnering with patients and families:
• One hospital that began involving patients and families in safety efforts after a highly publicized preventable death saw a culture shift that improved medication reconciliation and eliminated fatal medication errors during a 10-year period (Johnson & Abraham; Reinersten et al., 2008).
Satisfaction• A health system that began seeking input from patients and families decreased nurse turnover from 15 percent to 5 percent in three years and improved patient, staff and physician satisfaction (Johnson & Abraham).

WHAT CAN I DO TO ENGAGE PATIENTS?  Listen to your patients to identify their level of activation in their care as described, & communicate in ways that move them to the nextNURSEPatient level.

  • At stage 1, people do not yet grasp that they must play an active role in their own
    health, they may still believe that they can just be a passive recipient of care….
  • At stage 2, people may lack the basic facts or have not connected the facts into a larger understanding about their health or recommended health regimens….
  • At stage 3, people have the key facts and are beginning to take action but may lack confidence and skill to support new behaviors….
  • At stage 4, people have adopted new behaviors but may not be able to maintain them in the face of life stress or health crises.”  [source: Hibbard et al. at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955271/]

mythVStruth

FOR MORE INFO, check out the source of above:  Busting the Myths about Engaging Patients and Families in Patient Safetyquestion

CRITICAL THINKING: Think of a strategy that you ALREADY use or that you might start using to move patients up the stages of engagement in their own care. Be specific!

“Oh Baby!” Evidence-based Naming Prevents Events

EBP Preventive Action:  Evidence-based, distinct infant naming can avoid sentinel events related to misidentification of newborns (TJC, 2015).

Problem:  Misidentification errors of NICU babies are common newborn3(Gray et al., 2006).   About 12% of the 4 million born in U.S. hospitals were admitted to NICU’s.  At birth every infant requires quick application of an armband, and when parents have not yet decided on a name the assigned name is often quite nondistinct (e.g., BabySmith).


Evidence:
A pretest/posttest of a new, more infant-specific naming system was “conducted in order to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (e.g., Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes” (Adelman et al., 2013). newborn2Their results? RAR events were reduced by 36.3%.   Their recommendations? Switch to a distinct naming system.

Using something like Judysgirl Smith is infant specific. “In the case of multiple births, the hospital adds a number in front of the mother’s first name (ex: 1Judysgirl and 2Judysgirl)” (TJC).

TJC recommends:

  • “Stop using Babyboy or Babygirl as part of the temporary name.
  • Change to a more distinct naming convention.
  • Train staff on the distinct naming convention.
  • Follow the recommendation in National Patient Safety Goal 01.01.01 and implement use of two patient identifiers at all times.
  • As soon as parents decide on their baby’s name, enter that name into the medical record instead of the temporary name.”

Commentary: While this is just one study, RNs should evaluate whether it is riskier to continue any current practice of non-distinct naming or to switch practices to distinct naming. No risks were identified to the distinct naming system & it likely requires only the resource investment of educating staff.  Adelman et al.’s (2013) study is current, moderately strong, quasi-experimental evidence that showed a significant decrease in errors that could have sentinel event outcomes. Any who make the switch should monitor outcomes. All who don’t make the switch should, too!

Critical Thinking: Examine the risks, resources, & readiness of staff in your facility to make the switch to a distinct NICU infant naming system?  question Should the naming system be extended to all infants?

Want more information?  See

Don’t Just Wish Upon Falling Stars: Take Evidence-based Action

The Joint Commission (TJC) published, Preventing falls and fall-related injuries in health care facilities, a new Sentinel Alert #55 on September 28, 2015 at http://www.jointcommission.org/assets/1/18/SEA_55.pdf

What’s the problem? Falls with serious injuries are among the top 10 events reported to TJC.   Analysis of that data shows that contributing factors are related to:

  • Inadequate assessment
  • Communication failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision, staffing levels or skill mix
  • Deficiencies in the physical environment
  • Lack of leadership (page 1)

What to do?   Here are TJC recommendationsAction Plan

  1. Raise awareness of falls resulting in injury
  2. Establish an interprofessional falls committee
  3. Use a reliable, valid risk assessment tool
  4. Use EBP
    1. Standardized handoff including risk for falls
    2. One-to-one, bedside education of patients (& families?)
  5. Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patient (page 2)

questionCritical thinking:  How would you apply AHRQ toolkit: Preventing Falls in Hospitals to your unit.

Want more info?   For tools, resources, & more details on above, see Joint Commission (2015, September 28). Preventing falls and fall-related injuries in health care facilities, Sentinel Event Alert, Issue 55.  Retrieved from Joint http://www.jointcommission.org/assets/1/18/SEA_55.pdf