Provide one example, with supporting evidence, of nurses' involvement in activities that address national or international patient safety goals that led to an improvement in patient safety outcomes. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data
2014 National Patient Safety Goal 15.01.01 - Identify patient safety risks; find out which patients are more likely to commit suicide. Background Nurses are an integral component of patient safety on a daily basis within the hospital setting. Part of these safety issues that align with the 2014 National Patient Safety Goals revolve around identification of patients that are more likely to commit suicide. Goal Statement 100% compliance with Suicide Risk Assessment in Triage and on Unit. Identify those at risk for suicide and refer to proper connections. Intervention A Suicide Risk Do It Group (DIG) began in December of 2011, where multidisciplinary staff helped identify process guidelines within FF Thompson's Policy and Procedure and identify specific ICD9 codes related to psychological issues being seen in the Emergency Department (ED) and how to help nursing staff quickly identify those at risk for suicide. The DIG group met multiple times throughout the following 2012/2013 year to identify process improvement trends (Exhibit EP21EO.1).
Exhibit EP21EO.1
Exhibit EP21EO.1 DIG Meeting Minutes.pdf
Hospital staff met every morning for a bed meeting involving charge nurses, hospitalists, dietary, social work, physical therapy, and physicians. During the meetings, discussions took place regarding patients who were identified with specific needs that had to be met before discharge. The new Electronic Medical Record (EMR) McKesson, helped identify those in need of extra services. One of these needs is identified through the use of McKesson and T-System in regards to Suicide Risk Assessment. When a Suicide Risk Assessment is complete, the box that is checked automatically flags the electronic chart and sends a message to social work for a referral (Exhibit EP21EO.2) Exhibit EP21EO.2 Suicide Risk Assessment is also an annual competency that all nursing staff must complete. The Monthly Educational Component (MEC) for the 2014 year is Nursing Spectrum Article CE649: Preventing Suicide in the Hospital Setting. This one hour course provides nursing staff with insight into the Suicide Risk Assessment and how to discuss suicide with patients and families.
The DIG team also discussed the process of early identification of potential suicidal patients in the ED. The new tracking system in T-System, the electronic record used in the Emergency Department, was also updated in the 3rd quarter of 2014 related to DIG concerns to identify those patients at risk and would also alert Social Work to potential suicidal risks (Exhibit EP21EO.4). The "SAD PERSONS" acronym was also implemented into the T-System program, which creates a quick scoring system to help identify patients that are more at risk for suicidal incidents (Exhibit EP21EO.5). Depending on the patients score, another screen helps guide the nurse in questions related to self-harm and can alert Social Work if an issue is present (Exhibit EP21EO.6). Wallet cards regarding suicide are also now available in the ED in both English and Spanish (Exhibit EP21EO.7).
Exhibit EP21EO.4
Exhibit EP21EO.5
Exhibit EP21EO.6
Exhibit EP21EO.7
Exhibit EP21EO.7 Wallet Card.pdf
Participants Mary Savastano, LMSW, Director of Case/Quality Management, Patient Care Services Virginia Hebda, MSN, RN, CEN, previous Director of Emergency Department, Patient Care Services Donna Fulmer, MSN, RN, CPAN, NE-BC, previous Director of Perioperative Services, Patient Care Services Diana Ellison, MSN, RN,CNL, Clinical Nurse Leader, Nursing Administration, Patient Care Services Cathy Shannon, Director of Practice Management, Administration Stephanie Taylor, Medical Social Worker,Case Management and Social Work, Patient Care Services Rachel Wise, Social Worker, Case Management and Social Work, Patient Care Services Data
Outcomes The intervention of the DIG process was implemented in 1st quarter of 2013, with ongoing process improvements and changes to the EMR to provide the most accurate data collection possible. While the ultimate goal of 100% suicide risks completed was not met, the trended data above clearly displays that the DIG team is the driving force behind the attainable goal. With the launch of the new T-System upgrade, the Suicide Hotline number will print on all discharge instructions from the Emergency Department and help guide the discharged patient to needed resources.