Quality Improvement

Colleen Duckworth, Cailey Whittaker, Jennifer Castillo, RJ

Alejandrino
10/30/18
Background
A 72 year old man diagnosed with dementia and AKI has been on a medical surgical unit
for the past four days. His nurse during the day shift clamped his indwelling foley
catheter in order to obtain an ordered clean catch urine sample. The nurse is then
asked by her charge nurse to go on lunch and forgets to report the clamp to the
resource nurse.

During her lunch break, the patient becomes overwhelmed with the urge to urinate and
gets out of bed. The bed alarm does not go off and the patient falls to the floor and hits
his head.
Root Cause Analysis
The resource RN was not notified about the Foley clamp in
place so the pt’s urine did not properly drain, resulting in the
patient getting out of bed and falling.

Rules (Policies and Procedures)

Safeguards
Information Technology
Communication
Actions to prevent further
occurrence
**Departmental change to a foley with an external clean catch specimen port,
eliminating need to clamp foley for specimen collection. (Cost $8.99/each vs. cost of fall
~$30K/each) STRONG

*Creation of a policy requiring dual sign-off on the EMR of all lines associated with the
patient at each handoff. STRONG/INTERMEDIATE

*A timer option of 10 minutes on the EMR when a foley is clamped for specimen
collections. INTERMEDIATE/WEAK
Actions to prevent further
occurrence
1) The medical surgical department will now use the Kendall Precision 400 foley kits
with Luerlock sampling port. All clean catch specimens will be obtained aseptically
from the external sampling port on the drainage bag.
2) Patient care transfers to a new nurse (ie: at shift change, during breaks) require
both the leaving and incoming nurse to dual sign-off all lines associated with the
patient’s care (ie: foley catheters, ports, PICC, IV) for patency and status of the line,
on the EMR.
3) Nurses must start the EMR clamping timer whenever a clamp is placed on a foley
for a clean catch specimen, to alert the nurse when to return for the specimen
collection.
Outcome Measures
Numerator: Number of patients with foley catheters requiring a
clean catch urine specimen collection
Denominator: Number of adverse events (ie: falls, CAUTIs)
associated with urine specimen collection
Threshold: 95% of patients with an indwelling catheter will be
adverse event free from catheter associated events.
Timeframe: Data collection will be monitored monthly for three
months.
Outcome Measures Type
Adverse Event Outcome
Three months after staff training, the number adverse events
(patient falls, infection, patient removal of catheter) related to
clamped foley’s will be reduced by 90 percent on the med-surg unit.
The numerator will be the number of adverse events related to
clamped foleys.
 Stakeholder Analysis
Internal (unit) stakeholders
Nurses, patients, doctors, and lab are all affected. Nurses will have to receive training.
Patients will hopefully receive safer care. Doctors will have to understand how to order any new
equipment. The lab may have a delay in getting samples while everyone becomes accustomed
to the new methods, and they may want to be on the lookout for any errors in sample integrity.

External stakeholders
Managed care providers and home health agencies that work with patients who have Foley
catheters will be affected. They will have to understand the new changes and be able to
communicate the changes to the patient, their families, and those who care for them outside
the hospital. Members of the community are also affected. They need to know that the new
changes will be effective, and that the changes are worth the money that will be invested,
especially if funded by tax dollars.
 Force Field Analysis

● Patient safety ● Money $$$

● Threats to nurse ● Time to train
liability will be ● The assertion that
improved equipment shouldn’t
● Prevented falls, be needed to remind
infections, and nurses
other complication
risks
Strategies to mitigate restraining forces:
● Compile data on the cost effectiveness of complication prevention,
● Compile data on time saved in the hospital through preventing complications.
● Remind opposers that there may be emergencies or scenarios when accidents
are more likely to occur, and nurses have multiple priorities to handle.
References
US Department of Veterans Affairs. (2015). Root cause analysis tools: VA national center
for patient safety. Retrieved from
https://canvas.apu.edu/courses/4632/files/folder/Document%20Sharing/Quality
%20Improvement%20Project%20Resources?preview=239316