Provide one example, with supporting evidence, of an improvement in patient safety that resulted from nurses' involvement in facility or system-wide proactive risk assessment or error management. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Problem/Background
The delivery of high quality safe patient care is the main focus of FF Thompson Hospital . The risks that could pose potential harm to patients are constantly evaluated. One of the potential risks to patient safety is the possibility of a patient becoming trapped between the mattress or bed frame and the side rail, also known as entrapment. The events at another organization related to the entrapment of a patient prompted the evaluation of our current entrapment policy and procedure resulting in a proactive risk assessment. Goal
The goal of the proactive risk assessment was to evaluate the system wide procedure for preventing patient entrapment, and identify patients at risk for entrapment. Per Joint Commission standards all patients who are admitted into the hospital are to have an entrapment risk assessment completed. The first step of the project was to evaluate the current policy, procedure, and compliance of the regulatory guidelines related to entrapment. It was discovered that the existing policy, procedure and documentation tools were outdated. Next, an assessment of the current beds that were used within the organization was completed. The assessment was completed by facility services, by utilizing gap measurements on all beds. Recommendations from regulatory agencies were used to guide the facilities service team. Additionally, Facility Services created a procedure to ensure all new beds are checked upon introduction into the facility and routine monitoring for gap measurements on existing beds. The goals of the improvement project were: • To create an updated policy and procedure to address the patient risk of entrapment. • To assess the current bed status within the organization related to gap measurements. • To create a risk assessment within the electronic medical record to be completed on admission for all patients who are admitted into the hospital. • To educate all nursing staff on what is needed to complete a risk assessment for entrapment. • Purchase new beds that comply with regulatory standards related to decreased entrapment risk. • To remove all beds within the organization that do not meet the safety standards to prevent entrapment. • To educate all facilities services on gap measurements. This was a pro-active risk assessment related to patient entrapment. There were zero entrapments pre and post risk assessment. There is a heightened awareness of the risk for patient entrapment.
Participants: The participants who were involved in the planning and intervention of the entrapment initiative include the following: Hazel Robertshaw RN PhD VP of Patient Care Services, Director of Nursing, Hospital Administration Sarah Clayson RN BSN MHA, Nursing Supervisor, Nursing Administration
Elizabeth Alexander RN MSN CN-E, Medical Surgical Director, Nursing Administration Adrian Hordon MSN RN, Nursing Educator, Magnet Program Director, Nursing Administration Laurie McFetridge BSN RN, Nursing Informatics, Nursing Administration Richard Gerger, Director of Facility Services, Facility Services Thomas Weibel, Director of Purchasing, Purchasing Kiera Champlin-Kuhn RN, Director of Quality and Safety, Hospital Administration Kathy Wethington RN, MSN-CB, Clinical Nurse, Nursing 3 West Vicki Erway, RN, MSN-CB Clinical Nurse, Nursing Float Pool Elizabeth Talia VP of Legal & Regulatory Affairs & General Council, Legal, Hospital Administration
Interventions
There were 24 beds that were identified within the hospital that placed the patient at risk of entrapment as defined by the Joint Commission and FDA documents. The beds were labelled with large signs that stated "alert and oriented patients only." Staff members were educated to place the appropriate patients into those beds. Twenty-six new beds and mattresses were ordered to replace the old beds (Exhibit EP19EO.1). When the new beds arrived, the 24 old beds were removed from the hospital and destroyed. Exhibit EP19EO.1 Exhibit EP19EO.1 2014 Hill-Rom Beds.pdf
The policies and procedures were created through the regulations set by the Joint Commission, Department of Health, and the United States Food and Drug Administration (FDA). Drafts of the new policy and procedure were presented to the Nursing Leadership team and the Nursing Practice Council for review. The Nurse Practice Councils initial review was on December 18, 2013 (Exhibit EP19EO.2). The Quality and Safety Management Team provided oversight from the system wide perspective on the entrapment review process (Exhibit EP19EO.3a,b,c). Exhibit EP19EO.2 Exhibit EP19EO December 2013 entrapment NPC.pdf
Exhibit EP19EO.3
Exhibit EP19EO.3a March 14 2014 Q & S meeting minutes.pdf
Exhibit EP19EO.3b April 11 2014 assess built, .pdf
Exhibit EP19EO.3c May 16 2014 Q&S beds in and education done.pdf
The electronic nursing documentation was built by Laurie McFetridge BSN,RN, CPN (Exhibit EP19EO.4 ). An entrapment assessment had been built in the McKesson system as of March 14, 2014. A read and sign of the policy was completed for staff education. The Nursing Leadership team continued to review changes on June 11, 2014 (Exhibit EP19EO.5). The policy and procedure was finalized. The policy and procedure were approved by Nurse Practice Council on June 17, 2014 (Exhibit EP19EO.6 ). In addition to the read and sign, a power point document was created to provide further education (Exhibit EP19EO.7). The power point will be part of the yearly nursing educational requirements. The staff started documenting the entrapment risk for admitted patients upon admission on June 18, 2014.
Exhibit EP19EO.4 Exhibit EP19EO.4 Entrapment screen shot
Exhibit EP19EO.5 Exhibit EP19EO.5 on 6.11.14 Nursing Leadership
Exhibit EP19EO.6 Exhibit EP19EO.6 June 2014 Nursing Practice Council Meeting, Entrapment Policy Approved
Exhibit EPEO19.7 Exhibit EP19EO.7 Entrapment Education PPT
Data
Since implementation, clinical nurses are now identifying a small population of patients that are at risk for entrapment. This risk assessment was previously not being performed and now we are able to appropriately manage the at-risk population.
The outcomes that addressed the goal statement were met related to: • Addressed the need and created a policy and procedure for entrapment • A facility wide assessment of the beds that place patients at risk. • Identified 24 beds that placed patients at risk of entrapment and were destroyed • 26 new beds and mattresses were purchased • Implemented a new documentation system for assessing the entrapment risks • Created an audit tool to ensure compliance of documenting the assessment was completed on all patients who were admitted into the hospital. • Education was provided to staff related to entrapment