Terri Conner, Ph.D. Nybeck Analytics Partnership for Patients Initiative at Texas Center for Quality & Patient Safety. Comprehensive Unit-Based Safety Program (CUSP). Central Line Associated Blood Stream Infections. GOALS.
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Work to eliminate central-line associated blood stream infections (CLABSI) in your unit
Improve safety culture
Learn from defects
Remove unnecessary lines
Wash hands prior to procedure
Use maximal barrier precautions
Clean skin with chlorhexidine
Avoid femoral lines
Share about a patient who was infected
Post baseline rates of infections
Estimate number of deaths and dollars from current infection rates
Remind staff that most CLABSI are preventable
Conduct in-service regarding CLABSI prevention
Create forum to jointly educate physicians and nurses
Add CLABSI prevention to ICU orientation
Give staff fact sheets, articles, and slides of evidence
Monitor rates of infections using CDC definitions
Post rates of infections per year in the unit
Post number of weeks or months without an infection
Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and improve safety culture
A good approach whenever there is a gap between evidence-based practice and current practice on your unit.
Safety practices part of daily work
Implemented at the unit level
Led by clinicians
Structured program, yet flexible
Science of safety training
Assign executive to adopt unit
Learn from defects
Implement teamwork tools
Eyes and ears of patient safety
Disseminate Staff Safety Assessment Form
Combine results and prioritize defects
Anything you do not want to have happen again.
Blood stream infections are almost always preventable. They should be viewed as defects.
Four Key Questions
Reconstruct the timeline and explain what happened
Put yourself in the place of those involved, in the middle of the event as it was unfolding
Try to understand what they were thinking and the reasoning behind their actions/decisions
Try to view the world as they did when the event occurred
Arise from managerial and organizational decisions that shape working conditions
Often results from production pressures
Damaging consequences may not be evident until a “triggering event” occurs
Develop lenses to see the system factors that lead to the event
Defect: Nasoduodenal tube placed in lung
Intervention: Protocol developed for NDT placement
Defect: Bronchoscopy cart missing equipment
Intervention: Checklist developed for stocking cart
Defect: Inconsistent use of Daily Goals rounding tool.
Intervention: Gained consensus on required elements of Daily Goals rounding tool.
Staff Safety Assessment
Safety Issues Worksheet
Status of Safety Issues
Learning from Defects Tool
Case Summary Form
Daily Goals Checklist
Morning Briefing Tool
Shadowing Another Professional
Used to identify defects in the unit
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm.
Opportunities for improvement
Actions taken to prevent harm
Care plan for patients
Lists needs for the day to safely move a patient closer to discharge
Used to improve communication among care team members and family members.
Use during morning and evening rounds, and kept at patient’s bedside.
Adapt to your own unit’s environment.