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Strategies to Keep Your Patients SAFE TODAY

As a Nurse Executive with over 30 years of street credit in the industry, I am still mindful of the difference between the quality of patient care on nights and weekends versus day shifts. Many clinicians in the field might argue that this difference in quality of care is due to a lack of resources. While this may be a true scenario in some organizations, based on the research studies, this does not hold water as the primary reason for this disparity in care. What I know to be true is we all want to provide the highest level of care 24/7 but sometimes miss the mark.

There are some common factors that impact quality of care that must be considered and in place 24/7:

  • Highly engaged and clinically Competent Staff

  • Leadership visibility and ownership for patient and staff safety.

  • Relentless drive to High Reliability 24/7

  • Optimizing event analysis capabilities and improving organizational learning from events of through huddles, debriefings and post event briefings

  • Staff are aligned with organization goals, norms and processes

  • Transparency across the organization where results are monitored, measured and improved

  • Action oriented culture based on evidenced based research and Human Engineering Principles

  • Digital automation which supports point of care service

Let's consider a real scenario where safety systems were absent:

It was Saturday night and Mike has worked his third twelve hour shift. He is an experienced nurse, certified Paramedic and Respiratory therapist. He was caring for a patient who required a medication to help reduce the acid in his stomach. Mike went to the medication refrigerator and pulled two medications at one time, then put them in his pocket to take to his two patients. One patient required the acid lowering medication and the other patient was going to be placed on a ventilator requiring a paralyzing medication. Of course, you have already guessed what happened. Mike pulled the medications from his pocket and administered the paralytic to the wrong patient. The patient immediately stopped breathing; Mike immediately recognized error, and a reversal agent was given. The patient fully recovered from the near fatal incident but we discovered during our root cause analysis that there were human engineering factors related to the event. We also discovered that the severity in risk events occurred nights and weekends, and there was an opportunity for increased clinical education and collaboration on the night shift.

From our work with the clinician and organization, we were able to implement unit shift briefings, huddles, immediate post event debriefings, with targeted action plans to keep the next patient safe. We then streamlined and standardized workflow, storage of medications and eliminated process variations through Value Stream Mapping. In the end, the paralytic medication was moved to an alternate storage site, and not next to the stomach acidic prevention medication in the same refrigerator. Leader accountability was an imperative to ensuring safety checks were completed and the 10 rights of medication administration must be adhered to at all times. Educational opportunities were identified, clinical competencies reinforced, and the staff needed owned the medication process. Staff were also encouraged to speak up, and share stories of how to keep their patient's safe. The Pharmacy and Therapeutics Committee refined their work to ensure processes were formalized and communicated to all team members.

How confident are you that when you go to sleep at night that your patients or family members are receiving the highest level of care? Applying Human Engineering Principles, Lean Methodology, and Six Sigma provides for sustainable quality improvement and zero harm 24/7. To learn more about the Restoration Healthcare Design (RHD) approach to sustainable quality improvement and patient safety, email us at

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