Parent Concern Safety Bundle RCNIC

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Parent Concern Safety BundleRCNIC

• M. Victoria deCastro, BSN, RNC, Clinical Manager
• Debbie Hershberger, MSN, RN, Outcomes Manager
• Jason Olivea, Quality Improvement Consultant

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Parent Concern Safety Bundle Project

• The purpose of this project is to develop and
  facilitate the RCNIC Improvement Team in
  developing and cultivating a safety repertoire or
  bundle that engages families directly in error
  prevention.

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History-Why do we need a safety bundle to address
parent concerns?

• A mother questioned the nurse about the amount of
  weighed medication that was going to administered
  to her baby.
• The nurse reviewed the label and compared the
  dosage with the MAR. The dosage on the label and
  the dosage on the MAR matched.

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History-Why do we need a safety bundle to address
parent concerns

• The nurse verified with mom that both documented
  dosages matched, concluding that the packaged
  amount was correct.
• The medication was given per NG to the infant
  with feeding.
• Shortly after this feeding, the infant vomited
  and arrested due to presumed aspiration.

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History-Why do we need a safety bundle to address
parent concerns

• The mother again questioned the amount of
  medication that was administered, knowing that
  side effects of the medication were nausea and
  vomiting.
• Leftover baggies of the medication were taken to
  pharmacy and reweighed.
• It was discovered that the amount was over 10
  times the ordered dosage.
• This event was later deemed a serious safety
  event.

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Questions?

• What could have been done differently in this
  case to prevent the serious safety event?

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Beyond the RCNIC

• The engagement of patients and families in the
  culture of patient safety and error prevention is
  both a CCHMC-wide initiative and a National
  Patient Safety Goal.
• The safety bundle in the RCNIC will become the
  foundation for the CCHMC-wide initiative.

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2007 National Patient Safety GoalsThe Joint
Commission

• Goal 13 Encourage patients active involvement
  in their own care as a patient safety strategy.
• What do we need to do according JCAHO?
• Define and communicate the means for patients and
  their families to report concerns about safety
  and encourage them to do so.
• What is the rationale?
• Communication with patients and families about
  all aspects of their care, treatment or services
  is an important characteristic of a culture of
  safety. When patients know what to expect, they
  are more aware of possible errors and choices.
  Patients can be an important source of
  information about potential adverse events and
  hazardous conditions.

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The Aim Statement

• The Aim of the Safety Bundle To design high
  reliability processes in the RCNIC to ensure that
  care is put on hold until parental safety
  concerns are resolved (i.e. Stop the Line
• Developed from the key drivers or root causes of
  the original problem

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The Key Drivers

• See the Staff Resource Folder on E-Chirp for the
  Key Driver Diagram

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The Primary Goal

• To actively and consistently (100 of the time,
  with 100 of parents/families, and with 100 of
  staff) engage families in a formalized process
  that partners families with the healthcare team
  to ensure patient safety and to identify and
  address safety concerns directly at the point of
  care.

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How was the bundle developed?

• A high reliability process quality improvement
  methodology was used.
• This process focused on system solutions and a
  problem-solving approach (define, measure,
  analyze, improve, and control).
• Outcomes and improvement are systematically
  analyzed.
• High reliability strategies were developed as
  components of the bundle.

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How was the bundle developed?

• A RCNIC Improvement Team was brought together to
  develop standards for parental/family engagement.
• The current state of parental/family engagement
  was analyzed. Emphasis was placed on
  understanding where failures in communication may
  occur.
• Strategies were developed to combat these
  potential failures.

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What were some of the potential failures and
strategies to combat these failures?

• Parents do not express their concerns-Why?
• a. Lack of knowledge
• Not sure, especially at first, what to ask, how
  to ask questions, or who to direct their
  questions to
• There is a feeling of being overwhelmed by their
  babys illness or just by being a new parent
• b. Too Afraid
• Non-assertive-may need an invitation to ask
  questions or question care
• Worried about retaliation/punishment for asking
  questions or questioning care, concern about
  being viewed as pushy and asking too many
  questions
• Developmental issues-for example, teen parents
  versus adult parents
• Uncertainty about their expectations regarding
  safety vs. non-safety concerns-parents may not
  know what to do when they have a concern, lack of
  knowledge that they are allowed to stop care or
  change care

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What were some of the potential failures and
strategies to combat these failures?

• Reliable strategies were designed to combat the
  knowledge gap, fear, developmental gaps, and
  personality differences
• Standardizing expectations of parents/families
  and staff as partners
• To be discussed in detail 24-72 hours after
  admission, with documentation of this discussion
  in Education When
• Develop a standard process for addressing and
  resolving parent safety concerns and other
  clinical concerns
• Posting expectations process at each
  bedside-the orange dry erase boards with the
  bedside cards of expectations, Stop the Line,
  use of independent verification with the
  PCFs-See Staff Resource Folder for more on
  Independent Verification
• Hardwiring inviting questions-i.e. Do you have
  any concerns about feedings, medications, pain
  management, or any other safety concerns?, with
  documentation in the flowsheet and narrative
• Each of these strategies were tested, revised
  based on staff and parent feedback, and retested.
  Refinement of the process continues.

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The Process Map

• Click onto the Staff Resource Folder found in
  Blitz for the map of the entire process for the
  safety bundle
• This folder will be available on E-Chirp

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The Main Parts of the Bundle

• Hardwiring parental engagement into routine
  practice- This is achieved by posting and
  routinely asking and documenting the following
  "Safety Questions when parents arrive and
  depart from the unit and when parents call for
  updates-      
• Do you have any safety concerns regarding your
  baby's medications, feedings, pain management, or
  any other safety concerns? These questions are
  also posted on the orange dry erase boards
• Documentation of routine parent safety questions
  on the flowsheet (Safety Questions Asked or
  SQA)
• Documentation of parent safety concerns in the
  narrative to include concern, intervention, and
  resolution-The bedside prompts detailing the
  process will be posted at each bedside

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The Orange Dry Erase Board

• Posting the parental expectations and questions
  on a dedicated board at each bedside creates a
  reliable standard of practice
• The board is not meant to written on by
  parents-the marker is available during this test
  phase
• The marker is to be used to rewrite the questions
  in case it smears off
• Once we have determined the final wording, a more
  permanent version will be placed on the boards.

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The Bundle at Admission Days 1-3

• Day 1-Verbally invite and encourage parents to
  bring up safety concerns to direct care team, by
  asking them if they have any concerns as listed
  on the orange bedside boards. You can refer them
  to the bedside cards if you think they are ready.
  The following should be done daily-
• Questions should be asked when a parent calls,
  when a parent comes in, and when a parent leaves
  for the day
• Routine safety questions about feeding,
  medications, pain management and general care
  concerns. New questions or concerns may be added
  in the future.
• Day 2 or Day 3-Review bedside cards on the RCNIC
  Process for Staff to Resolve Parental Safety
  Concerns, Clinical Concerns, Parent Staff
  Expectations, and the SBAR Card. Document this
  review with the parents in Education When.
• On the flowsheet and narrative, document any
  concerns and responses from the parents,
  including how a safety concern is resolved, if
  applicable.

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The Main Parts of the Bundle

• Using highly reliable error prevention
  techniques to address parental safety concerns
• If a safety concern arises, related care
  processes are stopped. The staff person will
  assess the situation using SBAR. Then the staff
  person will call the PCF (charge nurse) to the
  bedside for independent verification (using SBAR)
  of the situation. Both persons will then
  determine who the expert (attending physician,
  pharmacist, for example) is and bring them to the
  bedside to resolve the parent concern prior to
  resuming related care.  

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Levels I II Concerns

• Because of staff feedback during testing of the
  bundle, categories of concerns and separate
  processes were defined
• Level I is a clinical concern or plan of care
  concern
• Level II is a safety concern or a clinical
  concern with actual or potential safety
  implications
• See Staff Resource Folder (Process Map) for Level
  I II Concerns
• Coming soon-guidelines defining levels of
  parental concerns to be available in the Staff
  Resource Folder

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Common Concerns and Other Considerations

• It is okay to individualize your approach to
  parents when asking the safety questions-if you
  think that the word safety is uncomfortable or
  worrisome for a specific family, then customize
  what you say to the parent and just ask them if
  they have any questions about feedings, etc.
• Also, depending on the babys status, you can
  include ventilator or oxygen questions or exclude
  feeding questions as applicable.

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Common Concerns and Other Considerations

• Why were feedings, pain management, and
  medications chosen as the focus of the safety
  questions?
• These were the top 3 incidents reported in the
  safety report system that involved parent
  concerns. The bundle may be revised to consider
  other safety reported incidents such as IV
  infiltrates, the top reported safety incident in
  the RCNIC.

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Common Concerns and Other Considerations

• How do I know if it is a safety concern?
• If a parent says he or she has a safety concern,
  then it is a safety concern.
• If an error related to the concern may or will
  jeopardize patient safety, you should treat the
  concern as a safety concern.
• If you are not sure if the concern is a safety
  concern, use SBAR to clarify the concern. If you
  are still uncertain, it is best and safest
  practice to treat the concern as a safety concern.

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Common Concerns and Other Considerations

• What do I do if the parents concern is a
  clinical concern or plan of care concern?
• Ask parents some clarifying questions using SBAR
• Address and resolve the concern appropriately
• On the flowsheet and narrative, document the
  concern, how you addressed the concern, and what
  was done to resolve the concern

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Common Staff Concerns and Other Considerations

• The parents I work with do not have a problem
  expressing their concerns. Do I still need to
  ask the questions?
• Use your own critical judgment and common sense
• If your parents have already verbalized their
  questions and concerns and you feel that their
  questions adequately address their concerns, you
  do not have the re-ask the questions. Remember
  to document the parent-directed questions as
  safety questions asked

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Lessons Learned Next Steps-The Data Collection
Phase

• Ways to improve the process will be continually
  looked at based on outcomes and feedback.
• Parents will be surveyed on the parent
  satisfaction survey about how well they perceive
  the RCNIC staff addresses their safety concerns.
• The percentage of concerns that are safety
  concerns will assessed (team rep meeting with the
  PCFs and team rep checklist).
• Data will be collected measuring how well the
  bundle is being followed.

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Lessons Learned Next Steps-Implementation and
Sustainability

• Permanent changes to the flowsheet will be done
  with the next revision.
• Work systems (such as addition of Stop the
  Line, documentation), standards, procedures and
  policies are being added and revised as needed.
• Official roll-out of the bundle unit-wide will
  occur in September 2007

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Lessons Learned A Parents Perspective

• Several parents, who have stated that they do not
  have problems speaking up about their concerns,
  have stated the bundle is a good way to help
  quieter, less assertive parents to feel
  comfortable discussing their concerns.
• These parents have also stated that having a
  formal invitation and explanation to talk about
  their concerns would have eased their initial
  discomfort and uncertainty in verbalizing their
  concerns.

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Lessons Learned A Parents Perspective

• Recently, a parent verbalized that she has
  noticed a positive change in how well staff are
  actively asking about her concerns
• She stated that she appreciates being invited to
  discuss her concerns, because she feels like
  staff want to hear about her concerns, and she,
  then, does not feel like the pushy parent,
  especially with staff she does not know well.

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The Safety Bundle in Summary

• On day 1 (of admission)-Ask the safety questions
  and document on the flowsheet/narrative
• Day 2 or Day 3-Review the entire process with
  parents
• Document this explanation in Education When
• Use SBAR to clarify concerns, especially safety
  concerns
• Use independent verification for safety concerns
• Involve the appropriate expert(s) to resolve the
  concern, such as the attending physician if it is
  a medical safety concern
• Document on the flowsheet and narrative

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Final Words

• This bundle is based on the best practices of
• parent engagement that already exists in
• the RCNIC, making those practices standard
• Unit-wide and hospital-wide.
• Thank you to everyone for all your input and
• hard work!!