CURRY COLLEGE Nursing Department

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Workarounds As Identified By

Senior Preceptored Students

QSEN ConferenceJune 22 – 25, 2008

Charlotte, NC

CURRY COLLEGE Nursing Department

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Project Team

• Elizabeth C. Kudzma, DNSc, MPH, WHNP-BC

• Maureen L. Murphy, PhD, EdM, CNM

• Cathleen C. Santos, MSN, RN

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CURRY COLLEGE Nursing Department

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Curry College: QSEN Strategies

1: Ask faculty to add “level of evidence” on all PowerPoint slides illustrating clinical studies application in classroom teaching (EBP).

2: Develop a modified PowerPoint presentation of When Things Go Wrong: Responding to Adverse Events to integrate into several nursing courses (S, QI).

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3: Adopt prepared institutional (BIDMC) resources, such as adverse event flow sheets, as teaching tools in selected nursing courses (S, QI).

4: Design and use student cards/tags for medication rights, SBAR, Rapid Response Team triggers (S).

5: Designate one clinical conference on quality improvement projects in the assigned care setting in each clinical rotation (QI).

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6: Revise the Critical Objectives for Clinical Evaluation adapting an institutional systems focus with the assistance of the practice partner (S, PCC).

7: Develop clinical assignments to assist students in identification of potential unsafe nursing practices including “work arounds”(S).

8: Involve the student in quality assurance projects (or committees) as part of precepted clinical practicum with the practice partner (QI).

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9: Participate in a Root Cause Analysis experience with the practice partner in selected nursing courses (QI, S).

10: Purchase First, Do No Harm Parts 1, 2, 3 (Safety, QI, PCC)

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CURRY COLLEGE Nursing Department

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Strategy # 7

Develop clinical assignments to assist students in the identification of potentially unsafe nursing practices including workarounds (WA).

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CURRY COLLEGE Nursing Department

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AHRQ Glossary:Workarounds: From the perspective of frontline

personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and actions are referred to as “workarounds.” Although workarounds “fix the problem,” the system remains unaltered and thus continues to present potential safety hazards for future patients.

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Faculty and StudentsClinical Organization to Point of Care

Introduced:When Things Go Wrong

Adverse Events ReportingRoot Cause AnalysisFair and Just CultureWorkarounds

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CURRY COLLEGE Nursing Department

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Faculty Assessment

QSEN Workaround Questionnaire:

1. Are you familiar with the term “workaround”2. Have you discussed workarounds with your students3. Would you be able to identify workarounds 4. Please list 3 examples of workarounds

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CURRY COLLEGE Nursing Department

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Faculty Assessment Outcomes

• Office phone limited access – uses personal cell• Cold classrooms – faculty/students wear layers• Scheduling classrooms – several administrators • Classroom vs. # of students – pulling in desks/chairs• Late withdrawals – calls Registrar directing

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Faculty Challenges

• Unfamiliar with quality and safety language• Some not currently in active practice • First-order problem solving viewed as innovative• Second-order problem solving viewed as time

consuming

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CURRY COLLEGE Nursing Department

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Faculty Project Activities• Faculty Educational Retreats:

October 26, 2007 February 02, 2008

May 15, 2008

Patricia Folcarelli, PhD, RN Director of Professional PracticeBeth Israel Deaconess Medical Center (BIDMC)

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Educational Retreat Content 10-02-07• Patient Safety Series Film: “When Things Go Wrong:

Voices of Patients and Families”• Swiss cheese model (Reason, 1991)• Blunt end and sharp end• Hindsight bias• High reliability organizations• Culture of safety• Person vs. systems paradigm - Workarounds

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Educational Retreat Content 02-02-08

• Error Classification Systems• Sentinel Events, Close calls/near misses• Accountability Determination Model• Root Cause Analysis (RCA)• RCA systematic and thorough-look everywhere• Team Structure and Climate• Supporting the second victim, frequently the nurse

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Educational Retreat Content 05-08-08• Adverse Event Reporting• Fair and Just Culture (James Reason, 1997)• Fair and Just Decisions on Individual Accountability• National Quality Forum – “Never Events”• Communicating in the Aftermath of an Adverse Event• Process for Reporting and Analyses - Adverse Event• Transparency - Adverse Event

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• Dedicated QSEN intranet access for all faculty• QSEN - standing department agenda item • > 50% faculty attended multidisciplinary QI/RCA clinical conferences hosted by BIDMC• Developed an appreciation for Transparency• Revised Critical Objectives for Clinical Evaluation

• Tucker, A. L. and Edmondson, A. C. (2003). Why hospitals don’t learn from failures: Organizational

and psychological dynamics that inhibit system change. California Management Review, 45 (2), 55-71.

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CURRY COLLEGE Nursing Department

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"Patient Safety and Health System Reform"Lucian L. Leape, M.D.

Curry College Keith Auditorium

September 23, 20084:30 p.m. – 5:45 p.m.

Reception to follow in the Parents’ Lounge

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CURRY COLLEGE Nursing Department

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Senior Precepted Student Assessment

QSEN Workaround Questionnaire:

1. AHRQ Glossary of Safety and Quality-Related Terms2. Have you discussed workarounds with your preceptor3. Were you able to identify any occurring on your unit4. Please list 3 examples of workarounds

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Senior Precepted - Assessment Outcomes

Identified Workarounds: • Equipment• Personnel - Nursing Staff• Medication Administration

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CURRY COLLEGE Nursing Department

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Senior Precepted - Assessment Outcomes

Equipment:• Silencing alarms w/o investigation• Failure to turn on bed alarm• Overriding IV infusion pump drug – rates• Using another’s ID to scan the use of glucometers

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CURRY COLLEGE Nursing Department

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Senior Precepted - Assessment Outcomes

Personnel – Nursing Staff:• Lack signage to indicate precautions• Failure to observe precautions • Failure to round q 2 hours to check restraints• Hourly checks not performed but documented• Failure to confirm code cart security

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Senior Precepted - Assessment Outcomes

Medication Administration• Orders verified to best suit needs of nurse• Failure to use Pyxis system as intended• Withdrawing medication prior rating pain level • Failure to confirm patient ID against MAR• Leaving medications at bedside• Failure to calculate/witness narcotic waste

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CURRY COLLEGE Nursing Department

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Senior Precepted Student Challenges

• Preceptors not familiar with term “workarounds”• One student viewed workaround as commendable• Conflict noted between optimal/actual clinical

nursing behaviors• May not recognize a workaround: trusted preceptor

was demonstrating proper nursing practice

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CURRY COLLEGE Nursing Department

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Senior Precepted Student Project Activities

• Blackboard: “QSEN Corner” Student resource• PowerPoint /Lecture/ Blackboard Documents• Interactive classroom RCA exercises• BIDMC access to multidisciplinary QI/RCA meetings• Exposure/appreciation for the concept of Transparency • AHRQ Glossary of Safety and Quality-Related Terms• Senior externship seminar discussions re: WA

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CURRY COLLEGE Nursing Department

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Senior Precepted Student Project Activities

• Clinical Response Sheets: When Things Go Wrong – PowerPoint Quality Improvement – clinical setting Workarounds – identify

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Teaching/Learning Strategies

• AHRQ glossary• Tucker, A. L. and Edmondson, A. C. (2003). • Seminar/Clinical discussions • Clinical preparation sheets - identify WA• Continue QSEN efforts with BIDMC• Duplicate QSEN efforts with other agencies

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Teaching/Learning Strategies

• ID first-order practice WA • ID second-order practice WA• Compare to practice guidelines

• ID first-order organizational WA• ID second-order organizational WA• Contribute to organizational culture change

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Curricular Changes

Initiate early introduction to :

• Workarounds• Fair and Just Culture • Root Cause Analysis• Adverse Events Reporting• When Things Go Wrong

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Sustainability• REVISED: Critical Objectives for

Clinical Evaluations (5/08)

• NSG 2041 Adult Health ISophomore

• NSG 2051 Maternal-Newborn Junior• NSG 3050 Advanced Med-Surg Senior• NSG 3982: Capstone Synthesis Senior• NSG 3983: Preceptored Clinical Senior

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CURRY COLLEGE Nursing Department

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To Lobby is Legal:

“Most Effective Clinical Partnership” 3 Onsite Faculty Retreats presented by BIDMC Access to BIDMC multidisciplinary QI/RCA meetings

“We Hit the Home Run” Lucian L. Leape – guest speaker

Harvard School of Public Health

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