My “aha moment” today was when Crystal mentioned that administration only knows about 4% of adverse events which occur because they are only being made aware of the events which are really catastrophic. However, if they had been made aware of every single adverse event, regardless of level of harm, there could have been strategies, plans, and policies put in place which may have prevented much of the 4% of catastrophic events.
This is a point that I intend to share with my team to encourage them to report patient safety events. I think many of my co-workers are only reporting the events which actually reach the patient, I am guilty of this myself. However I am realizing that it is of great importance to report the good catches so administration is aware of potential safety issues.
As healthcare professionals, I truly believe that the vast majority of us have the desire to provide safe, quality care to each and every patient. Our facilities push us toward reaching our goals of decreased safety events and increased patient satisfaction scores. Often, during particularly busy or complicated shifts in the ED, I find myself thinking “how can they expect us to reach our goals and keep our patients safe and satisfied under these conditions?” This question may enter my mind because there is a lack of resources, or acuity is high for all 4 of my patients and they are all priority but I am only 1 person, or I am boarding an ICU patient who really requires 1:1 care but I still have my other patients to care for, or one of the many other things that occur which are concerning to me. I have an amazing team but on nights like this they are equally busy and unable to assist. During these times I truly do not feel that my patients are as safe as they should be. I accepted the opportunity to be involved in this experience because I feel it is my responsibility to become a key factor in finding solutions.
So that’s the WHY in my story.
In general, I am introverted and not a conversation starter. I know this about myself. I have been this way for as long as I can remember. For the most part it has not negatively impacted my path in life. However, I am discovering that to truly be an advocate for my patients, for safety, or for anything, I have to change that about myself. I have to start the conversation, offer my opinions, voice my concerns, and get others on board. Before I can feel truly comfortable in doing so, I need to be well prepared. During this experience I hope to collect a box full of tools to take with me back to my department so I am prepared for this challenge.
So that’s what I want to take with me.
Now I ask myself, what am I willing to invest in achieving the purpose which brought me here? I am completely willing to jump out of my comfort zone to be the one who brings the collective concerns of my team to management and recommend solutions. Often in quiet conversations between staff we complain to each other. “Something has to be done about this pump issue. I’m so tired of delaying patient care because I’m searching for a pump, only to discover that they are all in use and I have to go call another unit to beg for a pump. I don’t have time for this.” Or “I don’t understand why we only have 1 attending physician from 2am to 7am. Hasn’t management picked up on the trend of longer wait times during those hours? I have a high priority patient who arrived by ambulance who has not yet been evaluated by a physician and he has been here for an hour.” I hear these types of complaints and even partake but I always assume that management is aware because “someone MUST have informed them already.” Right now I am willing to commit to throwing out that assumption and taking these collective concerns, along with our recommendations for possible solutions, to management.
Answering these questions for myself and really reflecting on them has brought me a great deal of motivation to get started.
As an RN in a, small, 20-bed ED I have the opportunity to work side be side, and have face-to-face communication with, the attending physicians (including the ED chair), physician assistants, residents, multi-functional techs, nursing supervisor, charge nurse, triage nurse, unit secretary, environmental services, X-ray technicians, CT technicians, US technicians, and transporters. The importance of open communication between all parties involved in patient care has been stressed since the first night I stepped onto the ED floor. During my orientation I was encouraged to, respectfully, question physician orders which did not make sense to me and now when I precept a new graduate I encourage the same. In our department we are able to question such orders without push-back from physicians, residents, or PAs. They are typically grateful when a nurse has caught a medication order which was meant to be ordered on another patient. Generally, they will take accountability… Continue reading