The Unfamiliar Catheter

Chris Hunziker, Kirstee Novak, Yliana PenalosaGNRS 586

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

MethodsManpower

Machines

Materials

Cerebral Air Embolism

Lack of Assistance from CRN

Incompetent RNPerforming procedure

without training

Performing unfamiliar procedure without supervision

Saline Flush Unfamiliar catheter

Lack of communication

+/- Clamp on catheterCath is capable of producing an air embolism

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.

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

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

DOCompetence training for

catheter use for all nursing staff on the unit

ACTPositive reinforcement and monthly nurse recognition

STUDYCompare number of incidents

before and after the competence training

PDSA

PDSA: AimExpand the culture of competence on the unit and establish clear communication.

Achieved through:● Patient safety● Safe Procedures● Patient advocacy● Training● Protocol

PDSA: PlanTasks Person

ResponsibleWhen Where

Overall review of competencies within the department through assessment and documentation

Nursing Administration & Management

Immediately

Hospital 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 unit

Ongoing Hospital unit

PDSA: PlanPrediction Measures 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.

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.

PDSA: StudyPrediction Outcome

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.

PDSA: Study Problem Solution

Lack of Competence Training, inservice, management, leadership, mentorship, communication, safety as a priority.

Safety was disregarded as top priority Adequate 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.

PDSA: Act

● Positive reinforcement for employees● Certificates of completion of competence● “Outstanding Nurse Communicator” Award● Expanding to other departments and other

medical team members

Stakeholder Analysis

●Internal (unit) stakeholders◦Hospital administrators◦Nurses◦Patients

●External stakeholders◦Patients/Families/Community◦Insurance companies◦Device Manufacturers

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

ReferencesMarquis, 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

Swayze, S. C., & James, A. (2013). The Unfamiliar Catheter . Retrieved July 2, 2015, from http://webmm.ahrq.gov/case.aspx?caseID=294