Patient Safety Commons^™

“I Know My Body Better Than Anyone Else” Perspectives Of People Who Inject Drugs On Antimicrobial Treatment Decision Making For Serious Infections, Amy Eckland, Michael Kohut Phd, Henry Stoddard, Debra Burris, Frank Chessa, Monica Sikka, Daniel Solomon, Colleen Kershaw, Ellen Eaton, Rebecca N. Hutchinson, Peter Friedmann, Thomas Stopka, Kathleen Fairfield, Kinna Thakarar

Costas T. Lambrew Research Retreat 2023

Introduction:

• Few studies have examined the perspectives of patients with lived experience regarding outpatient treatment options for injection drug use (IDU) associated infections.

• We sought to better understand the perspectives of both community partners with lived experience who work with people who inject drugs (PWID) and hospitalized patients with IDU-associated infections on shared treatment decision making.

Patient Transport In The Time Of Covid-19: Using Health Care Failure Mode And Effect Analysis With Simulation To Test And Modify A Protocol, John Kwock, Jeffrey Holmes, Shelly Chipman, Erin Siebers, Angela Berry, Sonja Orff, Victoria Boutin, Leah Mallory

Journal of Maine Medical Center

Introduction: In March 2020, in response to the COVID-19 pandemic, an interprofessional, interdisciplinary team at Maine Medical Center used Healthcare Failure Mode and Effect Analysis (HFMEA) and in situ simulation to rapidly identify and mitigate latent safety threats (LST) in patient transport protocols.

Methods: Following HFMEA steps, stakeholders representing a variety of disciplines assembled to address transport of patients with COVID-19. A process map was created to describe the process. With hazard analysis using table-top simulation followed by in situ simulation, we identified, categorized, and scored LSTs. Mitigation strategies were identified during structured debriefing.

Results: Fourteen LSTs were identified in …

Collaborative Strategies To Reduce Incomplete Operating Room Instruments Trays, Richard Neusch, Nicole Wagner, Colby Fike, Suneela Nayak

Operational Transformation

In an academic tertiary medical care center, the OR was receiving incomplete instrument trays. This issue became increasingly problematic in wasted staff time and cost to the institution.

Using a tracking system to generate a missing instrument report, baseline metrics were established. Reviewing each report, an interdepartmental team comprised of members of the OR and sterile processing departments, initiated a number of countermeasures.

Since the start of these countermeasures, there has been a reduction in the receipt of incomplete OR trays. Next steps include creating a tag process by which the OR instrument trays from one case would be kept …

The Development And Implementation Of A Resource Nurse In The Float Pool: A Review Of The Literature And A Pilot Study Plan, Crystal M. Wiley

Interprofessional Research and Innovations Council

The Development and Implementation of a Resource Nurse in the Float Pool: A review of the Literature and a Pilot Study Plan.

Crystal M Wiley, BSN, RN, CMSRN

Background/Literature: It is pivotal that resources are available at the point of care allowing excellence in nursing care and exceptional outcomes. Currently, the staff have multiple resources to help with ethical dilemmas, patients who are unstable, and research. Discussion with leadership revealed a need for a support to busy units with a few newly hired staff and an interest in a resource nurse program to address these concerns and areas for improvement. …

Improvement Of Chf Patients’ Fluid Restriction Education Through Self-Efficacy, Johanna Ruckey, William Fyler

Interprofessional Research and Innovations Council

Improvement of CHF patients’ fluid restriction education through self-efficacy

Johanna Ruckey RN and William Fyler BSN

Background: Dietary discretion through limited salt and fluid intake is an important aspect of heart failure (HF) management. Keeping accurate account of fluid intake has shown itself to be a difficult task, as both staff and patients often fail to do so on a fairly regular basis. Although staff are aware of a patient's fluid restrictions, there is a deficit in the patient's role in tracking their own intake. Patients often express confusion and frustration regarding their daily fluid intake, but also lack …

Did You Wash Your Hands?, Kelley Coyne

Interprofessional Research and Innovations Council

Did You Wash Your Hands?

Kelley Coyne, RN, OPD Maine Medical Center

Introduction: While there is great focus and education regarding the importance of hand hygiene among healthcare workers there appears to be less focus and education on the importance of patient’s hand hygiene. My observation, as a healthcare provider in pediatrics, is that patient’s compliance with hand hygiene is rare and it appears that there is a need to educate patients on the importance of hand hygiene. Hand Hygiene has the highest efficacy and is a cost effective measure for preventing infection. Researchers in London estimate that if everyone …

Reducing O Negative Blood Product Usage In A Tertiary Care Academic Medical Center, Wendy Weiler, Tracy Cook, Mmc Blood Bank, Mark Parker, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operational Transformation

MANAGEMENT OF O NEGATIVE BLOOD USE

O registered blood cells are the universal donor but it comprises only 7% of the blood supply. As a result, inappropriate use can result in shortages.

At an academic tertiary care medical center, a performance improvement goal was established that O negative blood cells would make up less than 12% of all blood type transfused by the end of their fiscal year.

A root cause analysis established reasons for the use of O negative blood cells. A number of countermeasures were initiated using the plan, do, study, act (PDSA) problem solving model. Using newly …

Patient Throughput Time In The Emergency Department: Can Obtaining Blood Specimens In A Pre-Hospital Setting Increase Timeliness?, Arielle Rancourt

Interprofessional Research and Innovations Council

Patient Throughput Time in the Emergency Department:

Can Obtaining Blood Specimens in a Pre-hospital Setting Increase Timeliness?

Arielle Rancourt RN

Abstract

The Emergency Department (ED) at Mid Coast Hospital currently follows a practice in obtaining blood specimens in-hospital by emergency department staff; this is done despite the ability of pre-hospital personnel to obtain specimens at the time of intravenous catheter insertions. Our current practice may not be the most effective and timely method. Studies showed that there was no increase in hemolysis of blood specimens drawn by Emergency Medical Services (EMS), and that laboratory results were received quicker when blood …

Does Medication Safety And Diversion Education Improve Medication Securement Practices In Scu Compared To Current Practice?, Natasha R. Stankiewicz

Interprofessional Research and Innovations Council

Does medication safety and diversion education improve medication securement practices in SCU compared to current practice?

Abstract

Natasha R. Stankiewicz, MS, RN, NE-BC, CCRN-CMC

This safety quality improvement project began as newly hired SCU2 team members saw an opportunity to improve our medication safety practices and culture. The convenience of having certain medications directly available at bedside was priority. There was a lack of awareness and interest in securing medications within the department. However, the risk to our patients, families, visitors and colleagues when medications are left out, available and unsecured was apparent to new staff and others. Prior to …