QI Project

GNRS 586 Leadership and Management in Professional Practice

Janet Wessels, MSN, RN, PHN
Tanya Simbra, Abigale Delatorre, Mary Spring, Yesenia Keller
July 12, 2017
Background
Jerry, a 70 year old man with complex medical history of
ESRD s/p right kidney transplant in 2007, CAD, PVD with
lower extremity bypass, was admitted to the ICU for septic
shock R/T lower extremity wound.
Jerry developed hypotension refractory to IV resuscitation.
The ICU team decided the pt required central venous
catheter placement in order to administer vasopressors to
improve his BP.
The ICU team decided to place the central line after
confirming with the surgical team
Jerry had a history of a right upper extremity AV fistula that After placement, the ICU team recognized their
failed and a left internal jugular vein catheter. Therefore mistake. Attempts were made to place a left
upper extremity catheter placement was no longer possible femoral catheter, but were unsuccessful. The
The ICU team decided to place a right femoral central line. ICU team and the surgical were tense, furious
and mistrustful
However, they failed to recognize the patients kidney
transplant was also on the right side and is contraindicated Jerrys kidney function and sepsis worsened,
because the risk of damaging the vein to which the kidney leading to MODs. Ultimately leading to Jerrys
was anastomosed. death.
 Manpower Environment Communication

Prior lack of cohesive Inaccurate

ICU Team communication about pt
team work
No standard communication
Surgical Team Hostility tool

Distrust between Lack of documentation and

teams using previous history in chart
Patient
Misplaced catheter

No brief between surgery and ICU team Consent with medical and
surgical history
Policy to look at chart and history
Lack of check list
Lack of form of consent for
procedures
Materials

Methods
Root Cause Analysis
Jerry died from sepsis and multiple organ dysfunction WHY?
Patient was administered vasopressors on the right femoral line despite
remaining hemodynamically unstable with a right transplanted kidney WHY?
The ICU team was not notified that the patient had a right transplanted kidney
and placed a right femoral central line (Contraindicated) WHY?
The interdisciplinary communication system did not allow the ICU and
Surgical team to discuss the history of a right kidney transplant
Actions to Prevent Further Occurrence
Who: All multidisciplinary hospital staff members involved in procedures on
patients (nurses, physicians, techs and aids). At least 1 member from each
department required and patient.

What: Implement a double check between departments prior to procedures

through the use of EHR barcoding, multiple sign off and checklist form. Procedure
will be ordered by performing physician and will be prescribed to a patient similar
to how medications are and scanning of the wrist band, and dual/multiple sign off
required before continuing can occur.
Actions to Prevent Further Occurrence
Where: At the bedside, with patient included

When: Prior to every procedure

How: Physician performing procedure will order the procedure and include
correct service with description and location specified. Order will be printed in the
form of a bar code. The wristband of the patient will be scanned, and the
procedure barcode will be scanned. At the bedside, members indicated will
discuss, review and agree, and then sign off before continuing.
Evaluation of Action
Intermediate

Rationale: Human reliance is decreased, however human error is not fully

controlled. Similar to how medication errors can occur, through avoiding, skipping
or mixing up the scanning portion, this can be done with procedures. Members of
team can ultimately still perform the procedure, without ever logging into the EHR
of the patient and completing the bar coding, checklist and dual sign offs.
Outcome Measures
Numerator: Use of a procedure barcode and multidisciplinary
department double check before invasive procedures

Denominator: # of times procedures are being ordered and # of

times the procedure barcode is being scanned

Threshold: 95% compliance of the new process

Timeframe: The use of the process in the EMR will be observed

for 6 months
Outcome Measures Type
Adverse Event Outcome Measure:
After 3 months of training on the new process, doctors
and team members will be at least 95% compliant and
there will be a reduction in the number of adverse events
due to invasive procedures on the intensive care unit. The
numerator will be the percentage of compliance for the
new process.
Stakeholder Analysis
Internal (unit) stakeholders
External stakeholders
Registered Nurse
Patient
Physicians
Health Insurance Companies
Training Staff
Case Manager
Patients
Families
Board of Directors
Force Field Analysis Forces AGAINST
Change
Forces FOR change (Restraining Forces)
(Driving Forces)
Resistance to new protocols
Surgical complications
RN
Physicians

Correct
Patient safety
RN communication to
Physicians prevent surgical
error

Hospital liability Implementation Costs

Implementing new
protocol
Engineering (IT)
Strategies to mitigate restraining forces:
Sharing Data/Stories
Benefits of new protocol
Cost of errors vs. cost to implement
References
Haas, B., & Gotlib, L. (2017). Communication Error in a Closed ICU. Retrieved
from https://psnet.ahrq.gov/webmm/case/409/communication-error-in-a-closed-icu

U.S. Department of Veterans Affairs. (2015). VA National Center for Patient Safety
RCA Tools