The Unfamiliar Catheter

1. The Unfamiliar Catheter Chris Hunziker, Kirstee Novak, Yliana Penalosa GNRS 586

2. Background • A 28 y/o F 20 months post-bilateral lung transplant presented to the ED with severe SOB • RN received order to draw labs from the large-bore central line placed in pt’s chest • RN had no previous experience with this catheter type • Upon asking Charge RN, RN wasinstructed to:“waste 3 cc, draw labs, flush with saline, & HEP-LOCK” • RN felt confident verbal instructions were sufficient and prepared to draw the patient’s labs • RN drew labs and after tubes had been filled, the patient stated “something doesn’t feel right” • RN reached for the saline flush and the pt began to convulse, lost • consciousness, fell, and bled from her catheter to the floor • RN called for help • Tests revealed the pt had a cerebral air embolism with temporary damage

3. Methods Manpower Performing procedure without training Incompetent RN Performing unfamiliar procedure without supervision Lack of Assistance from CRN Lack of communication Cerebral Air Embolism Unfamiliar catheter Saline Flush Cath is capable of producing an air embolism +/- Clamp on catheter Machines Materials

4. Root Cause Analysis COMPETENCE: Medical Competence: A principle of professional practice, identifying the ability of the provider to administer safe and reliable care on a consistent basis. • The charge nurse and registered nurse demonstrated a lack of competency in their roles as nurses by assuming proper care of a catheter without proper knowledge.

5. WHY? Bedside nurse not trained on this particular catheter type Root Cause Analysis WHY? Charge nurse not competent in management of nursing staff WHY? Not strictly adhering to policy/No available policy WHY? Patient should have been given to someone who was trained on the cath. WHY? Lack of communication between nurses Root cause- Lack of Competence

6. DOCompetence training for catheter use for all nursing staff on the unit Problem: Competence of Nursing Staff PLAN The hospital will ensure that nurses on the floor will be competent on the procedures being performed and understand the reason for the procedure PDSA STUDY Compare number of incidents before and after the competence training ACT Positive reinforcement and monthly nurse recognition

7. PDSA: Aim Expand the culture of competence on the unit and establish clear communication. Achieved through: • Patient safety • Safe Procedures • Patient advocacy • Training • Protocol

8. PDSA: Plan

9. PDSA: Plan

10. PDSA: DO

11. PDSA: Study

12. PDSA: Study Summary of findings: A “culture of competence” has been implemented throughout the unit.

13. PDSA: Act • Positive reinforcement for employees • Certificates of completion of competence • “Outstanding Nurse Communicator” Award • Expanding to other departments and other medical team members

14. Stakeholder Analysis • Internal (unit) stakeholders • Hospital administrators • Nurses • Patients • External stakeholders • Patients/Families/Community • Insurance companies • Device Manufacturers

15. Force Field Analysis Forces FOR Change (Driving Forces) Forces AGAINST Change (Resisting Forces) Competency CULTURE OF COMPETENCE Time consuming Patient safety Routine Improve culture Cost Patient Satisfaction Attitude

16. References Marquis, B. L., & Huston, C. J. (2015). Leadership Roles and Management Functions in Nursing (8th ed.). Philidelphia: Wolters Kluwer. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003. Saunders, an imprint of Elsevier, Inc 3 Jul. 2015 http://medical-dictionary.thefreedictionary.com/competence Swayze, S. C., & James, A. (2013). The Unfamiliar Catheter . Retrieved July 2, 2015, from http://webmm.ahrq.gov/case.aspx?caseID=294