It's a Crime to Risk Patient Safety

Sunday, June 16, 2013

Title: It's a Crime to Risk Patient Safety

Ryman Hall B4 (Gaylord Opryland)
Angel Cook, MSN, RNC-OB, c-EFM , Family Birthing Center, Mercy Health- West Hospital, Cincinnati, OH
Marie Leist-Smith, MSN, RNC, C-EFM , Fairfield Family Birth Center, Mercy Health Partners, Cincinnati, OH

Discipline: Advanced Practice (AP), Childbearing (CB), Newborn Care (N), Professional Issues (PI)

Learning Objectives:
  1. Identify one learning method of professional nursing competency validation.
  2. Describe implementation of the Crime Scene Invistigation Room for Patient Safety.
  3. Describe the role of the RN for patient safety in the Obsetic Setting.
Submission Description:
Purpose for the program:

Patient Safety was defined by the US institute of Medicines “the freedom from accidental injury due to medical care or from medical error.”  Creating a culture of safe patient care is leading the health care industry in terms of quality of care, medical reimbursement, patient outcomes, patient satisfaction, and nursing education. The purpose of this innovative education is to enhance the critical thinking skills of perinatal direct care nursing staff on patient safety hazards with the intent to decrease adverse patient outcomes.  The “Crime Scene Investigation” (CSI) education program was implemented to improve an overall safe environment that reduces the rate of adverse obstetric safety events.

 Proposed change:

Traditional nursing education includes self study packets, written exams, on-line learning modules, didactic oral presentations. As nurses we routinely use psychomotor skills however traditional nursing education fails to address how we perform and mentally and critically think. A CSI room was created to have the direct care nurses physically identify safety hazards in an obstetrics’ patient room.

Implementation, outcomes and evaluation:

A patient’s room was simulated into a “crime scene” with low fidelity mannequins over 35 patient safety hazards with various maternal education competencies including invasive lines, wound care, sepsis, respiratory, blood administration, medication safety, and falls. Neonatal patient safety hazards included patient identification, safe sleep, and radiant warmer equipment.  The nurses received information about the crime scene through a case study and then enter the room to investigate for patient safety hazards.  The investigating enhanced critical thinking skills and awareness of patient safety hazards. Direct care nurses engaged in communication about the safety hazards and discussed process and flow in the patient’s room.   Direct care nurses were able to identify areas of risk on the obstetric unit and implement ideas for process improvement.

Implications for nursing practice:

The CSI project impacted nursing care because it created a new type of learning environment that enhanced critical thinking skills and psychomotor skills.   Minimal cost was associated with the project as everything was preformed on the unit during the staff’s scheduled shift. This CSI education project is adaptable to any health professional education.  Avoiding preventable injuries to mother and neonates improves patient’s outcomes and is on the forefront of staff education and awareness.

Keywords:

Education, Professional Development, Critical Thinking, Simulation, Psychomotor Skills