Increasing Compliance with a New Interunit Handoff Process: A Quality Improvement Project.

INTRODUCTION: Current literature demonstrates that standardizing interunit patient handoff improves communication, information transfer, and patient safety. However, few studies have focused on increasing staff compliance with new handoff processes. The purpose of this quality improvement project was to incorporate both user input into process design and on-the-job coaching with a newly introduced nurse handoff process between the postanesthesia care unit and Medical/Surgical units. We hypothesized that staff compliance would be 100% within 90 days. METHODS: The team's intervention consisted of (1) involving representative frontline nursing staff in the standardization and modification of the handoff process and (2) providing on-the-job coaching as the new process was being trialed at the bedside. We designed the handoff process during a 2-day workshop and a 1.5-week pilot. Data included the number of observed noncompliant process elements and handoff duration. Three sequential 30-day plan-do-study-act cycles were followed, during which compliance observations and user feedback were used to refine the design and coaching iteratively. RESULTS: A total of 1,800 process elements were observed and coached throughout a 90-day trial period. The number of observed noncompliant elements decreased from 15% (92) to 4% (22) from the first 30-day interval to the final 30-day interval. There was no undesirable increase in handoff duration (mean, 8.05 ± 4.72 minutes), and several potential errors-related to orders, charting, and patient placement-were prevented by using the new handoff. CONCLUSIONS: User input and on-the-job coaching resulted in iteratively increasing frontline compliance with a new standardized handoff process.

Failure mode and effects analysis to reduce risk of heparin use.

PURPOSE: Failure mode and effects analysis (FMEA) was used to identify safety risks of unfractionated heparin (UFH) use and to develop and implement countermeasures to improve safety. METHODS: FMEA was used to analyze the transportation, preparation, dispensation, administration, therapeutic monitoring, and disposal of UFH in a tertiary care, freestanding pediatric hospital. The FMEA was conducted in a stepwise fashion. First, frontline staff mapped the different steps within the UFH use process. Next, key stakeholders identified potential failures of each process step. Finally, using calibrated scales, the stakeholders ranked the likelihood of occurrence, severity, and detectability for each potential failure's cause. The rankings were used to prioritize high-risk areas on which to focus efforts for improvement countermeasures. RESULTS: The analysis revealed 233 potential failures and 737 unique potential causes. After ranking of all identified potential causes, 45 were deemed high scoring. Those 45 causes were further refined into 13 underlying contributing causes. To address the contributing causes, selected team members developed 22 countermeasures. The FMEA showed that implementation of the countermeasures reduced the level of mathematical risk. CONCLUSION: FMEA was helpful in identifying, ranking, and prioritizing medication risks in the UFH use process. Twenty-two countermeasures were developed to reduce potential for error in the riskiest steps of the process.

Movements and muscle activity initiated by brain locomotor areas in semi-intact preparations from larval lamprey.

In in vitro brain/spinal cord preparations from larval lamprey, locomotor-like ventral root burst activity can be initiated by pharmacological (i.e., "chemical") microstimulation in several brain areas: rostrolateral rhombencephalon (RLR); dorsolateral mesencephalon (DLM); ventromedial diencephalon (VMD); and reticular nuclei. However, the quality and symmetry of rhythmic movements that would result from this in vitro burst activity have not been investigated in detail. In the present study, pharmacological microstimulation was applied to the above brain locomotor areas in semi-intact preparations from larval lamprey. First, bilateral pharmacological microstimulation in the VMD, DLM, or RLR initiated symmetrical swimming movements and coordinated muscle burst activity that were virtually identical to those during free swimming in whole animals. Unilateral microstimulation in these brain areas usually elicited asymmetrical undulatory movements. Second, with synaptic transmission blocked in the brain, bilateral pharmacological microstimulation in parts of the anterior (ARRN), middle (MRRN), or posterior (PRRN) rhombencephalic reticular nucleus also initiated symmetrical swimming movements and muscle burst activity. Stimulation in effective sites in the ARRN or PRRN initiated higher-frequency locomotor movements than stimulation in effective sites in the MRRN. Unilateral stimulation in reticular nuclei elicited asymmetrical rhythmic undulations or uncoordinated movements. The present study is the first to demonstrate in the lamprey that stimulation in higher-order locomotor areas (RLR, VMD, DLM) or reticular nuclei initiates and sustains symmetrical, well-coordinated locomotor movements and muscle activity. Finally, bilateral stimulation was a more physiologically realistic test of the function of these brain areas than unilateral stimulation.