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Are We Pushing Graduate Nurses Too Fast?
Matt Huang, Molly Nolan, Howie Realubit, & Karina Salas
Azusa Pacific University
GNRS 586 Leadership and Management in Professional Practice
Janet Wessels MSN, RN, PHN
July 12, 2017
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1.Background
Learn what CRRT is and how it is used in the SICU
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Case Profile● New grad, graduate nurse● Employed in the SICU● 1 year floor experience● 8 hour CRRT operator seminar● Independent (non-supervision)
● Patient has pancreatic cancer● Patient needing CRRT due to kidney
injury
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Background
Continuous Renal Replacement Therapy (CRRT)
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Error Incident● Inexperienced nurse operating CRRT
● 2 ultrafiltrate effluent bags○ new nurse tried to refill bags but no supplies
immediately available on the floor
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2.Fishbone Diagram
Finding the cause and effect
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MethodsManpower
Machines Material
A lack of assessing CRRT competency and poor internal communication led to a patient death by an inexperienced nurse operating the CRRT.
The nurse had training but insufficient experience
No double-check by another nurse
Need to initiate critical thinking of errors
No communication process for machine troubleshooting
The CRRT machine did not alert staff of problem
No machine warnings for bag replacement
No new dialysate bags available in supply
No competency checklist
No checklist for errors
Fishbone Diagram
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3.Determining Root Cause
AnalysisFocus on the most important cause
and effect
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What is the Root Cause Analysis?
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The 5 WhysNarrowing down the primary cause of a problem using the fish diagram
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But first,State the problem.
Lack of CRRT Competency
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Next,“eye”-dentify an indicator.
Patient is crashing!
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Why1? Because the CRRT
dialysis machine stopped working.
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Why2?The effluent bags were placed in the
wrong output.
Why3?The machine output line for hanging the effluent
bag looks just like the one for hanging
dialysate.
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Why4?The new grad nurse that
hung the bags had training but insufficient
experience.
Why5?Actions were not in place to
eliminate human error. Specifically, the dialysis
machine allowed for hanging both types of bags.
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5 Why Checklist - RCA Statement
▧ Problem ▧ Identifier ▧ Why 1 ▧ Why 2 ▧ Why 3 ▧ Why 4 ▧ Why 5
Crashing patient!Lack of Training?
Machine stalled → Right bags →
New nurse → → Insufficient training or Faulty Machine Design?
Wrong outlet →
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4.Actions
Actions to prevent recurrence
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Action 1Strong actions remove human
dependence entirely (“idiot-proof” - machine dependent, patient
centered).
VA National Center for Patient Safety RCA Tools REV.02.26.2015
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Prevents from hanging and
connecting the wrong bag to
the line
Change the Outflow Line Hookup
Pros: No human
involvement
Con: Non-transferability (machine
reliant)
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Action 2Medium actions reduces human
reliability but not human error. (Extra insurance).
VA National Center for Patient Safety RCA Tools REV.02.26.2015
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Provides additional
supervision/insurance
Place Checklist, Warning Label, & Dialysis/Preceptor Staff
Pros: Slightly reduces
unwanted outcome
Con: Requires
add’l staff and allows for human
error
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Action 3Less stronger actions clarify & support
the process, but relies entirely on humans. (Human driven).
VA National Center for Patient Safety RCA Tools REV.02.26.2015
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Change training
policy for all New Nurse
Transition Training
All New Nurses: Standardized Transition Program & Pre-stock Supply
Pros: Raise awareness Con: No
meaningful action (entirely human reliant)
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5.Outcome Measures
Measures and Type
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Outcome Measures
● Numerator: number of preventable adverse events for patients on CRRT
● Denominator: total number of patients on CRRT in the ICU
● Threshold: 0 deaths will occur
● Date: the collection will be monitored for six months
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Outcome Measures Type
● Adverse Event Outcome:◦ An improved staff training will be developed to
ensure competency.
◦ Six months following the improved staff training, the number of preventable adverse events for patients on CRRT will result in zero deaths.
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6.PDSA
Plan, Do, Study, Act
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PDSA: Aim
To reduce the number of adverse events related to CRRT machine use in the SICU to zero within 6 months of implementing the new training process.
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PDSA: Plan
Tasks Person Responsible
When Where
Develop streamlined training/education for all RNs on SICU current and future
Nurse Manager Within one weeks SICU & all units in hospital that utilize CRRT machine
Skills competency testing & re-testing
RN Bi-annually following initial training
Hospital
Implement “Buddy system” with 2 RN double check process
Nurse Manager First five times utilizing CRRT machine
Patient room
Designate a staff member to account for CRRT supplies each shift, restock, and report any missing items
Nurse Manager Within one week Supply room
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PDSA: Plan(continued)
Prediction Measures to Determine Prediction Success
All RNs in SICU will be able to properly use a CRRT machine with zero adverse events leading to death
- Standardized transition program- Evaluation of competency will be conducted on a
bi-annual basis via skills competency re-testing- RN preceptor double check buddy system between
inexperienced nurse with CRRT machine and experienced nurse for first five times using the CRRT machine with a patient
The CRRT machine supplies will remain fully stocked on a daily basis
- Supply checklist- Designated staff member checks every shift and
restocks as necessary as monitored by Nurse Manager
Nurse managers will be able to train and retrain at least 90% of nurses within two weeks
- Sign in sheet at each training session to keep track of who has been trained & retrained
Nurses will feel more competent and confident in using the CRRT machine
- Provide feedback and opportunities for reflection- Complete surveys- New nurses/inexperienced nurses will be supervised
and evaluated 5 times as part of the preceptor RN double check
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PDSA: Do
● It will take about one week to create and implement new & streamlined training and about two weeks to train and retrain all nurses currently working on the SICU
● Nurse managers will need to continually observe and monitor that training is being completed bi-annually, buddy system double checks are being utilized for the first five times using a CRRT machine, and that the designated staff member is keeping all CRRT machine supplies appropriately stocked
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PDSA: Study
Prediction Outcome
All RNs in SICU will be able to properly use a CRRT machine with zero adverse events leading to death
- 0 patient deaths- 1 near miss reported
The CRRT machine supplies will remain fully stocked on a daily basis
- The supplies were stocked 90% of the time
Nurse managers will be able to train and retrain at least 90% of nurses within two weeks
- 80% of nurses were retrained and passed the skills competency checklist
Nurses will feel more competent and confident in using the CRRT machine
- 95% of new nurses felt competent with the involvement of leadership staff in support of patient safety
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PDSA: Study(continued)
Problem Solution
Lack of transition from education to practice program
- Create competency checklist- Have preceptors oversee preceptee
handle CRRT machine at least 5 times before being deemed competent
- Simulation of the use of CRRT
Lack of supplies on the unit - Create supply checklist- Designate a staff member to count
supplies each shift and report any missing items
Summary of Findings:◦ Goal Met: Six months following the improved staff training, the number of
preventable adverse events for patients on CRRT will result in zero deaths.
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PDSA: Act
● Next Steps:◦ Clearly define staff roles: preceptor, preceptee,
“buddy” system
◦ Perform on-site observations
◦ Adjust checklist for restocking the CRRT machine
◦ Institute competency checklists across units
◦ Compare and share data across hospitals
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7.Stakeholder Analysis
...
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● Internal (unit) stakeholders:
◦ Patients
◦ New Nurses
◦ Charge Nurses
◦ Hospital Administrators
● External stakeholders:
◦ Family Members
◦ Dialysis Nurse Associations
◦ CRRT Trainers
◦ Hospital Investors
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8.Force Field Analysis
...
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Forces FOR Change (Driving Forces)
Forces AGAINST Change(Restraining Forces)
Strategies to mitigate restraining forces:● Orientation for new nurses and new nurse preceptorships for CRRT● Signs to remind nurses of critical CRRT processes● Ensure CRRT patients are covered by experienced CRRT nurses● Assign specific responsibilities to nursing staff● Lobby hospitals to increase resources for units with CRRT
● Nursing culture for new nurses on unit
● Additional time to reinforce procedures
● Additional resources (i.e. money and staff) to reinforce procedures
● Patients and their families
● New nurses● Dialysis nurses● Nursing associations● Hospital
administrations● Organizations for
patient safety
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Thanks!
Any questions?
Matt: AnalysesMolly: PDSA, OutcomesKarina: PDSA, Outcomes
Howie: Background, Actions
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References
Continuous Renal Replacement Therapy. (2017). Retrieved fromhttp://www.baxter.nl/healthcare_professionals/therapies/renal/acute_kidney_treatment/continuous_renal_replacement_therapy.html
Mrsiraphol. (2017). Hospital blur. Retrieved from http://www.freepik.com">Designed by mrsiraphol / Freepik
Tsai, C. (2009) Root Cause Analysis. Retrieved from https://www.slideshare.net/CharlesGYF/cat001-root-cause-analysis
VA National Center for Patient Safety RCA Tools REV.02.26.2015