In spite of efforts to improve patient safety since the 1999 report, To Error Is Human, recent studies have shown limited progress toward preventing serious error. Most hospitals use root cause analysis as a method of serious event investigation. The authors postulate that this method suffers from 4 problems: (a) the use of root cause analysis is neither standardized nor reliable between organizations, (b) hospitals focus on "who" did "what" rather than on "why" the error occurred, (c) the identified causes are often too nonspecific to develop actionable correction plans, and (d) a standardized nomenclature does not exist to allow analysis of recurring errors across the organization. This article describes the modification of the Human Factors Analysis Classification System based on James Reason's theory of error causation for use in health care. This method resolves the 4 deficiencies noted above. The authors' experience investigating 105 serious events over 2 years is described.

Simulation engages nurses in learning within a safe environment. This teaching method evaluates both skill and knowledge attainment, but evaluating the impact on patient outcomes after a simulation training event is limited. This article reviews the impact simulation training had on nurses' adherence to stroke quality measures.

Objective: The Joint Commission (TJC) Comprehensive Stroke Center (CSC) certification includes the standard that hospitals must use processes based upon clinical practice guidelines (CPGs) or evidence-based practice to facilitate the delivery of clinical care, including patients admitted directly from the Operating Room or Interventional Radiology. Included in this standard is the requirement that assessment and documentation post-procedure be consistent with selected CPGs. This project was designed to improve assessment and documentation adherence at a single academic hospital. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to improve compliance for required assessments when recovering a patient. The team reviewed current policies, guidelines, and order sets related to post procedure assessments. Comparison of pre-intervention and post-intervention adherence to charting standards was performed. Pre-intervention patients included a review of 4 records by TJC CSC reviewers during their on-site visit. Each patient had insufficient documentation; therefore, the institution was cited in this area. Post-intervention patients were prospectively identified. A Neuro ICU Self-Audit Tool was created to identify patients, remind staff of required assessments, and serve as a self-audit tool affirming their adherence to the guideline. Additional interventions included education (via email, poster in-services, staff meeting updates, and one-on-one teaching) for Neuro ICU nurses. A Post Cerebral Arteriography order set was created and the electronic health record modified to make it easier to document assessments. Results: Compliance improved to 98% in 4 consecutive months. 100% of cases were reviewed by the primary and charge nurses. 10% of cases were reviewed by the stroke program data analyst to ensure accuracy and inter rater reliability. Outliers were reviewed by the stroke leadership team and feedback given to unit nursing leadership and the nurse. Conclusions: Improvement of adherence to post-procedure assessments is possible using the PDSA methodology. The success of this project allowed this hospital to achieve its TJC CSC certification.

Background: Joint Commission Comprehensive Stroke Certification (CSC) standards include the use of a standardized stroke scale across the organization. Physicians were utilizing the National Institutes of Health Stroke Scale (NIHSS)and it was identified that nurses had a poor understanding of how to perform and interpret the scale. Purpose: To use Plan-Do-Study-Act methodology to guide a quality improvement project to increase understanding and utilization of the NIHSS by nursing staff. This includes training and certifying all the nurses in stroke patient care units; followed by implementation into nursing practice. Methods: A multidisciplinary team was created to assess the current situation,develop education and implement plans based on best evidence. A literature search was completed. A course was developed by the stroke team to train and certify 250 nurses. Course content included lecture, discussion and accepted training video offered by the National Stroke Association. The intent of the course was to expand nursing knowledge and comfort with NIHSS. A pilot course was offered to the providers outside of these three key units and feedback was used to modify the course. Nurse perceptions of the NIHSS were examined prior to the training (n=211) and 2 months after implementation of the scale into routine practice (n=68). Adjustments and resources were developed and implemented based on results. Results: The course offered a first time certification pass rate 96% and nursing documentation compliance was 83% a month after implementation. However, in the first 3 months, 80% of those who completed the survey reported feeling they could accurately perform the NIHSS but almost 60% had only performed the scale 1-6 times. Many nurses expressed concern about the scale to being too subjective (55%) and too time consuming (50%). Conclusions: Even though the staff has been trained and certified to complete the scale, steps in the scale are consistently reported as difficult to assess. Low patient volume, infrequent use and patient barriers may contribute to challenges with NIHSS.

BackgroundParents of children newly diagnosed with cancer are required to understand a significant amount of new information during a time of distress. Parents of children with cancer have expressed that concise information with visual cues, which can be repeated, positively influences their ability to understand.ObjectivesThe primary objective was to develop 2 concise, video-based education modules that are understandable to parents of children with cancer. A secondary objective was to determine feasibility of a future trial evaluating efficacy of video-based education.MethodsThe study was conducted in phases: script development, video creation, and feasibility testing. Topics were “managing fever at home” and “giving medications at home.” Content was developed by pediatric oncology experts and turned into video scripts. Scripts were refined through cognitive interviews with parents of children with cancer. Feasibility testing included recruitment of 20 parents of a child given a diagnosis of cancer within 4 weeks. Parents watched both videos and answered questions that assessed their understanding and perceived confidence.ResultsFinal scripts were reviewed by 25 participants. Feasibility was achieved with 20 parents recruited within 7 weeks, with 100% watching both videos and answering knowledge and confidence questions.ConclusionsWe successfully developed 2 educational videos for parents of children newly diagnosed with cancer. A future trial to test the efficacy of video-based education modules is feasible.Implications to PracticeDelivering quality education to parents of children newly diagnosed with cancer can decrease parental distress and improve safe care during a high-risk time for treatment-related morbidity and mortality.