CPS Nurse Reflects on Patient Safety

May 6, 2016    |   By: Tina Hilmas, RN, BSN, CPPS

Today is National Nurses Day and I had to take a moment and ponder my career as a nurse and please forgive me if I take a couple of sentences to get to my point. You see, this September will mark 30 years since I took my first clinical as a nursing student at The Ohio State University.  Wow!  30 years?! When I hear 30 years, I think about how I used to look up in awe at nurses who said they’d been in the field 30 years wondering if I’d ever make it that long! But to be honest, it truly doesn’t seem that long ago!  And if anything I am way more passionate about my chosen career now than I was 30 years ago starting my clinicals.  Why?  Two words: PATIENT SAFETY

When I joined the Center for Patient Safety two years ago, I became involved in patient safety and it was the best thing that ever happened.  Patient Safety is an area that nurses truly can take the lead and make a difference.  As a nurse, just like as a doctor, we are bound to do no harm to the patient.  I think where a major difference lies is as nurses we are charged with being a patient advocate.  As a patient advocate, that means we should be putting safety as a priority.  We, nurses, should be drivers of patient safety culture.  We are the ones at the bedside.  We should be noticing minute changes in the patients condition.  Many times it is us whom the patient confides when they don’t understand something.  Many times it is us that the patient confides in to say, they would like to take their medicine, but they can’t afford it.

While healthcare has traditionally been driven by a hierarchical culture and organization, it is time to step out of that mold! Just as I was told 30 years ago, nursing is part of the healthcare team!  Just because someone, a doctor, a surgeon, a supervisor tells you to do something, doesn’t mean you can’t question it. Everyone is a member of the healthcare team and as such should work together for the best interest of the patient.  As a patient advocate, it is up to you to make certain it is in the best interest of the patient.  Which brings me to another part of this hierarchical structure.  Nurses many times “eat their young”.  We tend to belittle the new nurse, the one who comes in with a fresh look, excited by the profession with a rosy outlook on what we can achieve.  Rather than becoming cynical and “eating our young” become rejuvenated, remember what you were like and think back and rekindle those goals you may have had.

Patient Safety isn’t just “a trend” it is a public concern.  We need to stop the cycle, we need to get back to our roots and that is helping the patient.  Do the little things, washing your hands.  Just putting on gloves doesn’t work, spend that extra 5 seconds at the bedside to find out that your patient can’t afford their medicine or doesn’t have transportation.  Make certain you do an appropriate fall risk assessment and put the appropriate precautions in place.  COMMUNICATE! I can’t emphasize that enough.  So many errors occur due to lack of communication.  Make certain that your communication is heard.  Remember that not all areas of healthcare operate the same.  Long term care facilities, clinics, ASC’s home health, hospice, all these areas have their own culture and organizational structure.  If you are a hospital nurse remember that when communicating.  Don’t rely on memory when communicating, use a checklist.  Many years ago, way before electronic records or email was even thought of being used in healthcare we had the kardex.  The kardex was a communication tool, it was the nurses bible.  When you gave your report, EVERYTHING was on the kardex.  History, surgeries, medication, procedures, schedules, and anticipated discharge.  It was all there in one location.  Be sure your checklist incorporates all these items.

Patient Safety Culture is real, and it needs to be implemented in healthcare.  We need to look to other high risk industries such as aviation, and nuclear power, industries that have highly reliable organizations and fashion healthcare after these models.  After all, healthcare is a high risk industry, we hold people’s lives in our hands on a daily basis.  Why should errors be kept confidential?  If an event happened and an organization learned from it, why not share that learning with all of healthcare so other facilities/organizations won’t make the same mistake?

As a nurse who is once again passionate about nursing, I applaud the ANA for putting Patient Safety Culture as a focus this year.  It couldn’t happen at a better time as new research is coming out showing that preventable medical errors are the third leading cause of death and we begin looking at where Patient Safety is today as we are now 16 years past the initial IOM landmark report “To Err Is Human” which brought patient safety into the national spotlight.  I think today, National Nurse’s Day is a day to not only celebrate being a nurse and honor our nurses, but also for our nurses to understand and realize the important and key role they play in patient safety. They have a golden opportunity to truly make a difference in their patients lives.

http://www.nursingworld.org/cultureofsafety

http://www.nursingworld.org/NationalNursesWeek-2016ResourceToolkit

http://www.nursingworld.org/NationalNursesWeek-2016

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More

RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.