In a section of the tool entitled "Identify Defects through Sensemaking" providers at various levels of hospital care, from pharmacy to nursing to physician staff, are seen in a video meeting talking frankly about an increase in readmissions because of poor handoff adherence. They also discuss the failure to stop antibiotic dosages in patients by 24 hours after surgery, which can increase antibiotic resistance. And they put it on a list to speak with providers about guideline compliance.
According to a news release, the toolkit "helps doctors, nurses, and other members of the clinical team understand how to identify safety problems and gives them tools to tackle these problems that threaten the safety of their patients."
Hickman said that one element of the program that helped her hospital succeed was that now, teams on each unit set 24-hour goals for each patient, and then bump that up to every 12 hours. That could hasten the removal of a central line that is no longer necessary, and eliminate increased risk of infection.
Another example of how unit-level attention and teamwork prevents errors is the problem of older nurses not being able to see the type of medication on an ampule because the type is too small. "We bought a whole bunch of magnifying glasses," which resolved the nurses' complaints, she said.