Saving lives with simple visual cues

February 12, 2016

What difference can 10 seconds make? For 40 per cent of residents on Unit 2-6 at Wascana Rehabilitation Centre, 10 seconds may be the difference between life and serious injury or death.

These residents – 14 in all – receive mechanical ventilation, either full or part-time. Each of them is connected by a breathing tube to a ventilator which moves air into and out of their lungs. If their tube isn’t properly connected to the ventilator, they either can’t breathe, or their breathing is compromised.

Ten seconds is the length of time a continuing care assistant, a nurse, the resident care coordinator or a registered respiratory therapist has contact with a resident.

The 10-second ventilator check was implemented in September. At that time, employees were able to correctly complete seven per cent of the required steps. When audited again in November, staff completed 100 per cent of the steps correctly.

As well, employees there also have easy access to a photo checklist – designed by 3sHealth – that shows them the proper sequence of physical checks they need to set up the connections and check that everything is working as it should. The photo checklist bridges language barriers and doesn’t leave the process up for interpretation, which dramatically increases patient safety.

The cards were introduced last summer in support of a large mistake-proofing project conducted by the Regina Qu’Appelle Health Region, with support from the ministry and 3sHealth. The overall goal of mistake proofing work is to achieve zero harm to residents and staff. At Wascana Rehab, their goal was to standardize patient checks so if one of many possible defects occurred, the problem would be caught before it caused harm to the patient.

“The vent check is a hands-on touch of the connections,” said Carla Wekerle, unit manager, who noted that residents can have multiple connects and disconnects throughout the day as they move from their bed and bedside ventilator to their wheelchair and a portable ventilator and back to their bed again. “Sometimes a tube can be connected but loose. By touching, staff can ensure all connections are sound.”

The most important change taking place, said Wekerle, is the culture shift.

Linda Trail, a continuing care aide, said “Things have changed. If there were incidents before, we didn’t hear about them.” Checks were the responsibility of registered nurses, who conducted them three times every 24 hours.

Staff now discuss occurrences at their daily huddle. Wekerle added, “People now feel safe to talk. Seasoned staff are teaching new staff and staff are picking up errors before they become a crisis.”

Dave Ambroz, who designed the photo instruction cards now in use at the facility, says he’s proud to have contributed to better outcomes for patients.

“Hearing what staff at Wascana Rehab have been able to achieve is amazing. I’m glad I had the chance to contribute something to the process.”

This project has helped some of the most vulnerable residents at Wascana Rehab and made it easier for the staff to provide high quality care said kaizen specialist and mistake-proofing event participant Jackie Rorquist.


pdf  2016-02-12-Saving-lives-with-simple-visual-cues.pdf

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