QI Project

Jamie, Irina, Jese

 Scenario and Background

M.P., a 24 year old female presents to the ED complaining of anxiety over the past
several days and insomnia. During the triage process, the nurse noted that the
patient was disheveled, had poor eye contact, was acting bizarre, and endorsed
vague suicidal ideation (I cant take it any longer, Id rather be dead than dealing
with this, etc.). The nurse took the patient back to the treatment room, put her on
the bedside monitor, brought her a warm blanket, closed the curtain, and notified
the primary nurse that she had a new patient.
 Scenario and Background

The primary nurse was caring for another patient which delayed the initial
assessment of her new patient. When she finally made it into the room of her new
patient, the nurse noticed that the patient was still in her clothes and her backpack
was on the end of the bed. Upon further investigation the nurse noticed there was
blood on the sheets and the patients clothes. The nurse called for help and upon
and discovered that the patient had used a sharp item to cut her left wrist. The
patient was immediately placed on a 24 hour hold by the attending ER MD.
 Methods Exposure

Not requiring patient to fully undress Only cooperative patients

Inadequate of protocol for suicidal patients

Limited encounters with psychiatric patients

Standard process for triaging patient with SI Knowledge deficit surrounding psychiatric
population

Delay in enforcing 24-hour hold Psychiatric patients left

unattended while in the
ED resulting in self-
No 1:1 supervision Busy Emergency Department
harm
Patients proximity to nursing station
Lack of psychiatric facilities to transfer

Unattended patient with curtain closed

Nurse/Staff coverage
No appropriate means to secure belongings

People Environment
 Root Cause Analysis
Rule #1: Cause & Effect
ED nurse left a potentially suicidal patient on her own without removing her clothing and any
harmful objects & without doing a further check to assess safety, which led to the patient cutting her
left wrist.
Primary nurse busy, which delayed initial assessment; short staffed, proximity to nurses station,
curtain closed.
ED staff with limited interactions with psychiatric patients
Rule #2: Avoid Negative/Derogatory Statements
The ED nurse had no clear protocol on interventions for potential suicidal patients in the
emergency department.
The primary nurse was busy with other patients on the floor.
 Root Cause Analysis
Rule #3: Each human error/mistake must have preceding system level cause
In this scenario, the ED nurse did not have proper protocol for suicidal patients, decreasing the
potential safety of the patient.
Rule #4: Violation of policy/procedures not root causes
There was no proper screening of psychiatric patients in place for the ED, therefore harmful
contraband was allowed with the patient in her room.
Rule #5: Failure to act is only casual when there was a pre-existing duty to act
The ED staff did not accurately screen and monitor the psychiatric patient, leading to a self-harm
event from the patient.
 Root Cause Analysis: Broken Down
Patient harmed In the emergency
herself. department.

During the time

By cutting her own she was left alone
wrist. in her room.

Left alone with all

belongings,
Psychiatric patient
closed curtains,
not enough staff
coverage
 Actions To Prevent Future Occurrence
How can we prevent this from happening again?

Create a policy for psychiatric patients in the ED: Removing all clothing, secure
personal belongings, place on 1:1, keep curtain open, move close to nurses
station

Provide nurses with proper training on safety measures for psychiatric patient.

Schedule more nurses (or qualified staff) depending on needs of the

department

Utilize patient observers for all psychiatric patients

 Actions To Prevent Future Occurrence
Strong: All nurses must follow the Psychiatric Patient protocol in the emergency
department. Psychiatric patients will be required to remove all clothing, belongings
will be secured in a bin at the bedside, patient will have 1:1 supervision while in
the ED, curtain will remain open. If possible patient will be moved closer to the
nurses station. A behavioral/psychiatric checklist will be created and implemented.

Intermediate: A psychiatric/behavioral protocol will be in place for the emergency

department.

Weak: All ED nursing staff must be vigilant of patients with psychiatric complaints.
Outcome Measures
Numerator: Number of patients where the psychiatric protocol is enforced

Denominator: all psychiatric patients that present to the ED that are placed on a
24 hour hold or require 1:1 supervision

Threshold: >95%

Timeframe: three months

Outcome
Adverse Event Outcome Measure.
1. Proper protocol for suicidal patients was created in ED.
2. RNs received training on how to properly care for psychiatric patients
3. On Call nurses are scheduled to prevent stuff from being overwhelmed during busy days
4. Patient observers (non-RN staff) are utilized
5. RNs follow the behavior/psychiatric checklist for suicidal patients that includes
a) securing personal belongings from suicidal patients
b) keeping suicidal patients close to the nursing station
c) keeping curtains open
d) using 1:1 patient observer
e) MD promptly placing appropriate patients on
24-hour hold
Goal Met!
Three months after creating the protocol, following the staff training, and implementing interventions and checklist
for psychiatric/suicidal patients, the use of the new protocol was >95%.
And more...
Implement in the ED

Implement hospital wide

Publish data

Share results with other hospitals

 Stakeholder Analysis
Internal: External:
Registered Nurses
Patients
Charge Nurses
Training Staff Health insurances companies
Training Department
Medicare/Medicaid
Payroll Department
Patients
Patients families
Board of Directors
 Force Field Analysis
Forces FOR Change Forces AGAINST change
Driving Forces Restraining Forces
PATIENT SAFETY!!! Increased cost to staff
Financial consequences if additional nurses/staff
harm or injury does occur Variability in presence of
Implementing patient psychiatric patients
observer allows more RN
availability

Strategies to Mitigate Restraining Forces

Flex additional staff (patient observers) if not needed, or

float to different area of the hospital
Hire non-nursing staff to fill patient observer roles to
lessen cost
If observer is not being used with a psychiatric patient,
find additional assignments/tasks for them to complete
References
VA National Center for Safety. (2015). Root cause analysis tools. VA National
center for patient safety.