UPMC ST. MARGARET Just Culture Presentation

Handoff Communication March 20 2013

Facilitator: Colleen Sunday MSN,RN

Kathy Fowler BSN,RN,CMSRN

EVENT DESCRIPTION Nursing/Physical Therapy Handoff

1. Patient escorted to therapy by volunteers

2. Patient oxygen tank discovered not on in therapy

3. Therapy notified the nursing unit

4. First time for clarification of oxygen rate

5. Second phone call the nurse was informed the patient assessed as having low O2 sat =64% , HR 133

6. Therapist was instructed by the nurse to put the patient on 6 liters of oxygen

7. The therapist was unable to get a O2 saturation reading-the patient did not appear in distress but it was noted the patient finger tips were described as cold to touch and blue in color

8. The patient was returned to the Nursing unit by the therapist

9. The patient did not receive therapy

Handoff Report /Policy Oxygen tank Verification

Education

People-

transport

responsibility differs

from volunteers

Standard: Ticket to Ride

not ut ilized

Unit typically utilizes a different tool green

card

Common for therapy to receive patients without

handoff report

Training of new nursing staff

Respiratory policy

Nursing reference on the tank storage compartment

Nursing knowledge of

difference

Transport carries Oxygen Tank reference and have criteria for min amount in the tank for transport

Volunteers do not check the O2 tank

volume

Patient Handoff

To copy all

f ishbone

"object s"

Use Cnt l-Shif t -A

Identified Root Causes

Responsibility to Check

Oxygen Tank-

Nursing, Transport, Volunteer, Sending Dept.,

Receiving Dept.( Oxygen

reference availability)

Ticket to Ride to

be utilized

as standard handoff

throughout the facility

Nursing awareness

of volunteers

vs. Transport

responsibilities

Clear communication between department

s:

Was the therapist talking to

the primary nurse?

PATIENT

Patient Transport Policy

Outcomes- Reference availability at POC( point of care)

INCREASE UNDERSTANDING OF ROLES WITH OXYGEN TRANSPORT

Transport It will be the responsibility of the licensed professional initially applying O2 to the patient to complete the form with the patient’s name/liter flow/date and their initials.

The staff, upon receiving the patient back on the

nursing unit, is to complete form documentation. A

licensed professional then places the patient on wall oxygen.

Nursing Ensure that the ticket to ride if properly filled out (including how much oxygen the patient is on)

Verify that there is enough oxygen for transport

Verify the nurse puts her/his name and phone number on the ticket to ride in case they need to be called.

Transport Verify that Nursing personnel has signed/documented the O2 prior to transport

Volunteer

Just Culture Means Accountability for Our Behaviors

Human

Error

Inadvertent Action:Slip,Lapse,

Mistake

Manage through changes in:

Processes

Procedures

Training

design

At-Risk behavior

A Choice: Risk not recognized or

believed justified

Manage through:

Removing incentives for at risk behaviors

Creating incentives for healthy behaviors

Increasing situational awareness

Reckless

Behavior

Conscious disregard of unreasonable risk

Manage through:

Remedial action

Corrective action

CONSOLE COACH CORRECTIVE