Original Article
Safety Huddles in the PACU: When a Patient Self-Medicates

https://doi.org/10.1016/j.jopan.2011.01.010Get rights and content

The implementation of safety huddles in the PACU has been effective in enhancing and promoting patient safety during the recovery period. The case scenario presented in this article demonstrates how the safety huddle can be used to examine nursing care in the PACU. Allotting time each day to address patient-related issues that arise during patient care allows the team to troubleshoot and resolve clinical issues. Through examination of nursing practices in the recovery period, PACU nurses are able to support the best perianesthesia care possible.

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

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Cited by (11)

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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

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