The S-Team: Attacking Safety Issues One Step at a Time

Purpose for the program:

The Labor & Delivery Unit at Baylor University Medical Center identified the need to put patient safety as priority and change the culture of safety within the unit to see improved outcomes.   The staff realized there were many opportunities for improvement in creating safe passage for both mother and child.

Proposed change:

The Perinatal Safety and Quality nurse identified the need to incorporate frontline staff in identifying safety issues, implementing change that promoted safety and reflected best practice, and engaging staff to move toward a safer practice.   The proposal was made to implement a unit-based safety and quality committee comprised of Labor and Delivery nurses, with the aspiration of moving toward an interdisciplinary safety committee. 

Implementation, outcomes and evaluation:

With executive leadership support, a unit-based safety and quality committee was formed within the Labor and Delivery unit.   To kick off the first meeting, a video clip of the Josie King Story was presented to highlight the importance of patient safety initiatives to provide only the best and safest care to the patients.  The Safety Team (S-Team) began brainstorming through safety concerns and prioritizing these concerns.   One of the initiatives employed to engage all frontline staff, was the implementation of random safety audits.   Evidence supports the use of random safety audits to improve standards of practice, provide real-time evaluation of clinical activity, allow for immediate feedback, and thus allow immediate practice change.   The S-Team identified five safety issues they felt were priority and needed immediate auditing.  The random safety audits were put on the unit for all employees to partake in the auditing process.   This method of auditing brought awareness to all staff and allowed for the real time feedback to change current practice.   It allowed the S-team to identify the top 1 or 2 priorities and make recommendations for practice change.  With frontline staff leading this safety initiative, staff was receptive to the changes and recommendations that were being made.   The S-Team meets on a monthly basis and continuously works on safety issues and identifying quality improvement projects.

Implications for nursing practice:

Development of a unit-based safety committee has engaged frontline nurses in improving the environment in which they provide care and ultimate safe passage for the patient.  They also foster a positive environment to enhance current practices on the unit and influence staff to participate in quality improvement efforts and even speak up when there is a patient safety concern.

Keywords: Safety Committee, Random Safety Audits, safety culture