Safety First

Patient Safety Nurses Improve Care

by Jennifer Walker

In 2009 a nurse in The Johns Hopkins Hospital psychiatric emergency department was physically assaulted by a patient. Incidents like this are not uncommon in the ED, says Michelle Patch, MSN, RN, ACNS-BC. As the Safety Officer and Patient Safety Nurse for the Department of Emergency Medicine, Patch’s job is to investigate what causes unsafe situations, then work closely with staff to improve future outcomes.

In the 2009 case, the nurse did not know her patient had a violent history. The solution?  Patch coordinated a multidisciplinary team to create a behavioral-alert flagging system. Using an electronic note, staff now alert care teams about patients with a history of violent behavior and offer recommendations for safer interactions. The ED’s behavioral-alert system was used as a template to create a similar system hospital-wide.

“We’re helping staff to proactively address escalating behaviors [and] provide the best care for our patients,” Patch says.
The first step that patient safety nurses often take is to lead debriefing sessions and simulations after a problem occurs.
On the OB/NICU unit, for example, a recent patient had a cesarean birth, started bleeding, and needed an emergent hysterectomy.  It’s a high-risk event that doesn’t happen often, says Susan Will, MS, RNC, an Obstetrical Patient Safety Nurse, but in these high-stress situations, one danger is that staff communication can break down.

Afterwards, Will facilitated a debriefing session with the care team, who reinforced the need to appoint a communication facilitator in all acute situations. Rather than providing care, this staff member focuses on streamlining communication and making sure staff are on the same page.  Will says her role is to provide staff with the tools they need to collaboratively improve patient care. “Communication is critical to patient safety,” she says. “It’s a team effort.”

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