implementation of a safety huddle for falls and near...
TRANSCRIPT
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IMPLEMENTATION OF A
SAFETY HUDDLE FOR
FALLS AND NEAR MISS
FALLS Brian Lane Nurse Unit Manager
Camden Rehabilitation Unit
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Camden Hospital – South Western
Sydney Local Health District
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Camden Rehabilitation Unit
20 Bed Sub Acute Unit
Complex Fracture NOF’s, CVA, General
Deconditioned Patients
Average Length of Stay approximately 24 days
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Safety Huddle
NUM Led Multidisciplinary review of a Fall or
Near Miss
Involving Team and the patient
Incidents / Near Misses are identified
Documentation of Incident / Near Miss and the
Recommendations / Plan
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Principles of the Safety Huddle
Prepare the patient (NUM)
Introduction
Description of the Fall / near fall by the patient
Apologise
Brainstorm with the team and the patient
Document Plan
Handover
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Documentation
Heading Safety Huddle and Incident
Who is present
Description of Incident “using patients own words”
if possible
Plan / Recommendations
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Safety Huddle
Documentation
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Safety Huddle in Action
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Results
Zero patients have had a repeat fall since the
implementation of the Safety Huddle. (October
2013 to May 10th 2015)
2012 – 2 patients had repeat falls
2013 – 2 patient had repeat falls
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Results
Year to date for
2015 – 5 Falls
to 8th May
2015.
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Pre Safety Huddle
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Post Safety Huddle
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Recommendations
Not one strategy works to prevent falls always a
combination.
Camden Rehabilitation Unit common falls prevention
strategies.
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Clothing Style Magnet Alarm
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Clothing Style Magnet Alarm
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Chair / Bed Sensor Style Alarm
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Chair / Bed Sensor Alarm
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Infrared Beam Style Alarms
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Beds
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Safety Huddle Examples
Patient in toilet – overbalanced fell from toilet, nurse
just outside toilet giving privacy but was checking
regularly
Safety Huddle held – Patient was attempting to
wipe self, lost balance and fell to floor
Options discussed, patient happy to
have constant supervision in toilet and
shower, and due to extreme risk
agreed to soft helmet.
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Unusual Fall
Developmentally delayed patient, parent staying on
ward with patient, assisting with care.
Parent attempted to transfer patient
Parent lowered patient to floor no injury sustained.
Safety huddle was held
Obvious recommendations post Safety Huddle ie
Wait for assistance
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Contributing Factor
These were the
socks the
patient was
wearing
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Picture here without tablets out.
Safety Huddles for other incidents
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Safety Huddles for other incidents
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The Salt Bottles
Phenergan Relaxo Gin (herbal medication used for
sedation and calmative) Mersyndol
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Patient Self Medicating
Staff Specialist, Registrar, RMO, NUM and patient
present for safety huddle
Patient apologised for “doing the wrong thing”
Dangers of self medicating discussed with patient
Promised staff that he would not take any more
Existing tablets removed with patients consent
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Safety Huddle Conclusion
Very Positive from a Managers perspective
Feel a sense of treating incidents seriously
Great for IIMS Management
Honest, transparent approach to when something
goes wrong
A comfortable way to offer an apology to the
patient
To date it is reducing repeat incidents
CORE Values Collaboration / Openness / Respect and Empowerment
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The Future
Safety Huddle used routinely for all incidents
Plans to Evaluate patient and staff satisfaction
Ethics approval currently underway to formally evaluate satisfaction
Publish Results with assistance from the Centre for Applied Nursing Research (CANR)
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The Future Continued
Preparation and development of an educational
DVD for staff and other facilities on performing a
Safety Huddle, and providing examples.
Preparation of educational patient video clip on
Safety Huddles as part of the orientation for
patients on the ward.
Recently Implemented on another ward at Camden,
with interest from other Hospitals.
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April Falls Day 2015
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Acknowledgments
Camden Rehabilitation Team for their enthusiasm
and commitment to patient safety
SWSLHD Falls Committee and Mathew Jennings for
the original idea to trial the Safety Huddle
Centre for Applied Nursing Research (CANR) for
their assistance and taking the Safety Huddle
further
Nursing and Midwifery Office NaMO for grant.