Safe passage nurse’ improves patients’ safety as they move through the system

Designated nurse coordinates multidisciplinary care

How would you like to increase occurrence reporting by 134% while improving patient safety and communication among your staff? If that sounds good, the Safe Passage Program, developed by Clarian Health Partners in Indianapolis, might be for you.

The Safe Passage Program led to Clarian’s director of risk management and patient safety, Kathy Rapala, JD, RN, recently winning the first Todd Pickett National Patient Safety Award from the American Society for Healthcare Risk Management (ASHRM). The award is named as a tribute to a patient, Todd Pickett of San Diego, who died in an incorrectly applied patient safety restraint.

Rapala was instrumental in creating the Safe Passage Program in 2001, thought to be the first of its kind in the United States. It supports a culture of safety by designating a "safe passage nurse," someone dedicated to assisting the interdisciplinary team in a patient care unit as they take patients through the health care system. The model empowers frontline workers to anticipate a variety of scenarios and prevent errors by working together.

"With the safe passage nurse, we decided we didn’t want just a safety nurse with a checklist," Rapala explains. "We wanted people to learn how to think about things differently."

Many staff trained in patient safety

At Clarian, Safe Passage is a collaboration between nursing and patient care services and risk management to safeguard all patients and staff and protect their rights to a safe passage through the health care system. Based on a zero-error tolerance model, the program operates throughout the entire Clarian health care system, which includes three hospitals.

Rapala says Clarian created the program as a by-product of its Synergy Model — the practice of matching patient needs with nursing expertise to improve patient outcomes and satisfaction. Clarian is the first hospital in the country to implement this model for patient care.

So here’s how it works: A team of more than 250 nurses and other clinicians including pharmacists and clinical engineers are specially trained in patient and staff safety. Each unit throughout the health care system has a Safe Passage nurse, who trains, oversees, and analyzes the unit by identifying areas for improvement.

Clarian leadership and the Clarian Board of Directors provide Safe Passage nurses time away from clinical or operational duties for training, safety-related initiatives, and monthly Safe Passage Council meetings. The Council includes staff from mother/baby, emergency and trauma center, and all three hospitals’ multispecialty and intensive care unit.

Staff are empowered to make changes to improve work environments. Rapala says the Safe Passage Program provides a forum that strikes a balance between necessary efficiencies and reliability. When Safe Passage nurses and other frontline staff identify a barrier that increases risk, changes are made to prevent or reduce risks or remove the barriers.

Here are the goals of the Safe Passage Program:

  • Provide nurses with a patient safety knowledge base that includes the most current patient safety information available.
  • Provide a communications network from top to bottom and bottom to top.
  • Prevent errors through planning for change and identification of gaps.
  • Create a mechanism to analyze and learn from errors.
  • Increase work efficiency and effectiveness.
  • Provide a mechanism for process improvement through evidence-based practice.

Staff level participation is key

Rapala and her colleagues started out by giving a presentation to 10 interested nurses. The idea went over well with them but then not much more happened. So they went back to the drawing board and came up with a plan that would disseminate the idea throughout the entire hospital.

Clarian has 10,000 employees, so that was no easy task. The Safe Passage Council was one strategy, along with subcouncils on a local level at each hospital. They meet monthly and discuss patient safety issues that affect their specific areas — obstetrics or the emergency department, for instance. Originally, the councils were made up entirely of staff nurses with additional training in patient safety, but this year Clarian added pharmacists and other practitioners. But they’re all staff level — that’s the main requirement.

"The reason for that is that they know the actual work so well," she says. "In the past, we had administrators and managers looking at a problem, and the fact is that sometimes I’m not as familiar with work at the bedside as I need to be for solving a particular problem. It turns out that the staff level members have much better ideas than we do."

Once a month, all the councils meet as a group. Each local council brings up safety issues from their own settings and, more often than not, the other participants realize that the same issues could affect their own areas. "The beauty of it is that we have all the problem solvers right there so they can start talking amongst themselves," she says. "It really raises the awareness immediately across all the settings."

Not easy to schedule meetings

Rapala says the administration of the Safe Passage Program has been challenging, in part because the staff level participants have such different schedules. Scheduling a meeting can be difficult, she says.

Each clinical unit at Clarian has a Safe Passage nurse who is responsible for letting the Safe Passage Council know about safety issues and for disseminating information to staff on their floor. Some units have one or two extra representatives — a change implemented when the original participants explained that they could not always make the meetings.

"With all the programs that recruit staff people to participate, ours has been very popular," Rapala says. "We think the reason is that this is all about how people work. People are asking them about how they work and how we can make that better, and people tend to be interested when you ask about their work."

Though the Safe Passage nurse is the floor’s designated patient safety representative, other staff are involved in patient safety initiatives. The Safe Passage nurse, however, receives special training and education in patient safety, and then he or she is expected to pass on that knowledge.

Good results after three years

The Safe Passage Program has improved quality and reduced errors throughout the Clarian health care system, Rapala says. She cites these results:

More trust. Instead of placing blame when an error is made, Safe Passage provides a process to analyze near misses. For example, if the wrong patient was taken for a procedure, but the error was caught, an analysis is done to reveal the work complexities that led to this near miss.

Improved communications. Safe Passage provides tools to help practitioners communicate clinical concerns to attending physicians.

• Increased reporting. Occurrence reporting increased by 134% at Clarian in 2003 because of Safe Passage initiatives.

More staff involvement in decision making. Because frontline staff are the best source to evaluate work design and work flow issues, Clarian now makes certain that no policy, procedure, improvement or technology is implemented without the consideration of the actual work environment, and that means consulting those on the front line.

• Reduced errors. Because its emphasis on improvement, analysis and training, Safe Passage helped identify that poorly designed and labeled bins caused the incorrect hanging of premixed intravenous fluids. Safe Passage has piloted standardized bins on key units, with a resulting decrease in incorrectly hung fluids. Systemwide implementation is under way.

Rapala says it is important to plot the reported incidents against serious and severe incidents. At Clarian, reported incidents are going way up but serious incidents are going down. "Eventually, from a risk management point of view we would hope that has an impact on claims," she says. "But that will take a couple of years to start seeing."

Program is extensive

Clarian has an extensive root-cause analysis program and uses it to study far more than just the incidents required by JCAHO. Rapala says the analyses find across the board that communication, particularly concerning patient handoffs, is the No. 1 root cause of serious incidents and near misses. "The great thing about the Safe Passage Program is that we now have a vehicle for saying we’ve noticed this trend and what do you guys think," she says. "They confirmed it hands down, so now that’s a separate project we’re working on."

Rapala says that Clarian also has started to quantify what potential problems are being caught out on the floor. She knew that was important in assessing the success of the program, but she also knew that staff did not want another form to fill out. So how do you track what staff are catching during a normal work shift?

"We just allow part of the monthly meeting for information sharing, people telling each other what they’ve caught, and what they’ve heard about on their unit," she says. "We want them not only noticing the issues but also starting to fix them. Just this past month we got an occurrence report about a near miss and the nurse said because of the Safe Passage Program, she took steps to keep it from happening again."

More eyes and ears for patient safety

That’s the ultimate goal of the Safe Passage Program, Rapala says. She wants to create an army of staff level patient safety experts who can recognize problems and solve them. "The thing that some people don’t like to hear is that it takes time," she says. "It takes two to three years to set up this structure so that it works."

And it also takes caregivers away from their duties. If you don’t have top-level support for Safe Passage, you’ll never be able to schedule staff level participants for meetings when their unit manager needs them working. At Clarian, participants report that they spend two to four hours a month on their Safe Passage activities in addition to the meeting time.

Rapala says the Safe Passage Program has been "one of the most effective risk management tools we’ve ever had." The reason is that the program provides a structure for disseminating information — such as an equipment hazard, for instance — throughout the entire organization quickly. The program also ensures a great many more eyes and ears are on alert for safety issues.

"The traditional risk management model has a couple of people in risk management who get the risk reports, but this model enlists a lot more people in the effort," she says. "You can’t beat all that brainpower and all those people helping you get the word out."