Original ArticleSafety Huddles in the PACU: When a Patient Self-Medicates
Section snippets
First Down
Patient safety is a priority of health care.2 Integrating safety measures into practice requires the blending of practice and standards. The PACU is faced with unique challenges in ensuring patient safety as a result of the continuum of the surgical process. Implementation of best practices, such as patient identification, fall prevention, appropriate staff ratios, and medication safety, must be reinforced to improve safe practice.
Medication errors are among the most common errors in patient
Fumble
One of the major contributors to medication errors in the health care setting is lack of communication among professionals and patients, creating an unsafe environment.4 Perioperatively, a patient may receive care from several health care workers within a very short period. Care may switch hands several times as patients transition from the presurgical area, through the operating suite, and into the PACU. Communication, both verbal and written, is essential in ensuring the patient transitions
The Game Plan
A Joint Commission analysis reveals that more than 70% of all sentinel events are the result of miscommunication. Literature on safety and error prevention states that “ineffective or insufficient communication among team members is a significant contributing factor to adverse events.”3 Breakdown in communication leads to increased length of stay and inadequate allocation of hospital resources.
In 2007, the Joint Commission on Accreditation of Health Care Organization (now the Joint Commission)
Safety Strategy
Implementing safety huddles was an initiative taken on by our hospital to work toward the goal of creating a culture of safety for patients. Safety huddles were piloted and had proven effective in other nursing units within our institution. Improvements were generated from topics presented in huddles based on the staff's recognition of potential safety issues. As a result, quality measures were instituted to improve safety in the units. Use of the huddle focused on obtaining quality-related
Huddles in Action
An obvious sign of success of the safety huddle in our unit has been that the staff actively participates in daily huddles, raising pertinent issues to troubleshoot as a team. The following safety concern was identified just a few days after implementation of safety huddles in the PACU.
A patient presented to the PACU after receiving general anesthesia for placement of a suprapubic catheter and cystoscopy. The patient had a past medical history of urinary retention with an indwelling catheter in
Offense and Defense
The issue of searching the patient’s belongings bag entered the discussion. One of the nurses felt that to search the patient’s bag without her permission violated the patient’s rights. Acting as an advocate for the patient’s autonomy and right to privacy, it was discussed that the patient should consent to be searched.10 Another nurse felt that the patient’s safety was at risk and it should be known whether there were pills in her bag. The patient was obtunded and could not answer to having
The End Zone
The nurse’s relationship with the patient enables nurses to provide the close observation required to identify both clinical crises and ethical dilemmas.11 Effective management of complex patient needs not only relies on nursing interventions, but on the veracity of the nurse-patient relationship. Veracity, or truth telling, is paramount in the nurse-patient relationship for the nurse to have a true understanding of situations at hand.12 Without the presence of this fundamental concept, patient
Field Goal
Before the implementation of safety huddles, we experienced an event in which a patient was exposed to harm by concealment of opioids in the PACU. Although this issue was addressed appropriately at the time, it was viewed as a patient-specific problem. After the initiation of the huddle, we were able to see a similar scenario unfold. This time the staff openly discussed and identified the problem as a team.
The outcome was that the staff communicated that there was a need for increased awareness
Touchdown
The use of the safety huddle allows the nursing team to collaboratively identify the safety challenges faced in the PACU. It provides a forum to effectively communicate and address clinical issues with the entire PACU team. Huddles help bring forward concerns from the bedside and allow for the opportunity to resolve conflicts that arise in practice. Through identification of new safety issues, we can effectively maintain a culture of safety in the recovery period for all patients.13
Conclusion
Safety huddles can be used to develop initiatives to support the best perianesthesia practice possible by creating a culture of safety for all patients. Through achieving a culture of safety, we can ensure our patients receive the high-quality, safe, effective care they deserve.
Jill Setaro RN, CPAN, is a nurse, Post Anesthesia Care Unit
References (13)
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Medication errors in the PACU
J Perianesth Nurs
(2007) Perianesthesia medication administration: Can we be too careful?
J Perianesth Nurs
(2003)Safety huddle: A fun method of increasing communication
J Vasc Nurs
(2009)- et al.
Perianesthesia nursing advocacy: An influential voice for patient safety
J Perianesth Nurs
(2008) Understanding never events
J Perianesth Nurs
(2009)- et al.
Improving patient safety by understanding past experiences in day surgery and PACU
J Perianesth Nurs
(2009)
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Daily organizational safety huddles: An important pause for situational awareness
2019, AORN JournalCitation Excerpt :Daily organizational safety huddles provide a platform to elevate clinical and operational concerns that could affect or be disruptive to patient or staff member safety.5,12,13 Leaders can dynamically and proactively allocate resources in real time to address and solve potential disruptions that could become patient safety issues when they understand the factors on a global and integrated scale that are disruptive to patient care across the organization.4,5,10,12 With intentional situational awareness, leaders are able to connect the right people at the right time to address and resolve safety concerns in real time.13
Huddles and their effectiveness at the frontlines of clinical care: a scoping review
2021, Journal of General Internal MedicineNon-clinical rounds in hospital settings: a scoping review
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2019, Journal of Palliative Medicine
Jill Setaro RN, CPAN, is a nurse, Post Anesthesia Care Unit
Mary Connolly, RN, is a nurse, Post Anesthesia Care Unit, Stony Brook University Medical Center, Stony Brook, NY