Parent Concern Safety Bundle RCNIC

1. Parent Concern Safety BundleRCNIC M. Victoria deCastro, BSN, RNC, Clinical Manager Debbie Hershberger, MSN, RN, Outcomes Manager Jason Olivea, Quality Improvement Consultant

2. Parent Concern Safety Bundle Project • The purpose of this project is to develop and facilitate the RCNIC Improvement Team in developing and cultivating a safety repertoire or bundle that engages families directly in error prevention.

3. History-Why do we need a safety bundle to address parent concerns? • A mother questioned the nurse about the amount of weighed medication that was going to administered to her baby. • The nurse reviewed the label and compared the dosage with the MAR. The dosage on the label and the dosage on the MAR matched.

4. History-Why do we need a safety bundle to address parent concerns • The nurse verified with mom that both documented dosages matched, concluding that the packaged amount was correct. • The medication was given per NG to the infant with feeding. • Shortly after this feeding, the infant vomited and arrested due to presumed aspiration.

5. History-Why do we need a safety bundle to address parent concerns • The mother again questioned the amount of medication that was administered, knowing that side effects of the medication were nausea and vomiting. • Leftover baggies of the medication were taken to pharmacy and reweighed. • It was discovered that the amount was over 10 times the ordered dosage. • This event was later deemed a serious safety event.

6. Multiple Barriers-Could a formal process for stopping care due to a parent concern have prevented the error? EVENTS of HARM Active Errors Medication dispensed incorrectly Medication administered despite mother’s concerns Latent Weaknessesin barriers-no formal process for stopping care due to a parent concern, the medication label was seen as correct and deferred to as the expert Questions? • What could have been done differently in this case to prevent the serious safety event?

7. Beyond the RCNIC • The engagement of patients and families in the culture of patient safety and error prevention is both a CCHMC-wide initiative and a National Patient Safety Goal. • The safety bundle in the RCNIC will become the foundation for the CCHMC-wide initiative.

8. 2007 National Patient Safety GoalsThe Joint Commission • Goal 13: Encourage patients’ active involvement in their own care as a patient safety strategy. • What do we need to do according JCAHO? • Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. • What is the rationale? • Communication with patients and families about all aspects of their care, treatment or services is an important characteristic of a culture of safety. When patients know what to expect, they are more aware of possible errors and choices. Patients can be an important source of information about potential adverse events and hazardous conditions.

9. The Aim Statement • The Aim of the Safety Bundle: To design high reliability processes in the RCNIC to ensure that care is put on hold until parental safety concerns are resolved (i.e. “Stop the Line” • Developed from the key drivers or root causes of the original problem

10. The Key Drivers • See the Staff Resource Folder on E-Chirp for the Key Driver Diagram

11. The Primary Goal • To actively and consistently (100% of the time, with 100% of parents/families, and with 100% of staff) engage families in a formalized process that partners families with the healthcare team to ensure patient safety and to identify and address safety concerns directly at the point of care.

12. How was the bundle developed? • A high reliability process quality improvement methodology was used. • This process focused on system solutions and a problem-solving approach (define, measure, analyze, improve, and control). • Outcomes and improvement are systematically analyzed. • High reliability strategies were developed as components of the bundle.

13. How was the bundle developed? • A RCNIC Improvement Team was brought together to develop standards for parental/family engagement. • The current state of parental/family engagement was analyzed. Emphasis was placed on understanding where failures in communication may occur. • Strategies were developed to combat these potential failures.

14. What were some of the potential failures and strategies to combat these failures? • Parents do not express their concerns-Why? a. Lack of knowledge: • Not sure, especially at first, what to ask, how to ask questions, or who to direct their questions to • There is a feeling of being overwhelmed by their baby’s illness or just by being a new parent b. Too Afraid: • Non-assertive-may need an “invitation” to ask questions or question care • Worried about retaliation/punishment for asking questions or questioning care, concern about being viewed as pushy and asking too many questions • Developmental issues-for example, teen parents versus adult parents • Uncertainty about their expectations regarding safety vs. non-safety concerns-parents may not know what to do when they have a concern, lack of knowledge that they are “allowed” to stop care or change care

15. What were some of the potential failures and strategies to combat these failures? Reliable strategies were designed to combat the knowledge gap, fear, developmental gaps, and personality differences • Standardizing expectations of parents/families and staff as partners • To be discussed in detail 24-72 hours after admission, with documentation of this discussion in Education When • Develop a standard process for addressing and resolving parent safety concerns and other clinical concerns • Posting expectations & process at each bedside-the orange dry erase boards with the bedside cards of expectations, “Stop the Line”, use of independent verification with the PCF’s-See Staff Resource Folder for more on Independent Verification • Hardwiring “inviting” questions-i.e. “Do you have any concerns about feedings, medications, pain management, or any other safety concerns?”, with documentation in the flowsheet and narrative Each of these strategies were tested, revised based on staff and parent feedback, and retested. Refinement of the process continues.

16. The Process Map • Click onto the Staff Resource Folder found in Blitz for the map of the entire process for the safety bundle • This folder will be available on E-Chirp

17. The Main Parts of the Bundle Hardwiring parental engagement into routine practice- This is achieved by posting and routinely asking and documenting the following "Safety Questions” when parents arrive and depart from the unit and when parents call for updates- • “Do you have any safety concerns regarding your baby's medications, feedings, pain management, or any other safety concerns?” These questions are also posted on the orange dry erase boards • Documentation of routine parent safety questions on the flowsheet (Safety Questions Asked or “SQA”) • Documentation of parent safety concerns in the narrative to include concern, intervention, and resolution-The bedside prompts detailing the process will be posted at each bedside

18. The Orange Dry Erase Board • Posting the parental expectations and questions on a dedicated board at each bedside creates a reliable standard of practice • The board is not meant to written on by parents-the marker is available during this “test phase” • The marker is to be used to rewrite the questions in case it smears off • Once we have determined the final wording, a more permanent version will be placed on the boards.

19. The Bundle at Admission Days 1-3 • Day 1-Verbally invite and encourage parents to bring up safety concerns to direct care team, by asking them if they have any concerns as listed on the orange bedside boards. You can refer them to the bedside cards if you think they are ready. The following should be done daily- • Questions should be asked when a parent calls, when a parent comes in, and when a parent leaves for the day • Routine safety questions about feeding, medications, pain management and general care concerns. New questions or concerns may be added in the future. • Day 2 or Day 3-Review bedside cards on the RCNIC Process for Staff to Resolve Parental Safety Concerns, Clinical Concerns, Parent & Staff Expectations, and the SBAR Card. Document this review with the parents in Education When. • On the flowsheet and narrative, document any concerns and responses from the parents, including how a safety concern is resolved, if applicable.

20. The Main Parts of the Bundle Using highly reliable error prevention techniques to address parental safety concerns If a safety concern arises, related care processes are stopped. The staff person will assess the situation using SBAR. Then the staff person will call the PCF (charge nurse) to the bedside for independent verification (using SBAR) of the situation. Both persons will then determine who the expert (attending physician, pharmacist, for example) is and bring them to the bedside to resolve the parent concern prior to resuming related care.  

21. Levels I & II Concerns Because of staff feedback during testing of the bundle, categories of concerns and separate processes were defined • Level I is a clinical concern or plan of care concern • Level II is a safety concern or a clinical concern with actual or potential safety implications • See Staff Resource Folder (Process Map) for Level I & II Concerns • Coming soon-guidelines defining levels of parental concerns to be available in the Staff Resource Folder

22. Common Concerns and Other Considerations • It is okay to individualize your approach to parents when asking the safety questions-if you think that the word “safety” is uncomfortable or worrisome for a specific family, then customize what you say to the parent and just ask them if they have any questions about feedings, etc. • Also, depending on the baby’s status, you can include ventilator or oxygen questions or exclude feeding questions as applicable.

23. Common Concerns and Other Considerations Why were “feedings, pain management, and medications” chosen as the focus of the safety questions? These were the top 3 incidents reported in the safety report system that involved parent concerns. The bundle may be revised to consider other safety reported incidents such as IV infiltrates, the top reported safety incident in the RCNIC.

24. Common Concerns and Other Considerations How do I know if it is a “safety” concern? • If a parent says he or she has a safety concern, then it is a safety concern. • If an error related to the concern may or will jeopardize patient safety, you should treat the concern as a safety concern. • If you are not sure if the concern is a safety concern, use SBAR to clarify the concern. If you are still uncertain, it is best and safest practice to treat the concern as a safety concern.

25. Common Concerns and Other Considerations What do I do if the parent’s concern is a clinical concern or plan of care concern? • Ask parents some clarifying questions using SBAR • Address and resolve the concern appropriately • On the flowsheet and narrative, document the concern, how you addressed the concern, and what was done to resolve the concern

26. Common Staff Concerns and Other Considerations The parents I work with do not have a problem expressing their concerns. Do I still need to ask the questions? • Use your own critical judgment and common sense • If your parents have already verbalized their questions and concerns and you feel that their questions adequately address their concerns, you do not have the “re-ask” the questions. Remember to document the parent-directed questions as “safety questions asked”

27. Lessons Learned: Next Steps-The Data Collection Phase • Ways to improve the process will be continually looked at based on outcomes and feedback. • Parents will be surveyed on the parent satisfaction survey about how well they perceive the RCNIC staff addresses their safety concerns. • The percentage of concerns that are safety concerns will assessed (team rep meeting with the PCF’s and team rep checklist). • Data will be collected measuring how well the bundle is being followed.

28. Lessons Learned: Next Steps-Implementation and Sustainability • Permanent changes to the flowsheet will be done with the next revision. • Work systems (such as addition of “Stop the Line”, documentation), standards, procedures and policies are being added and revised as needed. • Official roll-out of the bundle unit-wide will occur in September 2007

29. Lessons Learned: A Parent’s Perspective • Several parents, who have stated that they do not have problems speaking up about their concerns, have stated the bundle is a good way to help quieter, less assertive parents to feel comfortable discussing their concerns. • These parents have also stated that having a “formal” invitation and explanation to talk about their concerns would have eased their initial discomfort and uncertainty in verbalizing their concerns.

30. Lessons Learned: A Parent’s Perspective • Recently, a parent verbalized that she has noticed a positive change in how well staff are actively asking about her concerns • She stated that she appreciates being invited to discuss her concerns, because she feels like staff want to hear about her concerns, and she, then, does not feel like the “pushy” parent, especially with staff she does not know well.

31. The Safety Bundle in Summary • On day 1 (of admission)-Ask the safety questions and document on the flowsheet/narrative • Day 2 or Day 3-Review the entire process with parents • Document this explanation in Education When • Use SBAR to clarify concerns, especially safety concerns • Use independent verification for safety concerns • Involve the appropriate expert(s) to resolve the concern, such as the attending physician if it is a medical safety concern • Document on the flowsheet and narrative

32. Final Words This bundle is based on the best practices of parent engagement that already exists in the RCNIC, making those practices standard Unit-wide and hospital-wide. Thank you to everyone for all your input and hard work!!