Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to...

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CSI (Clinical Safety Investigation): Virtual Patient Safety Rounds Boston College VA Boston Healthcare System

Transcript of Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to...

Page 1: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

CSI (Clinical Safety Investigation):

Virtual Patient Safety Rounds

Boston College

VA Boston Healthcare System

Page 2: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

NERVANA: Northeast Region VA Nursing

Affiliates

• An academic partnership between the 2 VAs and 6 schools of nursing in the Boston area

Page 3: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 4: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

•Faculty

•Preceptors

Students: •BSN

•MSN

•DNP

•PhD

•Better care of the

veteran patient,

regardless of setting

•Transferable skills to all

healthcare settings

•Improved image of the

VA in the nursing

community

•Enhanced VA/academic

partnerships

•Collaborative

EBP/research activities

•BSN post-

conference

materials

•MSN rotations

•MSN EBP projects

•PhD research

•Workshops

•Internship

•Teaching materials

COHORT PROGRAMS OUTCOMES

Page 5: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

So…

Page 6: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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 patient safety

Provide highly reliable, effective care

Provide patient-centered care

Avoid needless waits, delays

Assure equal care

Page 7: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

Professional Mandates

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..

Joint Commission

• 1996: Sentinel event

policy

• 2002/03: 1st Patient

Safety Goals

• 2011: 50% of standards

directly related to patient

safety

Page 8: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 9: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 10: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 11: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

Project Rollout

•Mapping of Patient Safety Goals, associated

problems, needed video, & debriefing scenarios

•Scripts that contained defined elements; props,

and actors

•Consent was obtained from all actors. Filming &

editing of each vignette

•Two copies of each vignette with and without

the violations explicated, were produced

•Content validation by expert panel & graduate

nursing research class

•Vignettes prepared in a chapter DVD format

•Suitable for adaptation as Internet interactive

podcasts or MP3 podcast downloads

Content Grid

Storyboard

Filming & Editing

Validation

Dissemination

Page 12: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

Results

A DVD with 12 vignettes containing a total of 100

errors and supporting curricular materials

Page 13: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

Patient Safety Vignettes

Page 14: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 15: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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

Page 16: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

Error Identification

• Errors of Omission

• 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?

Page 17: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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?

Page 18: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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.

Page 19: Patient Safety Culture Survey 2009patient safety vignettes that allows pre-licensure students to detect patient safety errors and vulnerabilities while developing ethical and critical

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”


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