Quality Safety Advocate (QSA) David MacNeill RN BSN CCRN-CSC Charge Nurse SICU Co-Chair QSA Committee

Why the QSA Role? Recommendation by the PSN task force in August 2011. Quality Improvement and Patient Safety focus at the unit level. Partnership with unit manager: PSN review Trend identification Case presentation at Nursing Risk Committee

QSA Role PSN feedback to staff Still evolving Unit specific SBAR email Staff meetings Work closely with Quality Specialist and Risk Manager assigned to unit. Still evolving Update unit outcomes board Intranet webpage coming soon Role definition and expectations

QSA Accomplishments to date: QSA Charter Nursing Risk case presentations by QSA’s Increased unit awareness of when/how to fill out PSN’s (“PSN submissions on the rise, specifically near miss PSN’s”) Staff awareness of what happens to PSN’s after they are submitted and reviewed Partnered on the new PSN upgrade Acts as the PSN resource for staff

QSA Accomplishments Medication Safety Task Force data to unit level; Alaris override data Basic Infusion use Medications added/changed in Alaris Library Heparin error data Assisted in Dual medication check sheet development Just Culture presentation by Carolyn Sanders EPIC collaboration for PSN/QSA reporting follow up

QSA Accomplishments Roll out of 6 rights in 6 months campaign In conjunction with the Medication Steering Committee and the Unit Educators UHC Article

QSA How will we measure outcomes NDNQI survey Employee opinion survey Near miss PSN’s on the rise w/ Event Harm PSN’s on the decline

QSA Communication When in doubt fill it out Just the facts Just say no to Emotional Data Reporting (EDR) Know who your QSA, QI Specialist, and Risk Managers are The goal is transparency for all departments The PSN system is non-punitive

QSA Examples of EDR The primary RN and CNA were rolling patient during an incontinent episode and discovered a Type 1, Pressure Ulcer this patient had a foley and has left sided weakness r/t a past CVA, the patient's skin care was most likely not as sufficient as needed to be in the SICU.

QSA Reported by: Kelly McIntosh Event Narrative: Charge RN was notified by floor RN that there was a medical student removing JP drains without the direct supervision of a doctor. Charge RN went directly to pts room after returning to the floor. Medical student reported to charge RN that the drains were already pulled. Charge RN spoke with medical student and told him that he was not allowed to pull drains without the direct supervision of a doctor. Charge RN paged and spoke with Attending MD. Attending MD told Charge RN she did not know she needed to be with the medical student. Attending MD reported to the bedside within 5mins of phone conversation and asked for the policy regarding the matter. Charge RN printed the policy and gave a copy to MD. Attending MD later reported to Charge RN that she spoke with Surgery Medical Director and that the practice of medical students pulling drains would no longer happen.

QSA Reporter Berry Jennifer Event Narrative: Surgeon not available until 12:00, case scheduled for 7:30 case was scheduled for 07:30, I saw the patient at 06:50, and paged Surgeon at 07:00, she returned my call promptly and notified me that she was in meetings until 12:00 and the case can go then. I then notified Nurse Manager, Charge Nurse, and Anesthesia Personnel.

QSA Reporter: Krista Hall Event Synopsis: Krista noticed that a patient coming out from the OR with a known latex allergy had a latex foley catheter in place upon APCU admission. Krista exchanged the foley to a latex free catheter and medicated the patient with Benadryl. Great catch!

QSA Good Catch MD accidently ordered heparin gtt 800 units/kg/hour instead of 800 units/hr. It appeared in EPIC that the pharmacy had approved the order (when the medication was scanned there was not a msg indicating otherwise)when the RN was programming the alaris pump there was not a soft or hard stop to alert the RN to the large dose. the RN caught the high ml/hr and the gtt was not ever started.

QSA Questions???