Place your screenshot here

Are We Pushing Graduate Nurses Too Fast?

Matt Huang, Molly Nolan, Howie Realubit, & Karina Salas

Azusa Pacific University

GNRS 586 Leadership and Management in Professional Practice

Janet Wessels MSN, RN, PHN

July 12, 2017

1.Background

Learn what CRRT is and how it is used in the SICU

Case Profile● New grad, graduate nurse● Employed in the SICU● 1 year floor experience● 8 hour CRRT operator seminar● Independent (non-supervision)

● Patient has pancreatic cancer● Patient needing CRRT due to kidney

injury

Background

Continuous Renal Replacement Therapy (CRRT)

Error Incident● Inexperienced nurse operating CRRT

● 2 ultrafiltrate effluent bags○ new nurse tried to refill bags but no supplies

immediately available on the floor

2.Fishbone Diagram

Finding the cause and effect

MethodsManpower

Machines Material

A lack of assessing CRRT competency and poor internal communication led to a patient death by an inexperienced nurse operating the CRRT.

The nurse had training but insufficient experience

No double-check by another nurse

Need to initiate critical thinking of errors

No communication process for machine troubleshooting

The CRRT machine did not alert staff of problem

No machine warnings for bag replacement

No new dialysate bags available in supply

No competency checklist

No checklist for errors

Fishbone Diagram

3.Determining Root Cause

AnalysisFocus on the most important cause

and effect

What is the Root Cause Analysis?

The 5 WhysNarrowing down the primary cause of a problem using the fish diagram

But first,State the problem.

Lack of CRRT Competency

Next,“eye”-dentify an indicator.

Patient is crashing!

Why1? Because the CRRT

dialysis machine stopped working.

Why2?The effluent bags were placed in the

wrong output.

Why3?The machine output line for hanging the effluent

bag looks just like the one for hanging

dialysate.

Why4?The new grad nurse that

hung the bags had training but insufficient

experience.

Why5?Actions were not in place to

eliminate human error. Specifically, the dialysis

machine allowed for hanging both types of bags.

5 Why Checklist - RCA Statement

▧ Problem ▧ Identifier ▧ Why 1 ▧ Why 2 ▧ Why 3 ▧ Why 4 ▧ Why 5

Crashing patient!Lack of Training?

Machine stalled → Right bags →

New nurse → → Insufficient training or Faulty Machine Design?

Wrong outlet →

4.Actions

Actions to prevent recurrence

Action 1Strong actions remove human

dependence entirely (“idiot-proof” - machine dependent, patient

centered).

VA National Center for Patient Safety RCA Tools REV.02.26.2015

Prevents from hanging and

connecting the wrong bag to

the line

Change the Outflow Line Hookup

Pros: No human

involvement

Con: Non-transferability (machine

reliant)

Action 2Medium actions reduces human

reliability but not human error. (Extra insurance).

VA National Center for Patient Safety RCA Tools REV.02.26.2015

Provides additional

supervision/insurance

Place Checklist, Warning Label, & Dialysis/Preceptor Staff

Pros: Slightly reduces

unwanted outcome

Con: Requires

add’l staff and allows for human

error

Action 3Less stronger actions clarify & support

the process, but relies entirely on humans. (Human driven).

VA National Center for Patient Safety RCA Tools REV.02.26.2015

Change training

policy for all New Nurse

Transition Training

All New Nurses: Standardized Transition Program & Pre-stock Supply

Pros: Raise awareness Con: No

meaningful action (entirely human reliant)

5.Outcome Measures

Measures and Type

Outcome Measures

● Numerator: number of preventable adverse events for patients on CRRT

● Denominator: total number of patients on CRRT in the ICU

● Threshold: 0 deaths will occur

● Date: the collection will be monitored for six months

Outcome Measures Type

● Adverse Event Outcome:◦ An improved staff training will be developed to

ensure competency.

◦ Six months following the improved staff training, the number of preventable adverse events for patients on CRRT will result in zero deaths.

6.PDSA

Plan, Do, Study, Act

PDSA: Aim

To reduce the number of adverse events related to CRRT machine use in the SICU to zero within 6 months of implementing the new training process.

PDSA: Plan

Tasks Person Responsible

When Where

Develop streamlined training/education for all RNs on SICU current and future

Nurse Manager Within one weeks SICU & all units in hospital that utilize CRRT machine

Skills competency testing & re-testing

RN Bi-annually following initial training

Hospital

Implement “Buddy system” with 2 RN double check process

Nurse Manager First five times utilizing CRRT machine

Patient room

Designate a staff member to account for CRRT supplies each shift, restock, and report any missing items

Nurse Manager Within one week Supply room

PDSA: Plan(continued)

Prediction Measures to Determine Prediction Success

All RNs in SICU will be able to properly use a CRRT machine with zero adverse events leading to death

- Standardized transition program- Evaluation of competency will be conducted on a

bi-annual basis via skills competency re-testing- RN preceptor double check buddy system between

inexperienced nurse with CRRT machine and experienced nurse for first five times using the CRRT machine with a patient

The CRRT machine supplies will remain fully stocked on a daily basis

- Supply checklist- Designated staff member checks every shift and

restocks as necessary as monitored by Nurse Manager

Nurse managers will be able to train and retrain at least 90% of nurses within two weeks

- Sign in sheet at each training session to keep track of who has been trained & retrained

Nurses will feel more competent and confident in using the CRRT machine

- Provide feedback and opportunities for reflection- Complete surveys- New nurses/inexperienced nurses will be supervised

and evaluated 5 times as part of the preceptor RN double check

PDSA: Do

● It will take about one week to create and implement new & streamlined training and about two weeks to train and retrain all nurses currently working on the SICU

● Nurse managers will need to continually observe and monitor that training is being completed bi-annually, buddy system double checks are being utilized for the first five times using a CRRT machine, and that the designated staff member is keeping all CRRT machine supplies appropriately stocked

PDSA: Study

Prediction Outcome

All RNs in SICU will be able to properly use a CRRT machine with zero adverse events leading to death

- 0 patient deaths- 1 near miss reported

The CRRT machine supplies will remain fully stocked on a daily basis

- The supplies were stocked 90% of the time

Nurse managers will be able to train and retrain at least 90% of nurses within two weeks

- 80% of nurses were retrained and passed the skills competency checklist

Nurses will feel more competent and confident in using the CRRT machine

- 95% of new nurses felt competent with the involvement of leadership staff in support of patient safety

PDSA: Study(continued)

Problem Solution

Lack of transition from education to practice program

- Create competency checklist- Have preceptors oversee preceptee

handle CRRT machine at least 5 times before being deemed competent

- Simulation of the use of CRRT

Lack of supplies on the unit - Create supply checklist- Designate a staff member to count

supplies each shift and report any missing items

Summary of Findings:◦ Goal Met: Six months following the improved staff training, the number of

preventable adverse events for patients on CRRT will result in zero deaths.

PDSA: Act

● Next Steps:◦ Clearly define staff roles: preceptor, preceptee,

“buddy” system

◦ Perform on-site observations

◦ Adjust checklist for restocking the CRRT machine

◦ Institute competency checklists across units

◦ Compare and share data across hospitals

7.Stakeholder Analysis

...

● Internal (unit) stakeholders:

◦ Patients

◦ New Nurses

◦ Charge Nurses

◦ Hospital Administrators

● External stakeholders:

◦ Family Members

◦ Dialysis Nurse Associations

◦ CRRT Trainers

◦ Hospital Investors

8.Force Field Analysis

...

Forces FOR Change (Driving Forces)

Forces AGAINST Change(Restraining Forces)

Strategies to mitigate restraining forces:● Orientation for new nurses and new nurse preceptorships for CRRT● Signs to remind nurses of critical CRRT processes● Ensure CRRT patients are covered by experienced CRRT nurses● Assign specific responsibilities to nursing staff● Lobby hospitals to increase resources for units with CRRT

● Nursing culture for new nurses on unit

● Additional time to reinforce procedures

● Additional resources (i.e. money and staff) to reinforce procedures

● Patients and their families

● New nurses● Dialysis nurses● Nursing associations● Hospital

administrations● Organizations for

patient safety

Thanks!

Any questions?

Matt: AnalysesMolly: PDSA, OutcomesKarina: PDSA, Outcomes

Howie: Background, Actions

References

Continuous Renal Replacement Therapy. (2017). Retrieved fromhttp://www.baxter.nl/healthcare_professionals/therapies/renal/acute_kidney_treatment/continuous_renal_replacement_therapy.html

Mrsiraphol. (2017). Hospital blur. Retrieved from http://www.freepik.com">Designed by mrsiraphol / Freepik

Tsai, C. (2009) Root Cause Analysis. Retrieved from https://www.slideshare.net/CharlesGYF/cat001-root-cause-analysis

VA National Center for Patient Safety RCA Tools REV.02.26.2015