Workarounds As Identified By Senior Preceptored Students

1. Workarounds As Identified BySenior Preceptored Students QSEN Conference June 22 – 25, 2008 Charlotte, NC

2. Project Team • Elizabeth C. Kudzma, DNSc, MPH, WHNP-BC • Maureen L. Murphy, PhD, EdM, CNM • Cathleen C. Santos, MSN, RN

3. 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).

4. 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).

5. 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).

6. 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)

7. Strategy # 7 Develop clinical assignments to assist students in the identification of potentially unsafe nursing practices including workarounds (WA).

8. 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.

9. Faculty and Students • Clinical Organization to Point of Care • Introduced: When Things Go Wrong Adverse Events Reporting Root Cause Analysis Fair and Just Culture Workarounds

10. Faculty Assessment QSEN Workaround Questionnaire: 1. Are you familiar with the term “workaround” 2. Have you discussed workarounds with your students 3. Would you be able to identify workarounds 4. Please list 3 examples of workarounds

11. 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

12. 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

13. Faculty Project Activities • Faculty Educational Retreats: October 26, 2007 February 02, 2008 May 15, 2008 Patricia Folcarelli, PhD, RN Director of Professional Practice Beth Israel Deaconess Medical Center (BIDMC)

14. 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

15. 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

16. 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

17. 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.

18. "Patient Safety and Health System Reform" Lucian L. Leape, M.D. Curry College Keith Auditorium September 23, 2008 4:30 p.m. – 5:45 p.m. Reception to follow in the Parents’ Lounge

19. Senior Precepted Student Assessment QSEN Workaround Questionnaire: 1. AHRQ Glossary of Safety and Quality-Related Terms 2. Have you discussed workarounds with your preceptor 3. Were you able to identify any occurring on your unit 4. Please list 3 examples of workarounds

20. Senior Precepted - Assessment Outcomes Identified Workarounds: • Equipment • Personnel - Nursing Staff • Medication Administration

21. 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

22. 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

23. 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

24. 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

25. 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

26. Senior Precepted Student Project Activities • Clinical Response Sheets: • When Things Go Wrong – PowerPoint • Quality Improvement – clinical setting • Workarounds – identify

27. 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

28. 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

29. Curricular Changes Initiate early introduction to : • Workarounds • Fair and Just Culture • Root Cause Analysis • Adverse Events Reporting • When Things Go Wrong

30. Sustainability • REVISED: Critical Objectives for Clinical Evaluations (5/08) • NSG 2041 Adult Health I Sophomore • NSG 2051 Maternal-Newborn Junior • NSG 3050 Advanced Med-Surg Senior • NSG 3982: Capstone Synthesis Senior • NSG 3983: Preceptored Clinical Senior

31. 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