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ENA study cites barriers to NPSG compliance
Culture must change to engender safer processes
While the response rate (4.6%) was small, the message delivered in the results of a survey by the Emergency Nurses' Association (ENA) was huge: Significant barriers still remain to compliance with National Patient Safety Goals (NPSGs) in the ED.
The survey, which went out to 28,000 ENA members and 2,800 ED managers, was based on replies from 2,200 ED nurses and 129 ED managers, the results were published in the January 2009 issue of The Joint Commission Journal on Quality and Patient Safety.1
In the case of many of the NPSGs, respondents indicated that while policies were in place that reflected the goals, compliance still was being hindered. For example, while 85.7% of the EDs had universal timeout policies, only 23.2% reported no barriers to implementation. Regarding having at least two patient identifiers, while 96.9% of the EDs had a policy in place, only 46.3% reported no barriers to implementation. In some cases, even policies were lacking. For example, only 33.8% of EDs said they had a readily available and visible list of "Do Not Use" standard abbreviations, acronyms, and symbols.
While conceding that the current working environment in the ED — overcrowding, insufficient treatment space, boarding, longer wait times, and patients leaving without being seen — mitigates against compliance, the authors say there are steps ED managers can take to address barriers to implementation. "The first thing an ED manager has to do is look at where they stand on these findings. Some folks do not have as many barriers as others," notes Susan Paparella, RN, MSN, one of the paper's authors and vice president of the Institute of Safe Medication Practices in Horsham, PA. Send the right message and set a culture of shared responsibility for safety, she says. "Safety is not a project, but should be a thread running through all the things we do."
Debby Rogers, RN, MS, vice president of quality and emergency services for the California Hospital Association in Sacramento, agrees. "What I was struck by in reading about barriers is the culture," Rogers says. "For example, while most hospitals used two unique patient identifiers, 19.5% of the nurses said the bracelet was not always available [when meds were ordered], and yet they probably gave the meds anyway."
Changing the culture in the ED could be one possible solution, she suggests. "What if it becomes the culture of the ED that meds are never given without a bracelet?" Rogers poses. "Then that becomes the acceptable practice." Culture change drives the change in practice, she says. "You might look at the list of National Patient Safety Goals and assess the culture in ED around these areas," Rogers suggests.
To address culture change, the California Hospital Association is developing a California Hospital Patient Safety Organization. "The Association for Healthcare Research and Quality has a culture survey that hospitals can give every member of their staff," Rogers points out. "We have automated it, and we will try and get all the hospitals that want to, to use the survey."
The timing couldn't be better to revisit your compliance with National Patient Safety Goals: No new goals will be added this year, according to The Joint Commission.
For more information on complying with the National Patient Safety Goals, contact:
New ED processes remove barriers
While removing the many barriers to National Patient Safety Goal compliance that exist in the ED is not always easy, it can be done, as demonstrated by some of the safety improvement processes instituted in the ED at the University of Kentucky Medical Center in Lexington.
For example, in order to improve patient identification, you've got to introduce a standard method, notes Mary Rose Bauer, MSN, quality compliance coordinator for emergency trauma services and a co-author of a recent article in The Joint Commission Journal on Quality and Patient Safety that addressed many of these issues. "Since we're communicating across an entire system, it's important not only for the staff to understand what the identifiers are and when to use them, but to provide scripting," she says. "This is most important, so when the staff approaches the patient, they have a standard way of talking to them so they get the correct information."
In her ED, for example, every staff member says, "Tell me your name, and tell me your date of birth." "You do not want some people walking up to a patient and saying, 'Hi, Mrs. Smith, I see your date of birth is such and such,'" Bauer offers. "This tends to lead to problems in patient safety."
Here are some other methods used in the ED to ensure safe practices are followed:
Finally, she says, "during every staff meeting we have some form of Joint Commission training. We review all the National Patient Safety Goals and look at our compliance rates."
Understand the intent of NPSGs
One of the keys to improving your ED's adherence to the National Patient Safety Goals is to "appreciate their intent," says Susan Paparella, RN, MSN, vice president of the Institute of Safe Medication Practices in Horsham, PA, and one of the authors of a recent article in The Joint Commission Journal on Quality and Patient Safety that addressed many of the reasons EDs have difficulty complying with the goals.
"We found that there wasn't a clear understanding of the intent and how to work with staff to implement the goals in a safe way," Paparella says.
Often, ED nurse managers and nurses approach them "as another set of new rules," rather than trying to better understand the evidence behind their creation and then going back to their own practice setting and seeing where the gaps are, she says. This approach can present a challenge for some ED nurses, she notes. "ED nurses are very capable of changing on a dime, but without coaching on risky behaviors, they may do what they have always done and without realizing it they may be adding risk," Paparella says.
How can an ED manager gain a better understanding of the intent of the goals? "They're got to read up on them, and not just take them on face value," she says. "They also need to feel comfortable about accessing the requisite [hospital] resources in terms of their risk managers and patient safety officers." The goals are not limited to the ED, so talking to those individuals can be very beneficial, Paparella says. "The applications they use may require some reanalysis by the ED, but you should go to those folks because we all want to see these goals accomplished," she concludes.