- Email: [email protected]
What Can You Do? Follow Written Protocols
Journal of Radiology Nursing 35 (2016) 321e322
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Shielding from Harm
What Can You Do? Follow Written Protocols Lora K. Ott, PhD, RN * Indiana University of Pennsylvania, Indiana, PA
Health care quality and safety have been in the forefront of health care discussions and change since the sentinel IOM (2000) report To Err Is Human placed health care safety in the spotlight. Many strategies for improvement have been proposed, policies developed, and safety initiatives tested and implemented in the years since that sentinel publication. A reflection of this shift can be seen in the over 200 agencies and organizations who are committed to quality improvement across all areas of health care (Sherwood and Barnsteiner, 2012). A commitment to quality and safety can be seen from the accrediting agencies such as The Joint Commission (2016), the credentialing agencies such as the American Nurses Credentialing Center (ANCC, 2016), Magnet Recognition Program, and third-party payers such as the quality incentives of both federal, the Affordable Care Act (U.S. Health and Human Services, 2015), and private payers. The discipline of health care quality and safety can be overwhelming; making it easy for the individual nurse to view this as someone else's responsibility. Nothing could be farther from the truth. While yes, the improvement of our health care system is a daunting task, the improvement of your practice is your professional responsibility. We can improve health care one interaction at a time, one day at a time, and one shift at a time. So what can you do? To answer that question I will break it down to the four basic steps or behaviors identified by the Institute of Healthcare Improvement (IHI, 2016) in their patient safety modules. These four steps are to follow written protocols, speak up, listen to patients and colleagues, and take care of yourself. They seem simple at first glance but perhaps not so simple to actually put into practice. In the next four safety columns, I will reflect on each of these steps and with some suggestions to put them into practice specifically in radiology. Step Number 1 is to follow written protocols. It has long been recognized that evidence-based practice (EBP) improves safety (Melnyk & Fineout-Overholt, 2014). So much so that prelicensure students are taught EBP before they enter the workforce and the development of new practice policies are expected to be references and supported in the literature. Therefore, all our policies that direct our day-to-day practice are to be reflective of what we know to be the best practice to date. By following the policy, we would then draw the conclusion that we are * Corresponding author: Lora K. Ott, PhD, RN, Indiana University of Pennsylvania, 229 Johnson Hall, 1010 Oakland Ave., Indiana, PA 15705. E-mail addresses: [email protected], [email protected].
engaging in best practice. However, in our humanness, we are known to not always follow the directions; we bend the rules. A policy may be the very best ever written, but if it is not followed, it does not result in best practice. So, the first step in engaging in individual responsibility for health care quality and safety is to simply follow the written protocols. A policy may be a universal health care practice such as using multiple patient identifiers, a hospital-specific practice such as documenting oxygen tank levels before patient transport, and radiology-specific policies that reflect the complex, specialized procedures in our specialty. There is one fundamental truth about any policy, and, that is, it only works if the nurse follows it (IHI.org). So the simple answer is we must follow the policies and protocols as they are written and in addition we need to be certain that our team of colleagues is also doing the same. As we work with policies we often find that they do not always translate well into practice. Looking good on paper, but cumbersome to implement. This leaves the door open for drifting away from how policies or protocols are intended and making them more user friendly. If this is what you are seeing, then the policy needs revisited and you need to speak up (Behavior Number 2 and the topic of our next column). Radiology is a complex specialty within health care where we see a wide variety of procedures in multiple venues every day. A radiology nurse scheduled in the interventional suite may cover the same room for an entire shift and have no two procedures alike, or the nurse staffing a radiology procedure unit where patients are being prepped for and recovering from a variety of different procedures in any of the radiology modalities. Likewise, a nurse's responsibility may be to provide interventions necessary for procedures in process such as administering secretin for a magnetic resonance cholangiopancreatography or furosemide for a hematuria protocol. Radiology nurses are called upon to move between patients and procedures often quickly and with little prior knowledge of the patients we are providing caring. Each department needs to have clear, evidence-based policies and procedures in place to guide our practice. (If your department is lacking in this area, I suggest you take the initiative to get this done. It is for your protection and that of your patients.) It is our responsibility as the radiology nurse to follow those procedures or to improve the ones we find to be drifting. So many patients, so many policies, so little time…how do we do it all? How do we remember all the details when we may not be in a situation for weeks or months at a time? This is a real problem in
http://dx.doi.org/10.1016/j.jradnu.2016.09.002 1546-0843/$36.00/Copyright © 2016 by the Association for Radiologic & Imaging Nursing.
322
L.K. Ott / Journal of Radiology Nursing 35 (2016) 321e322
radiology and perhaps more specific to a specialty area like radiology where the variety of care we provide is so diverse. I encourage you to brainstorm a solution that works in your department. One truth is you cannot rely on your memory. Therefore, you need a reference. One that is easily accessible. A reference you can access when needed and quickly. Let me share one possible solution, although I do not suggest that this is the only solution. A very helpful tool that is available to me in my practice is a pocket guide of the policies and procedure specifics to the radiology department where I work. This has become such a valuable tool to me and has made it possible for me to look up the details of different procedures right in my pocket. No relying on my memory. In my department, this is done by an ebook that is downloaded right to my iBooks on my phone. Some hospitals issue smartphones to their nurses to carry every shift, and an ebook would be a simple addition. The same pocket guide is available to me on the computer via an intranet, also saved in my e-mail, and there is the traditional large binder policy manual, but nothing is as easy to use as the one in my pocket. It is not the full policy manual, it contains the highlights, the detail, and the specifics of common procedures. The table of contents directs me to information as basic and specific as the furosemide dose (40 mg IV push over 4 min per our department policy) for use in nuclear medicine renal scans, as well as the detailed nursing responsibilities of preparing a patient for intrahepatic chemoembolization and their postprocedure recovery care to be followed until discharge from radiology. Having a tool such as this provides a quick reference and removes the temptation to rely on memory. Let me give you an example of how this was put to use recently when I was called to administer cholecystokinin (CCK) to a patient during a hepatobiliary (HIDA) scan in nuclear medicine. I have personally administered this medication many times in my career, but it had been several months since the last time I had participated in an HIDA scan. So, my memory of the procedure was not reliable. My pocket guide contained the name of the scan, what the drug was
used for (so I could give an educated answer when the patient asked me), the dose, an example of how to calculate the weightbased dose, how the CCK is given, what supplies I needed to gather, how to set up the IV infusion and the normal saline flush to follow the infusion, and even a warning to remind me that the CCK comes in multiple concentrations and to ensure that I am using the correct one. So you can see that at any step in this procedure, my memory may have failed me setting the stage for a medication error. I encourage you to share your departments' solutions to keeping your nurses versed in and consistently following written policies and procedures. One place to share ideas is on the Association of Radiology and Imaging Nurses Website forum http://www. arinursing.org/resources/forum.cfm where you can share ideas and seek solutions from radiology nurses. Following written protocols is the first thing we as individuals can do to move health care quality and safety forward one interaction at a time, one day at a time, and one shift at a time. References American Nurses Credentialing Center. (2016) ANCC magnet recognition program. Retrived from http://www.nursecredentialing.org/Magnet.aspx. Accessed September 2, 2016. Institute for Healthcare Improvement. (2016). http://www.ihi.org/Pages/default. aspx. Accessed September 2, 2016. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Melnyk, B.M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. Ames, Iowa: John Wiley & Sons, Inc. The Joint Commission. (2016). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx. Accessed September 2, 2016. U.S. Department of Health and Human Services. (2015). HHS.gov. About the law. Retrieved from http://www.hhs.gov/healthcare/about-the-law/#. Accessed September 2, 2016.
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Shielding from Harm
What Can You Do? Follow Written Protocols Lora K. Ott, PhD, RN * Indiana University of Pennsylvania, Indiana, PA
Health care quality and safety have been in the forefront of health care discussions and change since the sentinel IOM (2000) report To Err Is Human placed health care safety in the spotlight. Many strategies for improvement have been proposed, policies developed, and safety initiatives tested and implemented in the years since that sentinel publication. A reflection of this shift can be seen in the over 200 agencies and organizations who are committed to quality improvement across all areas of health care (Sherwood and Barnsteiner, 2012). A commitment to quality and safety can be seen from the accrediting agencies such as The Joint Commission (2016), the credentialing agencies such as the American Nurses Credentialing Center (ANCC, 2016), Magnet Recognition Program, and third-party payers such as the quality incentives of both federal, the Affordable Care Act (U.S. Health and Human Services, 2015), and private payers. The discipline of health care quality and safety can be overwhelming; making it easy for the individual nurse to view this as someone else's responsibility. Nothing could be farther from the truth. While yes, the improvement of our health care system is a daunting task, the improvement of your practice is your professional responsibility. We can improve health care one interaction at a time, one day at a time, and one shift at a time. So what can you do? To answer that question I will break it down to the four basic steps or behaviors identified by the Institute of Healthcare Improvement (IHI, 2016) in their patient safety modules. These four steps are to follow written protocols, speak up, listen to patients and colleagues, and take care of yourself. They seem simple at first glance but perhaps not so simple to actually put into practice. In the next four safety columns, I will reflect on each of these steps and with some suggestions to put them into practice specifically in radiology. Step Number 1 is to follow written protocols. It has long been recognized that evidence-based practice (EBP) improves safety (Melnyk & Fineout-Overholt, 2014). So much so that prelicensure students are taught EBP before they enter the workforce and the development of new practice policies are expected to be references and supported in the literature. Therefore, all our policies that direct our day-to-day practice are to be reflective of what we know to be the best practice to date. By following the policy, we would then draw the conclusion that we are * Corresponding author: Lora K. Ott, PhD, RN, Indiana University of Pennsylvania, 229 Johnson Hall, 1010 Oakland Ave., Indiana, PA 15705. E-mail addresses: [email protected], [email protected].
engaging in best practice. However, in our humanness, we are known to not always follow the directions; we bend the rules. A policy may be the very best ever written, but if it is not followed, it does not result in best practice. So, the first step in engaging in individual responsibility for health care quality and safety is to simply follow the written protocols. A policy may be a universal health care practice such as using multiple patient identifiers, a hospital-specific practice such as documenting oxygen tank levels before patient transport, and radiology-specific policies that reflect the complex, specialized procedures in our specialty. There is one fundamental truth about any policy, and, that is, it only works if the nurse follows it (IHI.org). So the simple answer is we must follow the policies and protocols as they are written and in addition we need to be certain that our team of colleagues is also doing the same. As we work with policies we often find that they do not always translate well into practice. Looking good on paper, but cumbersome to implement. This leaves the door open for drifting away from how policies or protocols are intended and making them more user friendly. If this is what you are seeing, then the policy needs revisited and you need to speak up (Behavior Number 2 and the topic of our next column). Radiology is a complex specialty within health care where we see a wide variety of procedures in multiple venues every day. A radiology nurse scheduled in the interventional suite may cover the same room for an entire shift and have no two procedures alike, or the nurse staffing a radiology procedure unit where patients are being prepped for and recovering from a variety of different procedures in any of the radiology modalities. Likewise, a nurse's responsibility may be to provide interventions necessary for procedures in process such as administering secretin for a magnetic resonance cholangiopancreatography or furosemide for a hematuria protocol. Radiology nurses are called upon to move between patients and procedures often quickly and with little prior knowledge of the patients we are providing caring. Each department needs to have clear, evidence-based policies and procedures in place to guide our practice. (If your department is lacking in this area, I suggest you take the initiative to get this done. It is for your protection and that of your patients.) It is our responsibility as the radiology nurse to follow those procedures or to improve the ones we find to be drifting. So many patients, so many policies, so little time…how do we do it all? How do we remember all the details when we may not be in a situation for weeks or months at a time? This is a real problem in
http://dx.doi.org/10.1016/j.jradnu.2016.09.002 1546-0843/$36.00/Copyright © 2016 by the Association for Radiologic & Imaging Nursing.
322
L.K. Ott / Journal of Radiology Nursing 35 (2016) 321e322
radiology and perhaps more specific to a specialty area like radiology where the variety of care we provide is so diverse. I encourage you to brainstorm a solution that works in your department. One truth is you cannot rely on your memory. Therefore, you need a reference. One that is easily accessible. A reference you can access when needed and quickly. Let me share one possible solution, although I do not suggest that this is the only solution. A very helpful tool that is available to me in my practice is a pocket guide of the policies and procedure specifics to the radiology department where I work. This has become such a valuable tool to me and has made it possible for me to look up the details of different procedures right in my pocket. No relying on my memory. In my department, this is done by an ebook that is downloaded right to my iBooks on my phone. Some hospitals issue smartphones to their nurses to carry every shift, and an ebook would be a simple addition. The same pocket guide is available to me on the computer via an intranet, also saved in my e-mail, and there is the traditional large binder policy manual, but nothing is as easy to use as the one in my pocket. It is not the full policy manual, it contains the highlights, the detail, and the specifics of common procedures. The table of contents directs me to information as basic and specific as the furosemide dose (40 mg IV push over 4 min per our department policy) for use in nuclear medicine renal scans, as well as the detailed nursing responsibilities of preparing a patient for intrahepatic chemoembolization and their postprocedure recovery care to be followed until discharge from radiology. Having a tool such as this provides a quick reference and removes the temptation to rely on memory. Let me give you an example of how this was put to use recently when I was called to administer cholecystokinin (CCK) to a patient during a hepatobiliary (HIDA) scan in nuclear medicine. I have personally administered this medication many times in my career, but it had been several months since the last time I had participated in an HIDA scan. So, my memory of the procedure was not reliable. My pocket guide contained the name of the scan, what the drug was
used for (so I could give an educated answer when the patient asked me), the dose, an example of how to calculate the weightbased dose, how the CCK is given, what supplies I needed to gather, how to set up the IV infusion and the normal saline flush to follow the infusion, and even a warning to remind me that the CCK comes in multiple concentrations and to ensure that I am using the correct one. So you can see that at any step in this procedure, my memory may have failed me setting the stage for a medication error. I encourage you to share your departments' solutions to keeping your nurses versed in and consistently following written policies and procedures. One place to share ideas is on the Association of Radiology and Imaging Nurses Website forum http://www. arinursing.org/resources/forum.cfm where you can share ideas and seek solutions from radiology nurses. Following written protocols is the first thing we as individuals can do to move health care quality and safety forward one interaction at a time, one day at a time, and one shift at a time. References American Nurses Credentialing Center. (2016) ANCC magnet recognition program. Retrived from http://www.nursecredentialing.org/Magnet.aspx. Accessed September 2, 2016. Institute for Healthcare Improvement. (2016). http://www.ihi.org/Pages/default. aspx. Accessed September 2, 2016. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Melnyk, B.M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. Ames, Iowa: John Wiley & Sons, Inc. The Joint Commission. (2016). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx. Accessed September 2, 2016. U.S. Department of Health and Human Services. (2015). HHS.gov. About the law. Retrieved from http://www.hhs.gov/healthcare/about-the-law/#. Accessed September 2, 2016.