Presentation ID #11: Click here to view presentation.
Abstract: The Institute of Medicine’s report “To Err is Human” remains relevant two decades later: medical error is the fourth leading cause of death in the United States and 40% of hospitalized children experience medical error. One obstacle to safer care is lack of error reporting. That omission denies the opportunity to learn from those events. Safety Culture describes a work environment conducive to reporting, and its properties are measurable using the Safety of Patients Survey (SOPS 1.0 TM). On a pediatric acute care unit in a children’s hospital in southeastern U. S., SOPS 1.0TM scores and error reporting missed agency benchmarks. The purpose of this quality improvement project was to improve error reporting and SOPS 1.0TM scores relative to reporting through a Safety Huddle Intervention. Marshall Ganz’s Change through Public Narrative Framework provided the theoretical design for this project: a story of self, a story of us, a story of now. The SOPS 1.0 TM was implemented before and after the six-week intervention on the project unit and a comparison unit. Monthly error reporting was tracked before and after the intervention on those same units. The 5 composites of SOPS 1.0 TM purported to measure reporting culture showed no statistically significant differences after the intervention, or between the project and comparison units. Error reporting increased after the intervention on the project unit (p=0.0121) but not the comparison unit. Of note, this quality improvement project took place during the COVid 19 pandemic, and survey results revealed a preoccupation with staffing as an overriding concern in patient safety.
Peggy MacKay is a faculty member in the UNC Charlotte who teaches pediatrics in the prelicensure program. She is a licensed Clinical Nurse Specialist and is certified in both pediatric nursing and nursing education. Her prior work on Quiet and its effects on pain in children after surgery was the recipient of an American Nurses’ Foundation Grant, and this work was done in a bedside nursing role. The project presented here was funded by the Elinor Caddell Grant for Faculty Scholarship. Peggy formerly served on the Board of Directors for the Society of Pediatric Nurses. She continues to enjoy a bedside practice caring for children and families at Levine Children’s Hospital.