In traditional hospital safety initiatives, errors are reported to leadership through a formal reporting tool, and managers determine which mistakes merit private discussion with the employee or broader discussion with the team. In 2015, using a different approach, a group of USIP nurses from the Dell Children's Medical Center of Central Texas began publishing a monthly newsletter with "good catches" (near misses) and reports from formal and informal medical care. and medication errors.
The strategy behind this newsletter is 100 percent of the errors present teaching opportunities for 100 percent of staff members. The newsletter, published monthly by the Medical Director, is now distributed to all USIP medical and nursing staff. This model of open and blind declaration of all errors has improved reporting and improved safety of culture in intensive care units. In a November 14 webinar, the team will describe how it works. They also shared this work during the conference on the quality and safety of children in 2017.
A new approach
Using the newsletter moves the team beyond the traditional error response. "With traditional approaches, the assumption is that the person who made the mistake is the problem," says Michael Auth, M.D., D.O., medical director of the USIP. "It also discourages people from reporting things, we all go ashamed, and maybe the only person who learns is the nurse who made the mistake.
Monica Smith, RN, a critical care nurse with Dell Children's, began publishing the Critical Care Safety Bulletin in 2015. Each monthly email includes good catches and all the errors that occurred that month. By compiling errors, it deletes information about staff and patients and sends the edited description to the staff members who have been involved to ensure that it is a fair representation of what has happened.
Then the reviewers validate the information and add any follow-up training that the staff should know. "Then we take another look at the e-mail and take off any blame or tone we feel when we read it," says Smith. In the middle of the month, the e-mail is sent to the list of 200 staff members, including all critical care nurses, floating nurses, physicians, respiratory therapists, pharmacists and quality analysts.
The newsletter follows the same format each month. "All events are shared in a spirit of improvement and awareness, and then there is the wrong sandwich," says Smith. "It starts with good catches and ends with positive behavior, but in the middle is a list of everything that went wrong: medication errors, side effects of patient care, falls, or events we learned from. another unit. of."
She says it works because every mistake deserves the attention of everyone in the team. "It also helps eliminate the gossip that occurs with events because they are anonymous, and helps reduce the negative emotions and shame that occur when you make an event," she says. "We give the same amount of screen time to every bad thing that happens on the unit, resulting in increased reporting."
Now in its third year of publication, the newsletter has become a valuable resource for staff. "We are receiving constant feedback that staff are forced to change through anecdotal experiences, not aggregated data," says Smith. A hospital-wide safety bulletin is being prepared and other units are also launching their own versions.