The Atlas of Shared Learning
Safety on board – reducing risk
A Ward Sister at Solent NHS Trust led the implementation of a Patient Safety Board on a neuro-rehabilitation ward which has significantly improved staff accessibility to patient information relating to risk. This has improved patient safety, staff and patient experience and use of resources.
Where to look
The importance of patient handover and good communication is well documented. An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care (Smeulers et al., 2014).
Staff on the neuro-rehabilitation ward at Western Community Hospital care for patients who have a variety of neurological conditions and support needs. These patients are often at risk of falling, have swallowing problems and are under The Deprivation of Liberty Safeguards (DoLS) which is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm.
The necessity for staff to check information on computer systems and notes was observed to be having an impact, delaying the right care being delivered and causing some near miss incidents. The Ward Sister identified that as well as being an inefficient use of staff time, there were significant issues with accessibility of patient information. This meant there was unwarranted variation in the process for effectively identifying and communicating any risks during handover. This was not in the best interests of their neuro-rehabilitation patients.
What to change
All patient notes contained comprehensive and up-to-date handover information about DoLS, resus status, ‘do not attempt CPR’ (DNACPR) orders as well as swallowing and falls risk. However, these records were not always in the same place reducing ease of access for staff and sometimes leading to risk factors not being recorded which could impact on quality of care delivery.
At the Nursing and multidisciplinary team (MDT) meeting, discussions identified that the accessibility of important information was an issue and the need to make changes to improve this was the way forward.
How to change
The Ward Sister, with support from the Quality Improvement team, undertook an audit to look at staff knowledge of three risk areas in relation to patients currently on the ward. Whilst all eight staff taking part knew which patients were not for resuscitation, only a quarter knew how many patients were under DoSL, and no-one had knowledge of the current patients with swallowing difficulties.
After further discussions with the MDT it was agreed to introduce patient information relating to swallowing problems, fall risks and DoLS on the existing white board in the ward office. The board was chosen because it was well utilised by the entire MDT, kept up-to-date, and in a central accessible position in the ward office. It was also considered a pragmatic approach.
Magnets were used on the board to identify the risk issues with a reminder colour-coding key for staff:
- yellow for swallowing problems;
- blue for fall risks;
- black for DoLS; and,
- red for do not resuscitate.
It was easy for staff to update the board using the magnets and enabled any rotational or agency staff to easily see and understand the new system.
The new process was initially tested for two weeks, during which the Ward Sister gathered feedback from staff. Some changes were made to the initial board template to make it easier to read and sustain, and the process was tested for a further two weeks to ensure it was working well. The board and magnets are being used daily and the change is now embedded into the ward routine.
Better outcomes – An audit was undertaken a month after the board had been introduced by the Ward Sister and Quality Improvement Team. Using the same baseline measurements, they found that 100% of staff now knew which patients were under DoLs, at fall risk, had swallowing problems and were not for resuscitation compared to the initial 42% overall at the start of the change improvement. The ward has a very low incident rate and therefore there has not been a significant change in this. The information being provided by the different coloured magnets are a simple way of preventing error and ensuring staff have the correct information to hand.
Better experience – The magnets on the board are a simple and quick reference point for staff to find out the information required in an area where clinical conversations occur. Feedback includes “why did we not do it before”. Patients are receiving appropriate care immediately as the appropriate information is to hand.
Better use of resources – As information is now easily accessible to staff, they are no longer spending lots of time looking for it and can spend that time giving the right care at the right time for patients.
Challenges and lessons learnt for implementation
There was little resistance to the change because the team felt involved in the decision and had identified the problem themselves. The key to the project being successful was knowing the staff group and listening to their opinions and suggestions. This ensured that the whole team were engaged with the change.
Staff acknowledged that this was a small-scale change which had a large impact and this has motivated them to make further quality improvements relating to patient safety and their clinical handover.
Find out more
For more information contact:
- Karen Kingston, Ward Sister, Solent NHS Trust, email@example.com