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Spotlight on safety: Communication training leads to drop in adverse patient events

Monday, May 9, 2016   (0 Comments)
Posted by: Nadia Tamez-Robledo
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When it comes to increasing patient safety, TNA member Thalia Martin, DNP, RN, CPHQ, is opening the lines of communication.


Martin is the market director of quality and patient safety for the Hospitals of Providence in El Paso. She developed her newest safety initiative while looking for ways not only to mitigate adverse patient events but to also prevent situations from ever turning into adverse events.


Martin trained six nurses, who earned the title safety advisors, in peer accountability and situational awareness. An overall training was later held for all unit staff.


 “During the first four months, we saw a tremendous decrease in adverse events and a decrease in severity,” she said of the initiative, which was rolled out in the 60-bed medical/renal unit of the Sierra campus in November.


The peer accountability component involved using the ARCC model – ask, request, concern, chain of command – to empower nurses in alerting their peers to an unsafe situation. Nurses bring the situation to their peers attention first as a question, then request they address the potential hazard. The third step, if needed, is to state their concerned. If none of these verbal cues are heeded, a nurse then alerts leadership to the problem through the chain of command.


“Peer accountability was probably the hardest one because it’s about the way you say it,” Martin said, stressing that the aim was to make nurses feel supported rather than accused. “I think the overall training the entire staff helped bridge that so it was a little easier for the participants to enact. Five months into the program, no one has had to invoke the chain of command.”


The situational awareness component aimed to help nurses, who are busy from start to end of their 12-hour shift, see beyond what’s going on with their patients.


“Nurses are busy on the floor. It is a tough job nursing, and it is very easy to get tunnel vision,” Martin said. Nurses might think, “’These are my six patients, and this is what I see and what I do.’ Situational awareness is teaching them to see beyond d those six rooms.”


 Using situational awareness to promote safety could be as simple, Martin said, as a nurse noticing and taking action if they see another nurse’s patient walking down the hall has an IV line that is about to get tangled in the wheels of an IV stand. Even addressing a coffee spill, thus preventing a slip and fall, makes a difference.


The number of adverse events in the unit fell by nearly 39 percent during the first four months of the program.  Now her hospital system is looking to pilot the program in a larger group of hospitals, she said.


 “I would say one of the biggest things I learned about this project is teaching my nurses about situation awareness and accountability is great, but all staff should have that training because anyone can use it. Everyone would benefit from that skill set.”

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