Patient Safety Culture Survey 2009

CSI (Clinical Safety Investigation):
Virtual Patient Safety Rounds
Boston College
VA Boston Healthcare System
NERVANA: Northeast Region VA Nursing
Affiliates
• An academic partnership between the 2 VAs and 6
schools of nursing in the Boston area
NERVANA
• Employs an innovative educational model to:
• expand and enrich nursing students and faculty
• educate nursing students in the care of veterans
• expose nursing students to the advanced models
of medical informatics, patient safety, quality
improvement and integrated systems of care
employed by the VA’s national healthcare system
COHORT
•Faculty
•Preceptors
PROGRAMS
•Workshops
•Internship
•Teaching materials
OUTCOMES
•Better care of the
veteran patient,
regardless of setting
•Transferable skills to all
healthcare settings
Students:
•BSN
•MSN
•DNP
•PhD
•BSN postconference
materials
•MSN rotations
•MSN EBP projects
•PhD research
•Improved image of the
VA in the nursing
community
•Enhanced VA/academic
partnerships
•Collaborative
EBP/research activities
So…
Starting with Patient Safety Initiatives
• Theoretical Support
•
•
•
•
First step in quality care
Accidents are avoidable
Burden of injury
Understandable to providers,
consumers, & payers
• All participants could benefit
• Pragmatics
• New professional mandates:
Joint Commission and AACN
• VA is a leader in patient safety
• Student knowledge
Assure
equal care
Avoid needless
waits, delays
Provide patientcentered care
Provide highly reliable,
effective care
Assure patient safety
Professional Mandates
Joint Commission
• 1996: Sentinel event
policy
• 2002/03: 1st Patient
Safety Goals
• 2011: 50% of standards
directly related to patient
safety
AACN: Essentials of Education
Baccalaureate Education
II: Basic organizational & systems
leadership for quality care and
patient safety
Masters Education
VI: Use quality processes &
improvement science to evaluate
care & improve patient safety…
DNP Education
II: Organizational & systems leadership
for quality improvement..
Patient Safety at the VA
• First Patient Safety Event Registry—1997
• Longstanding practices:
• Interdisciplinary offices of patient safety within all VA
medical centers
• CPRS that is vertically and horizontally integrated
• Universal adoption of BCMA
• Ongoing:
• System redesign and innovation
• Toolbox of instruments & products
Patient Safety Projects
Graduate Patient Safety Curriculum
• Innovative service-academic-curricular project
• Students join the current patient safety team and
work on interdisciplinary projects
• Course credit awarded as:
• Elective credits
• Clinical practica
• EBP/research project requirements
Patient Safety Projects
CSI: (Clinical Safety Investigation):
Virtual Patient Safety Rounds
Purpose: To develop a video-based library of
patient safety vignettes that allows pre-licensure
students to detect patient safety errors and
vulnerabilities while developing ethical and critical
decision-making skills needed to advance a culture
of patient safety
Project Rollout
Content Grid
•Mapping of Patient Safety Goals, associated
problems, needed video, & debriefing scenarios
Storyboard
•Scripts that contained defined elements; props,
and actors
Filming & Editing
•Consent was obtained from all actors. Filming &
editing of each vignette
•Two copies of each vignette with and without
the violations explicated, were produced
Validation
•Content validation by expert panel & graduate
nursing research class
Dissemination
•Vignettes prepared in a chapter DVD format
•Suitable for adaptation as Internet interactive
podcasts or MP3 podcast downloads
Results
A DVD with 12 vignettes containing a total of 100
errors and supporting curricular materials
Patient Safety Vignettes
Designed for Flexible Use
• In classroom settings to introduce the concepts
• In clinical conferences to discuss:
• Monitoring personal behaviors and practices
• How to handle departures by colleagues from safe
practices
• As part of simulation experiences
• As part of staff orientation programs in clinical
settings
Appropriate for either individual or group learning
Features
• Vignettes initially are shown with the errors
embedded but not labeled
• Vignettes are then shown again, with the errors
labeled
• Types of errors:
• Errors of omission
• Errors of commission
• Situations are included that are frequently considered errors but
are not
Error Identification
• Errors of Omission
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•
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No hand cleansing
Insufficient patient verification procedures
Failure to dispose of syringe; dirty clothes
Failure for appropriate handoff
• Errors of Commission
• Dangling jewelry
• Unnecessary gloving
:
• How would work with UAP around safety errors?
Questions for Discussion
• Whose responsibility was it for each of these
errors?
• What do you do if you see a breach in patient
safety that wasn’t your direct responsibility?
• How would you work with a UAP around safety
training; safety errors?
Summary
• Because this project draws on the complementary
strengths and resources of academic institutions
and clinical agencies, high quality, clinical relevant,
pedagogical materials can be developed that are
appropriate for multiple settings
• Ideally, this project can serve as a model for other
combined academic-practice partnership
educational efforts.
Support for this project came from:
• The Veteran’s Administration
• National Center for Patient Safety
• VA Boston Healthcare System
• Boston College
• William F. Connell School of Nursing
• Carroll School of Management
• “Friends & Family Philanthropic Foundation”