Evidence-Based Practice Poster Session (Posters #11-#20)
17 - How to CUSS with Kindness in the OR
Description: PROBLEM Communication issues amongst staff, physicians and patients contribute to Serious Safety Events. For example nurses sometimes feel intimidated to speak up when they find an unsafe order or when a younger less experienced nurse sees a senior staff member not following policy but doesn't feel able to speak up. These things can and have lead to Serious Safety Events.BACKGROUND Serious Safety Events were occurring too often hospital wide. One was too many. Dignity Health recognized a way to facilitate that nurses had a tool they could utilize to empower nurses to identify safety issues, confront physicians when incorrect orders are placed, encouraging the report of events when they did occur. All to improve safety for not only the patient but staff as well.CLINICAL QUESTION How can we reduce Serious Safety Events and make both the staff and patient safer?DESCRIPTION OF EVIDENCED-BASED PROTOCOL Teaching staff how to C.U.S.S. appropriately in the O.R. and throughout Pre-op and Post Anesthesia Care Unit (P.A.C.U.)"C" - To say "I have a CONCERN"..."U"- To say "I am UNCOMFORTABLE"."S"- To say "STOP this is a safety issue.""S"- To say "I need my SUPERVISOR"By teaching staff the tool/identified verbiage of how to approach other staff and physicians empowers them to speak up to prevent S.S.E's. By encouraging accurate reporting allows better data collection to identify areas for both education and change in policy. All to improve safety.IMPLEMENTATION To provide education of how and when to C.U.S.S. in the O.R. and Perioperative service area including Pre-op/P.A.C.U. This education occurs with every new-hire and well as during annual learning modules for all staff.RESULTS From May 2018 through May 2019 data has shown a decrease in Serious Safety Event from 2+ events per average per month to a 0-1 event per month hospital wide. Graph will be added to Poster to reflect this improvement. With the inspiration of these results we have decided to focus in on O.R. perioperative services to gather data from this service line for future improvement/education. CONCLUSION/DISCUSSION We conclude that by teaching staff the proper way to approach a fellow staff person or physician when a potential action, medication, or practice concern arises will inevitably improve communication thereby preventing a Serious Safety Event. This improves the safety of all patients, all staff including housekeeping, admitting, scrub techs, video techs, nurses, surgery schedulers etc.PERIOPERATIVE NURSING IMPLICATIONS Empowerment of staff to speak up when even a POTENTIAL for a safety event to occur both reduces Serious Safety Events, improves overall Perioperative safety culture and improves the safety of both patients and staff. Better communication leads to better patient care.