BREMERTON, Wash. - The Navy Nurse Corps staff at Naval Hospital Bremerton bolstered the command’s 2016 Patient Safety Awareness Week campaign of Mar. 13-19, 2016 by organizing a hands-on "Patient Safety Seek and Find" exhibit.
The event was organized in NHB’s Simulation Lab with a medical mannequin, giving staff members the overlapping opportunity of testing their awareness, knowledge and familiarity of patient safety by trying to identify and locate as many potential risk hazards as possible.
“We want all staff members, not just nurses and corpsmen, to take part in this. It’s a good interactive exercise. A staff member writes down what they see could increase the risk of the patient whether it’s from such a possibility as falling or getting the wrong medication,” said Lt. Lauryn Rutherford of NHB’s 4OB department.
The ‘patient’ was Mr. James, a 64-year old male, in the second day of hospital admission with a diagnosis of right total knee arthroplasty. His medical history was significant for being insulin dependent for diabetes. His previous surgical history shows lymph nodes removed in left axilla, and a known allergy to silk tape.
The directions informed staff that they should enter the patient’s room and immediately begin reviewing three high-risk areas of concern; avoiding falls, avoiding infection transmission, and avoiding medical errors. They then had to review the patient’s information and medical history before seeing if they could find 15 problems which placed the patient’s safety at risk.
Staff were also reminded that patient safety encompasses a broad array of risk reduction strategies to avoid harm, so some of the potential problems were not part of the three high risk areas mentioned.
“This was a good awareness drill. It made us critically think. There were some problems that were easy to overlook. But by really looking, you do notice them,” said Cmdr. Nanette Brown, 4OB Department head.
Hospitalman Kelsey Yarbrough noted that there were a few obvious safety hazards, but then found more than anticipated.
“The hand sanitizer, didn’t get that one,” she said, referring to the hand sanitizer dispenser in the patient rom that had an expiration date for the contents.
The obvious "clues" included mock details for a fluid spill on the floor, a "bloody" hand print on the bed railing, and improper needle disposal. Other indicators had to be systematically searched for, such as a medication error, mislabeled wristband and wrong personal data recorded.
“Every problem places the patient’s safety at risk,” Rutherford said.
Avoiding falls remains a top priority in patient safety awareness. Falls are a common cause of patient injury, both within and outside of a health care setting. It is estimated that more than one-third of adults over 65 fall each year, and in a hospital environment, falls tend to happen during a trip to and fro the restroom.
A fall can cause such injuries as fractures, bleeding and sometimes even death. Patients may be at increased risk of falls if: they have impaired memory; they have muscle weakness; they are older than 60; they use a cane or walker; and they are on certain medication.
“We take falls very seriously here and employ many steps to reduce any risk associated with any patient falling,” said Cmdr. Annie Case, NHB Quality Management Department head.
Avoiding infection transmission is also important in preventing any type of contamination and the Centers for Disease Control and Prevention estimated that approximately one million deaths worldwide could be prevented with proper hand hygiene.
A significant cause of medication errors usually happens if there is an interruption during the medication administration process. Staff are trained that in order to reduce distractions, it is best to prepare the delivery of medications in a designated quiet zone. Practicing the six rights of Nursing is considered essential; "Right Patient, Right Medication, Right Dose, Right Route, Right Time and Right Documentation."
Using the Sim Lab as part of Patient Safety Awareness Week provided the convenient option for expanded hands-on training. NHB healthcare providers had the opportunity to replicate the experience of going through actual patient safety protocols and care by developing both didactic and kinesthetic skills by using the low, medium, and high fidelity simulation state-of-the-art medical mannequins that have cutting edge technology.