ICU after a rapid response. I saw what appeared to be a purple band on the patient. At my hospital, like at many hospitals across the country, a purple band designates a DNR (Do Not Resuscitate) code status. There was no indication of a DNR order for this patient, so I asked the patient about the purple band. The patient told me she was wearing it because she'd had an implantable port placed, and the band was part of the kit provided by the vendor. Staff at the surgical center suggested that the patient wear the band to remind health care providers of her port. When I looked at the band closely, I noticed it was actually a gradation of colors, purple fading to gray. I clarified the patient's code status with her and removed the band for patient safety.
I also completed an unusual occurrence, which brought the situation to the attention of our risk manager. The risk manager reported the event to the FDA through a MedSun report as a near miss. MedSun told us later that they worked with the manufacturing company to change their practices. The company was not aware of the national efforts underway to standardize arm band colors and has now stopped including the purple band in their port kits.
Nancy Withers, BSN, RN
Former Clinical Leader, ICU, Edward HospitalCurrent Educator, Clinical Educator, Novasyte Health representing Hill‐Rom.
Baldrige Award
The Baldrige Award is conveyed by the National Institute of Standards and Technology (NIST), which is part of the U.S. Department of Commerce. NIST recognizes organizations that have improved and sustained quality results. The Baldrige Award in health care is designed to challenge organizations to improve their effectiveness of care and health care outcomes to pursue excellence, which moves organizations toward becoming an HRO. The Baldrige framework is built on core values and concepts and requires measurement, analysis, and knowledge management. The framework embraces integration between leadership, strategy, customers, workforce, operations, and results (National Institute of Standards and Technology (NIST), n.d.).
Accreditation Agencies
The three hospital accrediting agencies address patient safety. These agencies include Det Norske Veritas Healthcare, Inc. (DNV), Healthcare Facilities Accreditation Program (HFAP), and TJC.
Det Norske Veritas Healthcare, Inc.
Det Norske Veritas Healthcare, Inc. (DNV) empowers quality and patient safety through an outcomes‐based accreditation program. They received authority from the Centers for Medicare and Medicaid (CMS) to provide accreditation to hospitals in 2008, and integrate the CMS Conditions of Participation with the ISO 9001 Quality Management Program. The ISO 9001 quality system is a structured way of delivering a better service or product, supported by detailed procedures such as work instructions, quality manuals, and written quality policies to provide all employees with detailed, understandable, and workable instructions that define expectations and actions to achieve the stated quality goals. DNV's goal is to enable a broader culture change toward high performance and continual improvement by combining the mandatory CMS evaluation with a quality management system into one seamless program (DNV, 2018).
Healthcare Facilities Accredition Program
Healthcare Facilities Accredition Program (HFAP) was originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals. In 1965, HFAP received authority from the Centers for Medicare and Medicaid to provide accreditation to hospitals, ambulatory care/surgical facilities, mental health facilities, physical rehabilitation facilities, clinical laboratories, and critical access hospitals. HFAP adopted the 34 Safe Practices set forth by the National Quality Forum (NQF) in 2009 (HFAP, 2017).
The Joint Commission
The mission of TJC is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value (TJC, 2018a, 2018b, 2018c). Founded in 1951, TJC uses the Donabedian conceptual framework of structure, process, and outcomes to assess an organization. TJC (March 1, 2017) identified 11 leader expectations for developing a safety culture, as outlined in Table 4.7. These expectations are very appropriate for nurse leaders in every level of an organization.
Table 4.7 Joint Commission Expectations for Leaders in Developing a Safety Culture
| Create a transparent, non‐punitive approach to reporting and learning from adverse events, close calls, and unsafe conditions.Establish clear, just, and transparent risk‐based processes for recognizing and separating human error and error arising from poorly designed systems from unsafe or reckless actions that are blameworthy.Adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.Establish, enforce, and communicate to all team members the policies that support safety culture and the reporting of adverse events, close calls, and unsafe conditions.Recognize team members who report adverse events and close calls, who identify unsafe conditions, or have good suggestions for safety improvements.Establish an organizational baseline measure on safety culture performance using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture or another tool, such as the Safety Attitudes Questionnaire.Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.Develop and implement unit‐based quality and safety improvement initiatives designed to improve the culture of safety.Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.Proactively assess system strength and vulnerabilities and prioritize them for enhancement or improvement.Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement. |
Source: The Joint Commission. (2018b). 2019 Hospital National Patient Safety Goals. Retrieved from www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final.pdf.
Summary
The journey toward high reliability is complex and involves every aspect of an organization. The role of the governance or the board of directors is essential. Table 4.8 identifies questions board members should ask to ensure that the health care organization is focused on safety (American College of Healthcare Executive, 2017). Nurse leaders must put resources in place and create a culture so that these questions can be answered affirmatively.
Table 4.8 Questions to Confirm a Healthcare Organization's Focus on Safety
| Is safety positioned as an uncompromising core value?Is there a comprehensive plan for improving patient and workplace safety and for monitoring progress?Is transparency embraced for sharing adverse patient safety events and lessons learned across the system?Is there a healthy reporting environment and a fair and just culture?Is respect expected for patients, co‐workers, and physicians within the organization?Are patient stories heard regularly?Are quality and safety implications considered for every major organizational decision?Does the board of directors or governance structure devote sufficient time to safety, quality, and the patient experience of care? |
Source:
