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Preventing Harms One Front-Line Nurse at a Time

Credits: None available.

Purpose: The purpose of this leadership initiative was to decrease the harms on a 25-bed transitional care unit in Northern Kentucky using positive role modeling and real-time education and feedback. Harms included in this initiative were catheter-associated urinary tract infection (CAUTI), central line-associated blood stream infection (CLABSI), methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDIFF), hospital-acquired pressure injury (HAPI), and patient falls all measured in events per 1,000 patient days.

Description: The nurse manager, assist nurse manager, and charge nurse designed and developed a new rounding process called “zero-harm rounding.” The process created a daily opportunity for peer-to-peer learning to reinforce the organization’s evidence-based practice in place to reduce harms across the board in a non-punitive manner. The rounds were interactive, collaborative, and educational; the goal was to ensure all members of the team were knowledgeable and aware of each element of practice to reduce harms for all patients. The leadership provided weekly data on all harms on the unit to track progress and celebrate successes. The leaders also provided real-time feedback to the primary nurse if there was a missed opportunity to provide evidence-based care. For example, if a patient had a central line and the chlorohexidine biopatch was not placed on the patient, one of the leaders would educate the primary nurse about the appropriate placement and documentation of the biopatch to reduce CLABSI harms.

Evaluation/outcome: The implementation of the zero-harm rounding process has led to a decrease of harms across the board (CAUTI, CLABSI, CDIFF, HAPI, MRSA, and patient falls) from pre-intervention rate of 40.65 harms per 1,000 patient discharges in September 2020 to a post-intervention rate ranging from 0.0 – 7.69 harms per 1,000 patient discharges as of April 2021. The work continues today and has spread to other units throughout the organization. As health care organizations are all striving to prevent harms and do so in a cost-effective manner, it is this team’s belief that zero-harm rounding can and does make a difference. Although the leadership driving this project was important, it also must be said that part of the success was due to the bedside nurses and other ancillary staff being able to share barriers with the leaders in real time. This improvement in communication and early identification of barriers is one of the main reasons this process was successful and has been sustained. In a busy health care world, we all have to remember that it truly does take a village to provide the best care to all our patients.

Evidence-based references
1. American Hospital Association/Health Research & Educational Trust (2016). Hospital engagement network 2.0: Final project report. Retrieved from: AHA/HRET HEN 2.0 Final Project Report (patientcarelink.org)
2. American Hospital Association (2021). Retrieved from: Garfield Medical Center - Reducing Readmissions | AHA Health Research and Educational Trust (n.d.). Guide: Improving harm across the board template. Retrieved from: AHA_HRET_HEN_Harm_Across_Board_Guide_05142013.pdf (mtha.org)



Credits: None available.

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