Healthy Workplace = Quality + Patient Safety

Regulation of professional nursing practiceA few weeks ago we summarized features in the new edition of the Correctional Nursing: Scope and Standards of Practice (ANA, 2013).  The scope and standards are described first, as the foundation for professional nursing practice regulation because they define the specialty for nurses as well as the public. The are broad statements about the practice of the profession that transcend geographic location, type of employer and population served. The nurse practice act in the jurisdiction where the nurse is licensed provides the second level of specificity and guidance related to practice.  The employer, organization or institution  provides the third level of specificity by establishing policies, procedures and a work environment that supports professional nursing practice.  The final level in the regulation of professional nursing practice is the individual nurse who is responsible and accountable for their competence and nursing decisions (White & O’Sullivan, 2012).  This description is depicted in the diagram on the left of this post.

There is a strong link between work environments that support professional nursing practice, quality of care and patient safety.  The American Nurses Association (ANA), The Joint Commission (TJC 2012), the International Council of Nurses (ICN 2007) and the American Association of Critical-Care Nurses (AACN) are organizations that have used evidenced-based research to develop resources and establish standards for the workplace that support quality and patient safety. What are the characteristics of work environments that support nursing practice?  The AACN standards align with the core competencies for health care professionals recommended by the Institute of Medicine (IOM). The AACN provides many resources on the web and so their six standards for the healthy workplace were selected to highlight along with examples here:

  1. Nurses are as proficient in communication as they are in clinical care. Examples of practices that improve nurses’ communication skills include nursing grand rounds, assistance to publish articles and present at conferences.
  2. Nurses are relentless in pursuit of true collaboration. Examples of practices that improve nurses’ skills in collaboration include the development of nurse to nurse collaboration such as rapid response teams, development of clinical practice protocols, and participation in CQI activities.
  3. Nurses make policy, direct and evaluate clinical care, and lead organizations. Examples of practices that support nurses’ participation in the development of policy and other aspects of organizational leadership include membership on interdisciplinary committees such as Pharmacy and Therapeutics (P&T), Continuous Quality improvement (CQI), Ethics and Infection Control and other committees responsible for guidance regarding clinical patients care.
  4. Staffing effectively matches patient needs and nurse competencies.  An example of this are systems that acknowledge nurses for clinical expertise in direct patient care by rewarding advancement in clinical education and certification.
  5. Nurses are recognized and recognize others for the value they bring to the organization. Examples of practices that support meaningful recognition include clinical ladders, identification of expert nurses and publication of nurse’s advancement clinically.
  6. Nurse leaders authentically live and engage others in the achievement of a healthy work environment. Examples of practices that support authentic leadership include participation in key decision making forums, access to essential information and the authority to make necessary decisions regarding the professional nursing workforce (AACN, 2005; Vollers, et.al. 2009).

One of the distinguishing features of correctional nursing and indeed one of the challenges in the practice of correctional nurses is that prisons, jails and other correctional facilities do not have a health care mission but instead a mission of safety and security. A major role for correctional nurses is to negotiate with the correctional environment to support appropriate patient care delivered in ways that are consistent with the standards for professional practice. In order to support professional practice nurses must be knowledgeable of the state or licensing jurisdiction’s nurse practice act as well as the characteristics of work environments that are linked to quality patient care and patient safety such as the AACN described here.

What successes have you experienced supporting professional nursing practice while negotiating the differences in the mission of the criminal justice system and the delivery of health care?  Please share your experiences by writing in the comments section of this post.

For more on the topic of environments that support professional nursing practice in the correctional setting see Chapters 4, 17 & 19 of the Essentials of Correctional Nursing. The text can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

References and Resources:

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

White, K., O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD.

International Council of Nurses (2007) Positive Practice Environments: Quality Workplaces=Quality Patient Care. Geneva (Switzerland): International Council of Nurses. Accessed 6/10/2010 at http://www.icn.ch/images/stories/documents/publications/ind/indkit2007.pdf

American Association of Critical-Care Nurses. Accessed 6/10/2013 at http://www.aacn.org/wd/hwe/content/resources.content?lastmenu=#articles

The Joint Commission. Improving Patient and Worker Safety (2012).  Accessed 6/10/2013 at http://www.jointcommission.org/improving_Patient_Worker_Safety/

The American Nurses Association.  Accessed 6/10/2013 at http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment

Photo Credit:  American Nurses Association Model for Regulation of Professional Nursing Practice

Drug Diversion or Bad Habits?

Packs of pillsYou have been asked by the CQI (continuous quality improvement) committee to initiate a weekly review of accountability for administration of controlled substances.  Your facility recently installed an automatic dispensing cabinet (ADC) in the clinic to store controlled substances. Nurses withdraw medication from the cabinet that corresponds to a specific patient order.  A feature of the ADC is that every transaction involving the administration of narcotics is recorded electronically and counts are verified at the time of each transaction.

Your first step is to review a report of all transactions that took place last week. The report lists each medication and whether it was removed, returned or wasted.  The information included with each of these transactions is the date and time, the order number, the quantity, the patient identifier, and the identity of the nurse responsible for the transaction.  You randomly select eight medication administration events to review.  The results are surprising.

Problems with accountability for controlled substances are identified in four of the eight instances reviewed. These problems are:

1. The nurse removed two tablets of tramadol HCL when the patient’s order was only for one tablet. On the medication administration record (MAR) only one tablet was documented as given. The second tablet was not accounted for.

2. The nurse removed a dose of clonazepam for a patient at 5 pm when the order was only for a morning dose. There was no documentation that the dose removed from the cabinet at 5 pm was ever given to the patient or returned to the cabinet later.

3. One nurse removed a dose of clonazepam at 5:30 AM but it was recorded as given by another nurse at 9:00AM.

4.  A nurse records wasting 50 tablets of tramadol HCL at 10:20 PM. There is no record that another nurse witnessed the event and the number of tablets wasted is not consistent with the count of tramadol HCL kept in the cabinet.

You report these findings to the CQI committee and after some discussion an action plan is developed which will continue monitoring and follow up of discrepancies. The plan also includes informing nursing staff about the methods that are used to monitor accountability for administration of controlled substances, the definition of drug diversion and associated risk behaviors, and recommended best practices to improve accountability for controlled substances.

Nurses who fail to account for controlled substances violate the state nurse practice act, the Controlled Substances Act and may be at risk of criminal sanctions as well. Drug diversion is defined by the U.S. Department of Justice simply as diverting drugs from their original purpose (2013). A discrepancy between the patient’s MAR and the controlled substance log can be sufficient evidence to prove drug diversion (Mooney, 2013).  A discrepancy is lack of documentation to account for each step in the administration of a controlled substance after its removal from the narcotic cabinet. Instances 1, 2 and 4 described above are discrepancies because there is insufficient documentation to verify the disposition of each dose removed from the ADC.

Other practices that are associated with increased potential for drug diversion include:

  • Excessive amounts of controlled substances signed out
  • More sign outs by a particular nurse
  • Lack of waste or excessive wasting
  • Documentation of medication administered for pain that does not correspond to the patient’s rating of pain.
  • Lengthy periods of time between sign out and administration to the patient (Mooney, 2013; LaFerney, 2010; Vrabel, R. 2010).

Instance 3 described above involved a controlled substance that was signed out four hours before it was administered. It also was given by a nurse other than the one who signed it out. Instance 4 involved excessive wasting and was not verified by a second nurse.

After further follow up of each of these instances no additional evidence is found to support a conclusion that any of these nurses were diverting controlled substances. Instead each involved poor work place practices, time and staffing constraints. The nursing staff was surprised at how many problems were brought to light by simply monitoring the controlled substance log against the MAR and discussed the steps they would take to better account for the disposition of each medication dose. Your subsequent audits provide feedback and evidence of improvement in accountability for controlled substances.

Additional resources on accountability for controlled substances and recommendations to prevent and detect diversion can be obtained at the Institute for Safe Medication Practices and from a series of articles that appeared in Volume 42 of the journal, Hospital Pharmacy, published in 2007 (McClure et.al. 2011). For more on best practices for medication administration in the correctional setting see Chapter 4 of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Have you had success solving problems with accountability for controlled substances that you would like to share with others? If so please tell us about it by writing in the comments section of this post.

References:

LaFerney, M.C. (2010) Dealing with drug diversion. Reflections on Nursing Leadership. 36 (2).

McClure, S.R.; O’Neal, B.C.; Grauer, D.; Couldry, R.J. (2011) Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals. American Journal of Health-System Pharmacy. 68: 689-694

Mooney, D. H. (2013). Investigating and Make a Case for Drug Diversion. Journal of Nursing Regulation. 4 (1): 9-13.

U.S. Department of Justice, Office of Diversion Control. (2013). Code of Federal Regulations 21 Part 1300. Retrieved 5/30/2013 from  http://www.deadiversion.usdoj.gov/21cfr/cfr/2100cfrt.htm.

Vrabel, R. (2010) Identifying and dealing with drug diversion. Health Management Technology. 31 (12):1-5

Photo Credit: © oksix – Fotolia.com

Best Practices to Promote Hand Hygiene

Word cloud for Hand washing“Hand hygiene seems so simple but is complex in health professionals minds otherwise it would be done all the time. Having hand washing ‘handy or in close proximity’ to the work seems to be one key. We need dispensers on all medication and treatment carts as well as all other trays or patient care areas. Then the real effects of hand washing and hygiene can be felt with reduced illness and infection among patients as well as care givers” commented Gayle Burrows, an experienced correctional nurse administrator, on the previous post. Her observation echoes recommendations from the Institute for Healthcare Improvement that hand hygiene of healthcare workers improves greatly when the following “best practices” are in place at the worksite.

Best Practices for Hand Hygiene

1. Healthcare workers demonstrate knowledge of the key elements of hand hygiene practice which are:

A. If hands are not visibly soiled, decontaminate with an alcohol-based hand rub:

  • Before and after direct contact with patients.
  • Before and after invasive procedures.
  • After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled.
  • After removing gloves.

B. Wash hands with soap and water:

  • When hands are visibly dirty or soiled with blood or other body fluids.
  • When caring for patients with diarrhea like illnesses.
  • Before eating.
  • After using the restroom.

C. Wear gloves when in contact with:

  • Excretions
  • Secretions
  • Mucous membranes
  • Non-intact skin.
  • Perform hand hygiene immediately after gloves are removed.
  • Change gloves when moving from a contaminated site to a clean site on the same patient.
  • Change gloves after caring for each patient.

2. Healthcare workers demonstrate appropriate hand hygiene techniques which include:

A.    Hand rubbing

  • Use an alcohol-based hand hygiene product (rub, gel, or foam). Antimicrobial-impregnated wipes (i.e., towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap.
  • Use enough to cover all surfaces (palm, back of hand, fingers, fingertips, and fingernails);
  • Rub until dry (at least 15 seconds).

B.  Hand washing:

  • Wash hands with soap and water, including contact with soap for at least 15 seconds.
  • Cover all surfaces including palm, back of hand, fingers, fingertips, and fingernails.
  • Rub with friction.
  • Use paper towel to turn off the faucet.
  • Dry hands with fresh paper towel.
  • Take gloves off inside out so the hands are not in contact with a contaminated glove surface.

C. Removing gloves

  • Take gloves off inside out so the hands are not in contact with a contaminated glove surface.

3. Hand hygiene supplies are available at the point of care.

  • Availability of alcohol-based hand rub at the point of care minimizes the time constraint associated with hand hygiene during patient care and is a predictor of better compliance.
  • The cost of hand hygiene products should not be the primary factor influencing product selection. Hand-hygiene products should have low potential for irritation.
  • Provide hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing.
  • Availability of gloves in appropriate sizes at the point of care for use in high-risk situations when barrier technique is indicated.
  • Sterile gloves are not required for this purpose.

Here are the answers to the questions about hand hygiene that were posted last week.  Did you use any of these as a test of knowledge for yourself or among your co-workers?  How did you do? Please share your experiences improving hand hygiene by responding in the comments section of this post.

Question 1: A Question 2: B Question 3: A Question 4: A
Question 5: B Question 6: B Question 7: A Question 8: A
Question 9: A Question 10: A Question 11: 4 Question 12: C
Question 13: C Question 14: D Question 15: 3 Question 16: C

For more on hand hygiene in the correctional setting please refer to the Essentials of Correctional Nursing particularly Chapter 4 in relation to patient safety and Chapter 10 as part of the discussion about infection control.  You can order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © intheskies – Fotolia.com

What is Your Hand Hygiene IQ?

800x600Last week we shared information about health care organizations that had improved compliance with best practices for hand hygiene into the 90% range.  If patient safety (i.e. reduction in healthcare acquired infection) is to be accomplished hand hygiene must become highly reliable. One of the measures to monitor and improve hand hygiene the Institute for Healthcare Improvement (IHI) recommends is that healthcare workers demonstrate their knowledge of the key elements of hand hygiene practice.

Below are 16 questions so that you can test your knowledge about hand hygiene. Next week the answers will be posted. You could pick perhaps five questions and post them in the workplace or pass them out at a staff meeting to generate discussion among your colleagues.  The IHI recommends only using a few at a time so that people are not burdened by the exercise. All of the possible questions are listed here so you can choose how you want to use them.

1. If infectious matter gets on your hands:

A. The sooner you wash it off, the less chance you have of getting infected.

B. It is okay to wait as long as you wash it off when you can get to it.

2. The Centers for Disease Control (CDC) recommends that healthcare professionals was their hands with soap and water for at least:

A. 30 seconds

B. 15 seconds

C. 20 seconds

3. According to the CDC the most effective way to reduce multi-drug resistant pathogens on the hands is to:

A. Use an alcohol based sanitizer.

B. Wash with warm water and soap.

C. Use prepackaged antibacterial wipes.

4. To reduce contamination after washing your hands turn off the faucet by using:

A. A paper towel.

B. Your elbow.

C. The top of the hand.

5. Which substances are considered most likely skin irritants:

A. Alcohol-based sanitizer.

B. Soap and water

C. Prepackaged antibacterial wipes.

6. Alcohol-based sanitizer is effective against Clostridium difficile.

A. True

B. False

7. Glove use when in contact with patients is a useful strategy in reducing transmission of infectious organisms.

A. True

B. False

8. How often should you clean your hands after touching a patient?

A. Always

B. Often

C. Sometimes

D. Never

9. How often should you clean your hands after touching an environmental surface in a patient care area?

A. Always

B. Often

C. Sometimes

D. Never

10. Artificial nails worn by a healthcare worker poses an infection risk for patients.

A. True

B. False

11. In which of the following situations should hand hygiene be performed?

A. Before direct contact with a patient.

B. Before an invasive procedure.

C. When moving from a contaminated to a clean body site.

D. After direct contact with a patient

E. After removing gloves.

     Answer choices:

1. B and E

2. A, B, and D

3. B, D, and E

4. All of the above

12. Which of the following is most effective in reducing bacteria on the hands when they are not visibly soiled or contaminated?

A. Washing hands with plain soap and water.

B. Washing hands with antimicrobial soap and water.

C. Using alcohol-based sanitizer and rubbing until dry.

13. How are antibiotic-resistant pathogens most often spread among patients in healthcare settings?

A. Airborne transmission from coughing and sneezing.

B. Contact with contaminated equipment.

C. Inadequate environmental sanitation.

D. Contamination on the hands of clinical staff.

14. Hand hygiene including proper use of gloves prevents transmission of the following  to healthcare workers:

A. Herpes simplex virus

B. Methicillin-resistant Staphylococcus aureus

C. Hepatitis B

D. All of the above

15. Which of the following pathogens survive in the patient care environment for days to weeks?

A. Escherichia coli

B. Klebsiella spp.

C. Clostridium difficile

D. Methicillin-resistant Staphylococcus aureus

E. Vancomycin-resistant enterococcus

     Answer choices:

1. A and D

2. A and B

3. C, D, and E

4. All of the above

16. Which of the following statements about alcohol-based hand sanitizer is most accurate?

A. It dries the skin more than washing with soap and water.

B. It causes more allergy and skin irritation than products made with chlorhexidine gluconate.

C. In the presence of a pre-existing skin condition it can cause some stinging.

D. It is effective when hands are visibly soiled or contaminated.

E. It destroys bacteria more slowly than antiseptic soaps.

Do you have some hand hygiene questions you would add to these? What ideas do you have about how to generate interest in improving hand hygiene knowledge and practice? Please share them with others by responding in the comments section of this post.

For more on hand hygiene in the correctional setting please refer to the Essentials of Correctional Nursing particularly Chapter 4 in relation to patient safety and Chapter 10 as part of the discussion about infection control.  You can order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: provided courtesy of Novant Health at http://www.washinghandssaveslives.org/download/

Hand Hygiene: A simple habit embedded in the complex process of care.

800x600Last month the Institute for Healthcare Improvement (IHI) sponsored a discussion about what it takes to improve healthcare workers compliance with recommended hand hygiene practices.  Less than 50 % of the healthcare workforce demonstrate adherence to hand hygiene procedures. Reasons for non-adherence include:

  • Skin irritation
  • Use gloves instead
  • Equipment & supplies not accessible
  • Forgetfulness
  • High workload-understaffing
  • Patient need for care was a higher priority
  • Lack of knowledge
  • Insufficient time
  • Interferes with the patient relationship

What do you think the rate of adherence with hand hygiene practices is within the healthcare program at your facility?  Have you experienced difficulty carrying out proper hand hygiene in your practice? If so was it because of any of the reasons listed above? See a post from last August on the challenges of hand hygiene for correctional nurses at Correctional Nurse.net.

In the last several years the World Health Organization, the Joint Commission and the Centers for Disease Control (CDC) have targeted reduction in healthcare acquired infection as a primary patient safety goal.  The proposed standards for patient safety in prisons include the recommendation that correctional facilities comply with all category 1 recommendations in the CDC’s hand hygiene guidelines.  The reason the Institute for Healthcare Improvement (IHI) held the forum last month was to discuss how some facilities have increased hand hygiene adherence into the 90% range. The main points from this discussion were that hand hygiene is a habit that develops well before the professional training of health care workers and that while it is a simple task; it is embedded in the very complex process of patient care.

Organizations which have achieved these high adherence rates took these three steps:

  • Bring awareness of hand hygiene to the front of the mind.  Developing posters, screen reminders and simple signs to remind healthcare workers to wash their hands. In one facility the nurse manager writes a simple reminder on the white board in every patient room every day. Here is one of many resources for such reminders: http://www.washinghandssaveslives.org/download/
  • Link patient-centeredness to hand washing. Another facility mapped the process of care delivery and found that hand hygiene did not take place because it interfered with greeting the patient and bringing supplies into the room. The corrective action involved moving a privacy curtain and identifying more appropriate hand hygiene products available at the point of care.
  • Hold healthcare workers accountable for avoiding harm. One of the facilities described coming to an understanding that compliance rates were simply an average.  When they realized that while some staff were very adherent others were less compliant or not at all, a more individualized and targeted approach to improving hand hygiene was initiated. An audit procedure was established to observe healthcare workers and to provide individual, specific feedback on compliance. Providing feedback was described as an opportunity for a conversation that was sincere and serious. Failure to improve was escalated up the chain of command but still treated as an important conversation. By focusing on individual knowledge and practice competency, overall compliance rates increased.
  • Demonstrate that avoiding harm is a priority. Leadership needs to demonstrate the priority of hand hygiene in patient safety.  Already described were nurse managers putting new reminders in patient care areas every day. Another example is a CEO who tests knowledge of staff about hand hygiene while on rounds at the facility.  He selects five questions each week to keep the dialogue around hand hygiene fresh and interesting.

Share your thoughts about how to improve hand hygiene practices in correctional nursing practice by responding in the comments section of this post.

For more on hand hygiene in the correctional setting please refer to the Essentials of Correctional Nursing particularly Chapter 4 in relation to patient safety and Chapter 10 as part of the discussion about infection control.  You can order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. 

Photo Credit: provided courtesy of Novant Health at http://www.washinghandssaveslives.org/download/

Improving Patient Safety with a Hand-Written Medical Record

files

The medical record is a primary source of communication among health care staff and serves as a permanent record of care and treatment delivered to a patient. Lack of adequate communication and miscommunication can seriously jeopardize patient safety. Many correctional facilities still use a handwritten patient chart, although most traditional settings have moved to electronic documentation. If you are still hand-writing patient care information, here are some tips to improve patient safety in key areas of your documentation.

‘Do Not Use’ Abbreviations

We can get pretty creative with abbreviations when time is short. I have seen some interesting configurations on medical records in the correctional setting. Would you be able to translate “GEE wnl” or “AOB at intake”* Maybe so, if you worked within that particular facility, but, then again, maybe not. What if you needed to interpret the abbreviation in order to provide medication or treatment? “SS per FSBS QD @ 4A”** Would your patient get the right treatment? Inconsistent or confusing abbreviations are risky business.

The Joint Commission issued a list of common abbreviations that frequently result in misinterpretation and treatment error. Eliminating use of these abbreviations can significantly improve patient safety at your facility.

Do Not Use List

The Joint Commission short list above is a good start. A longer list of error-prone abbreviations is provided by the Institute for Safe Medical Practices. Consider eliminating their more extensive list of poor abbreviations from your clinical documentation.

Keeping It All Together

Patient safety is compromised when the medical record is not complete. Even when attempting to document all assessments, interventions, treatments, and outcomes; information can go missing. Here are some common ways communication gaps develop:

  • Loose notes such as sticky notes, post-its, or slips of paper are used to communicate findings among staff members. These may actually start on the chart but then fall out or loosen over time. Always chart communication directly on the medical record.
  • Several medical records exist for the patient and are used by different disciplines. Frequently the patient has both a medical and mental health chart. A complete picture of the patient is difficult to develop without the full chart.
  • Documentation takes place long after care is delivered. When sick call takes place in the housing units or treatment line takes place in a satellite office, documentation may start on scraps of paper or be left to memory for later documentation. A busy day can lead to scattered or absent documentation about important clinical events and observations.

Check That Off the List

In the Checklist Manifesto, surgeon Atul Gawande applies the concept of safety checklists long used in the aeronautic and nuclear power industries to healthcare with exceptional results. Up to a 75% reduction in surgical errors have been attributed to the use of checklists in the operating room. How can we apply this information to the correctional setting? Suggested areas include discharge planning, release from suicide precautions, return from the hospital, and post-emergency documentation. Checklists help us remember important steps in a busy and distracted situation. In some ways, pre-printed forms and flowsheets provide checklist-type prompting to our documentation. Use them whenever possible.

What documentation challenges to you see in your setting? Share your thoughts in the comments section of this post.

*general eye exam within normal limits; alcohol on breath at intake

** Use Sliding Scale to treat Finger Stick Blood Sugar result every day at 4am

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © Byron Moore – Fotolia.com

Silence Kills: Communicating for Patient Safety

covering mouth dog

What do you do if you see a fellow nurse not washing her hands after a dressing change or not checking the MAR (Medication Administration Record) before administering routine medication to a patient? Speaking up about breaches in safety rules or other concerning issues can be a struggle of conscience. Staff nurses like to avoid conflict. This can be particularly true in a correctional setting where a punitive culture may pervade (See an earlier post on this topic). Nurses must be able to speak up on critical issues of patient safety. The HealthGrades Quality Study of 2004 estimates that each year one in twenty patients will receive a wrong medication, over 3 million will obtain an infection from unwashed hands and nearly 200,000 will die of a mistake while hospitalized. How many of these poor outcomes and deaths might have been avoided if someone had spoken up about what they observed?

Maxwell et al. surveyed healthcare staff from a variety of professions and settings to determine the primary areas of concerning behaviors. Results indicate that many of us are witnessing team members cutting corners, breaking rules and being disrespectful but few are addressing these concerns. Surprisingly, the majority of those surveyed did not believe it was their responsibility to address these patient safety issues. The following seven areas of concern emerged as key issues we need to actively address.

  • Broken Rules – Examples include standard safety rules such as checking doses or wearing gloves when drawing blood.                                              
  • Mistakes – Involve Incorrect judgments, poor assessments, or not getting help when needed.
  • Lack of Support– Can include reluctance to help, impatient, refuse to answer questions, or a teammate who complains when asked to help out.
  • Incompetence– Both doctors and nurses expressed concern about the competence of a few of their team members.
  • Poor Teamwork-Gossiping and cliques are mentioned in this category.
  • Disrespect– Examples include condescending, insulting, or rude comments. A small percentage of respondents also reported verbally abusive conduct such as yell, shout, swear, or name call.
  • Micromanagement-This category includes abuse of authority such as pulling rank, threatening, bullying or forcing a point of view on others.

How many of these concerns have you experienced in your correctional nursing practice? Although intervening in the face of any of the above situations is difficult, correctional nurses are called to protect their patient’s safety in every possible area. We must find ways to overcome our discomfort to advocate for our patients.

Are you challenged to speak up when you see mistakes, incompetence, or disrespect? Share your experiences in the comments section of this post.

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © javier brosch – Fotolia.com

Patient Safety and Correctional Nursing Fatigue

Beautiful fatigue doctor woman with a stethoscope

Janet was at the end of her third 12-hour night shift when it happened.  She was giving the morning insulin at 4 am, as she had done so many times in her 3 years at the prison. This time, however, she drew up and administered regular insulin instead of NPH to Inmate Russo. The error wasn’t discovered until after he had passed out in the chow line. Although he recovered with glucagon administration and had no permanent injury, Janet was devastated by the error and is questioning her nursing abilities.

Correctional nurses work hard…and long…with many schedules based on 12 hour shifts. Considering the transit time it can take to get to a remote prison location and the effort to pass through security and various sally ports, longer shifts seem practical. However, research is growing to indicate that nurse fatigue can have a detrimental effect on patient safety.

Research on the effects of nurse fatigue indicate that nurses working more than 12 hours a day are three times more likely to make a patient care error. Additional research into nurse fatigue confirms that long shift length increases error, close calls, and decreased vigilance. This later finding can have particular application in the correctional setting where nurses must be vigilant, not only for patient safety but also their own safety in a secure setting. A study of shift workers found that risk of accident escalated over time so that the risk of accident was 17% higher on the fourth straight night of shift work.

According to the Joint Commission’s review of research on health care workers, the following outcomes have been linked to fatigue:

  • lapses in attention and inability to stay focused
  • reduced motivation
  • compromised problem solving
  • confusion
  • irritability
  • memory lapses
  • impaired communication
  • slowed or faulty information processing and judgment
  • diminished reaction time
  • indifference and loss of empathy

Strategies to Reduce Nurse Fatigue

  • Education: Many nurses are unaware of the degree to which lack of sleep affects performance. We can start by being educated about the issue.
  • Sleep Hygiene: Just like our patients, we, too, need to have good sleep habits for our health and for patient safety. Having a regular bedtime, getting at least 7 hours of sleep, and avoiding alcohol or caffeine near bedtime can help.
  • Organizational Culture: Organizations can set limits on the number of shifts and hours worked by nursing staff. Nurses can feel pressure to fill empty shifts to assist workmates or meet management expectations. This pressure should be withdrawn and other measures sought to meet staffing needs.
  • System Checks: Consider staff fatigue when performing root cause analysis for quality improvement purposes. Implement second check processes for critical tasks to overcome fatigue-related error potential. Many traditional health care settings require a second check on insulin administration like the one in our case study.

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © pablocalvog – Fotolia.com

Creating a Culture of Patient Safety in Corrections

Organizational behavior is bone background concept

Work culture is created by the values, attitudes, perceptions and behaviors of the work team. It is most simply defined as ‘the way we do things here’ and grows over time to be a stable presence in the life of an organization. The prevailing work culture in corrections can be militaristic and punitive. Creating a culture of patient safety in the correctional setting is challenging but rewarding.

Elements of a Safety Culture

According to the Institutes of Medicine’s Patient Safety publication, there are 5 key components to a culture of safety. These elements can be applied to correctional health care to move us toward a culture that advocates for patient safety at all levels.

  • Shared beliefs and values – All staff, and particularly site leadership, must share a value of patient safety and its central importance to care delivery. As much as we seek error-free practice, human systems mean errors are going to happen. “However, hazards and errors can be anticipated, and processes can be designed both to avoid failures and to prevent patient harm when a failure occurs” (IOM, 2004, pg 175). Patient safety should be seen as an investment rather than a cost.
  • Recruitment and training with patient safety in mind – Much of our orientation of new staff is focused on necessary procedures and tasks involved in the position.  Orientation programs need to be revisited with an eye toward a patient safety perspective.
  • Organizational commitment to detecting and analyzing patient injuries and near misses – openness about errors and near misses can be particularly threatening in correctional health care. A culture of silence can exist that thwarts efforts to uncover system and clinician error. Once detected, injuries and near misses need adequate analysis to determine root causes and make system changes that will support safe patient care. This can be hard work and a punitive culture may wish to assign blame to individuals rather than seek to improve safety systems.
  • Open communication regarding patient injury results – This open communication is needed in order to truly improve the system. Once again, transparency is challenging in our care setting.  Some systems may value the appearance of error-free work while hiding the actual reality of human systems.
  • A just culture – A just culture is a component of an overall safety culture that seeks a balance of learning from mistakes while taking disciplinary action when appropriate. Although many errors are the result of system flaws, inadequate processes or lack of training; some errors are caused by negligent or reckless behavior. A just culture differentiates among the causes of error and intervenes appropriately.

Organizations with a positive safety culture have several characteristics in common including staff communications founded on mutual trust, shared perceptions of the importance of safety, and a confidence in the safety systems that are in place. When patient safety is perceived as important, staff members are more willing to take personal responsibility for safety and act to preserve patient safety when it is jeopardize. Within a context of mutual trust, staff are willing to communicate safety concerns and modify behavior based on lessons learned from mistakes. And, confidence in the safety systems in place allows staff to focus on their primary roles while seeking additional safety enhancements to add reliability to the system.

According to the IOM, moving an organizational toward a patient safety culture can result in reduced clinical error and improved patient care outcomes. That is good news for our correctional health care settings.

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Proposed Standards for Patient Safety in Prisons

Patient Safety 2

Some patient safety standards from traditional healthcare settings are applicable in corrections; most notably patient identification, medication administration, and hand hygiene. Many, however, are of little effect in this setting. Several years ago, a panel of correctional health care experts was convened to propose patient safety standards for prisons. This group considered the standards currently in place for traditional settings, as well as the unique nature of correctional health care practice. Although dominated by physicians, the panel of 30 correctional healthcare professionals also included several nurses.

The outcome of this project was the creation of a list of 46 standards in seven categories. Conveners suggest that implementing these proposed standards will greatly improve patient safety in corrections.  The following standards are of particular importance to correctional nursing practice:

  • Medication References: Staff need up-to-date reference material to consult regarding unfamiliar medications or dosage ranges.
  • Medication Labeling: Keep-on-Person medications should be fully labeled with patient name and number, prescriber, medication name, strength, dose, frequency, number of pills or time frame, lot number, date dispensed, expiration date.
  • Topical Medication: should be stored separately from medications for internal use.
  • Multi-dose Vials: should be clearly labeled with date opened and date for discarding (maximum of 30 days).
  • Dangerous Abbreviations: Eliminate Do-Not-Use abbreviations from all documentation.
  • Patient Involvement: Provide full information for active patient decision-making and informed consent. Share all test results with the patient.
  • Pressure Ulcer Prevention: Have protocols in place to monitor for and treat pressure ulcers for all non-ambulatory patients.

The above standards are generally in place in traditional settings and this corrections-specific listing affirms their need. The following additional safety standards proposed by the panel are specific to the correctional health care delivery system:

  • Nonmedication information (e.g., allergies, mobility limitations, language or communication limitations, and other disabilities) is reconciled whenever patient transitions from one primary provider or health care setting to another (e.g., infirmary to general population, prison to community, prison to hospital, prison to another prison).
  • Patients admitted who are pregnant and opioid dependent, including those on methadone maintenance, will receive adequate opioid dosing to prevent withdrawal during pregnancy.
  • The correctional environment is adjusted to special health needs of an inmate (e.g., adding air conditioning).
  • Interpretation services are available for clinical encounters; interpreters should be qualified/certified; should not be custody staff or other prisoners except in emergencies.
  • The following nationally accepted guidelines are followed for chronic disease management: (1) guidelines published by NCCHC; (2) correctional consensus psychiatric guidelines; (3) all patients receiving certain high-risk medications for ≥180 days receive appropriate lab test monitoring annually (or more often if clinically indicated).

Are you implementing patient safety standards in your correctional nursing practice? Share your tips in the comments section of this post.

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. 

Photo Credit: © JiSIGN – Fotolia.com