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What’s New in the
Patient Safety World
May 2020
A Takeoff on the
Patient Safety Scavenger Hunt
Over 10 years ago, we wrote a column on doing patient safety scavenger
hunts (see our March 16, 2010 Patient Safety Tip of the Week “A
Patient Safety Scavenger Hunt”).
In that column we noted you can also make patient safety fun at the same time
you are identifying hazards in your organization. We provided the example of
the “Patient Safety Scavenger Hunt”. In this exercise you award points for
identifying patient safety hazards or risky situations or practices. Give your
staff a finite period of time (eg.
2 hours) to look for these and award points for each item identified within
that time frame. Use multiple staff and you may need to pair them up for the
search for some of the items (like the suicide risk ones). We provided some
examples you could award points for:
- Alarms disabled (or
otherwise manipulated to make them less likely to alert staff to dangerous
situations)
Suicide risk hazards - Hand hygiene patrol
(identify instances where a healthcare worker goes from one patient room
to another without washing his/her hands)
Delirium risk - Catheter patrol
- Dangerous
abbreviations
- Look alike/sound
alike drugs (LASA’s)
- BMV workarounds.
Identify examples where the safety mechanisms in a bedside medication verification
(barcoding) system are purposefully bypassed
We provided a sample scorecard in that
column.
Jane Bell, from Cityview
Surgery Center in Fort Worth, Texas, recently described in Outpatient Surgery
Magazine a takeoff on the patient safety scavenger hunt (Bell 2020). She
describes a game/exercise in which two
staff members stage 20 to 25 errors at a bedside in their PACU. These would
include things like a bloody tourniquet left on a patient’s bedside stand, a
surgery schedule in full view, an overflowing sharps container, and others.
The next day staff
are divided into two teams. Each team is brought in to view the room for 30
seconds, and members write down all of the errors they
can find. (She notes that the 30-second time limit is key because if your staff
can spot problems quickly and under pressure, there’s
a good chance they’ll do the same during a stressful surgery.)
After the scores are
tallied (a point for each mistake noticed), the team that spots the most errors
wins. They gave every member of the winning team a Starbucks gift card. The
winning team actually correctly guessed all 25 of the
errors in their “Secret Room”.
The point is that
you can combine fun with learning and identification of patient safety hazards
at the same time. Try these exercises in your organizations.
References:
Bell J. Ideas That Work: Secret Room. Help Staff Spot Mistakes in Seconds. Outpatient Surgery Magazine 2020; XXI(2): February 2020
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