TeamSTEPPS and Reducing Patient Falls
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Transcript TeamSTEPPS and Reducing Patient Falls
TeamSTEPPS and Reducing Patient
Falls
Prepared for the RHQN
December, 2013
Introduction
Jefferson Healthcare
25 beds
CAH
Port Townsend, WA
Background
The Oregon Experience
ORHQN
Strategy for training
Implementation
Hard-wiring
Results?
What is TeamSTEPPS?
Team Strategies and
Tools to Enhance
Performance and
Patient Safety
Why use TeamSTEPPS?
Goal: Produce highly effective medical teams that optimize
the use of information, people and resources to achieve the
best clinical outcomes
Teams of individuals who communicate effectively and back
each other up dramatically reduce the consequences of
human error
Team skills are not innate; they must be trained
AHRQ, 2012
Patient Falls
Falls account for nearly 40% of accidents in hospitals
Leading cause of injury and death among older adults
Root causes of falls in rural facilities
Not identifying patients at high risk for falls
Failure to implement safety strategies
Failure to routinely complete fall risk assessments
Failure to complete post fall assessment
Ruddick, Hannah, & Schade, 2008
Team Events
TOPIC
Brief - planning
Who is on core team?
Huddle – problem solving
All members understand
and agree upon goals?
Debrief – process
improvement
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
Leadership Skills
Resource Management
A strategy for balancing
workload
People, knowledge or
information to complete a
given task
Goal is to prevent overload
situations that compromise
situation awareness
Delegation
Re-Distributing tasks or
assignments
Four steps:
What to delegate
To whom to delegate
Communicate clear
expectations
Request feedback
Develop a Shared Mental Model
Situation
Monitoring
(Individual Skill)
Shared
Mental Model
(Team Outcome)
Situation
Awareness
(Individual
Outcome)
Situation Monitoring
(Individual Skill)
Staff need to:
Be aware of what is going
on
Prioritize and focus on
different elements
Share this information with
others
“Teams that perform well hold
shared mental models.”
(Rouse, Cannon-Bowers,
and Salas 1992)
Situation Awareness
(Individual Outcome)
The state of knowing the current
conditions affecting the team’s work
Knowing the status of a
particular event/patient
Knowing the status of the
team’s patients
Understanding the operational
issues affecting the team
Maintaining mindfulness
Strategies to Increase Situation
Awareness
Visual Cues
Posey System
Arm bands
Colored socks
Magnets on doors
Engage patients and family members
White boards in rooms
Patient Journals
Education
Hourly Rounding
Post Fall Huddle Debrief
Implement a post fall huddle or rapid response team
Interdisciplinary
Stabilize the patient
Process improvement
Debrief: Designed to improve outcomes
Use post fall assessment tool
An accurate reconstruction of key events
Analysis of why the event occurred
What should be done differently next time
Feedback
Implement a process for feedback
RCA
Debriefing
Incident reports
Quarterly newsletters
Staff Meetings
Leadership Briefings
Safety Rounds
“Feedback is the giving, seeking,
and receiving of performance-related
information among the members of a team.”
(Dickinson and McIntyre 1997)
Questions?
Brandie Manuel,
Director of Patient Safety & Quality
Jefferson Healthcare
Port Townsend, WA 98368
(360) 385-2200 ext. 2076
[email protected]