1. The Unfamiliar Catheter Chris Hunziker, Kirstee Novak, Yliana Penalosa GNRS 586

2. Background A 28 y/o F 20 months post-bilateral lung transplant presented to the ED with severe SOB RN received order to draw labs from the large-bore central line placed in pt’s chest RN had no previous experience with this catheter type Upon asking Charge RN, RN was instructed to:“waste 3 cc, draw labs, flush with saline, & HEP-LOCK” RN felt confident verbal instructions were sufficient and prepared to draw the patient’s labs RN drew labs and after tubes had been filled, the patient stated “something doesn’t feel right” RN reached for the saline flush and the pt began to convulse, lost consciousness, fell, and bled from her catheter to the floor RN called for help Tests revealed the pt had a cerebral air embolism with temporary damage

3. Methods Manpower Machines Materials Cerebral Air Embolism Lack of Assistance from CRN Incompetent RN Performing procedure without training Performing unfamiliar procedure without supervision Saline Flush Unfamiliar catheter Lack of communication +/- Clamp on catheter Cath is capable of producing an air embolism

4. Root Cause Analysis COMPETENCE: Medical Competence: A principle of professional practice, identifying the ability of the provider to administer safe and reliable care on a consistent basis. ●The charge nurse and registered nurse demonstrated a lack of competency in their roles as nurses by assuming proper care of a catheter without proper knowledge.

5. Root Cause Analysis WHY? Lack of communication between nurses WHY? Patient should have been given to someone who was trained on the cath. WHY? Not strictly adhering to policy/No available policy WHY? Charge nurse not competent in management of nursing staff WHY? Bedside nurse not trained on this particular catheter type Root cause- Lack of Competence

6. Problem: Competence of Nursing Staff PLAN The hospital will ensure that nurses on the floor will be competent on the procedures being performed and understand the reason for the procedure DO Competence training for catheter use for all nursing staff on the unit ACT Positive reinforcement and monthly nurse recognition STUDY Compare number of incidents before and after the competence training PDSA

7. PDSA: Aim Expand the culture of competence on the unit and establish clear communication. Achieved through: ●Patient safety ●Safe Procedures ●Patient advocacy ●Training ●Protocol

8. PDSA: Plan TasksPerson Responsible WhenWhere Overall review of competencies within the department through assessment and documentation Nursing Administration & Management ImmediatelyHospital unit Enhancement of Charge Nurse management and leadership skills Nursing Administration & Management Immediately & ongoing Hospital unit Review of policies and procedures manual, making sure it is being utilized, it is current, and accessible Charge nurse & Nurse Educator Immediately & ongoing Hospital unit Encourage all aspects of safety as a priority including adequate closed-loop communication between nursing staff Nursing staff on unitOngoingHospital unit

9. PDSA: Plan PredictionMeasures to determine if prediction succeeds Nursing staff will obtain knowledge of catheter type and become competent in catheter care All bedside nurses will be assessed and skills documented by management per hospital policy. Charge nurse(s) will demonstrate nursing leadership skills by mentoring nurses and providing supervisory assistance when needed Surveys for staff nurses that will provide feedback regarding approachability, mentorship, and assistance of the charge nurses Reviewing procedures and protocols will reduce the number of adverse incidents Weekly accident reports Encouraging safety as a priority using effective communication among the nursing staff Weekly accident reports & surveys to rate nurse's ability to use closed-loop communication.

10. PDSA: DO Implementation Nurse educators will assess skills of all bedside nurses by using tests, return demonstration, or simulation during inservice. Nursing unit manager will work alongside and evaluate charge nurse’s communication and leadership skills providing coaching and mentorship to the unit Charge Nurses. Charge nurse will review policies and procedures manual with all registered nurses to confirm that procedure manuals are clearly understood, utilized and accessible. Require all staff nurses to utilize readback method for closed-loop communication, including bedside shift reports and SBAR to promote safety as priority.

11. PDSA: Study PredictionOutcome Nurse who have demonstrated procedural competency in the competency check off are less likely to make a mistake in the process of a procedure. Decrease in competence-related incidents and increase in patient safety Charges nurses who receive mentorship, accountability, and assistance when needed will be more likely to provide the same to staff nurses. Increase in mentorship of staff nurses by charge nurses and supervisory assistance. Availability of protocol and procedures manuals will increase the likelihood of nurses confirming protocol. Nurses become more familiar with procedures, knowledgeable, and decrease number of mistakes made. Nurses utilizing readback methods for closed-loop communication including SBAR and bedside reporting promotes safety. Reduce the amount of mistakes due to miscommunication.

12. PDSA: Study ProblemSolution Lack of CompetenceTraining, inservice, management, leadership, mentorship, communication, safety as a priority. Safety was disregarded as top priorityAdequate communication between nursing staff including charge nurse, thorough review of policies and procedures manual, and ensuring mentorship and assistance is provided by charge nurse. Summary of findings: A “culture of competence” has been implemented throughout the unit.

13. PDSA: Act ●Positive reinforcement for employees ●Certificates of completion of competence ●“Outstanding Nurse Communicator” Award ●Expanding to other departments and other medical team members

14. Stakeholder Analysis ● Internal (unit) stakeholders ◦ Hospital administrators ◦ Nurses ◦ Patients ● External stakeholders ◦Patients/Families/Community ◦Insurance companies ◦Device Manufacturers

15. Force Field Analysis Competency Patient safety Improve culture Patient Satisfaction Time consuming Routine Attitude CULTURE OF COMPETENCE Forces FOR Change (Driving Forces) Forces AGAINST Change (Resisting Forces) Cost

16. References Marquis, B. L., & Huston, C. J. (2015). Leadership Roles and Management Functions in Nursing (8th ed.). Philidelphia: Wolters Kluwer. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003. Saunders, an imprint of Elsevier, Inc 3 Jul. 2015 http://medical-dictionary.thefreedictionary.com/competence http://medical-dictionary.thefreedictionary.com/competence Swayze, S. C., & James, A. (2013). The Unfamiliar Catheter. Retrieved July 2, 2015, from http:// webmm.ahrq.gov/case.aspx?caseID=294