“Mistake proofing is one of the most effective ways for us to connect to our work,” said Dr. Susan Shaw, co-lead of Safer Every Day, at the Mistake Proofing Collaborative report out held last week.

Mistake proofing is a process that examines the root causes for mistakes that occur and aims to prevent them before they occur again. The Mistake Proofing Collaborative is one of seven teams of the Safer Every Day initiative.

Four mistake proofing teams, brought together as part of Safer Every Day, presented their final reports on December 8.

The Mistake Proofing Collaborative initially met back in October for training and to choose their projects. They reported out on their work on December 8.

The Mistake Proofing Collaborative initially met back in October for training and to choose their projects. They reported out on their work on December 8.

The first team looked at preventing mistakes in identifying and assessing risk factors for falls on the convalescent unit at Saskatoon City Hospital (SCH).

The goal of the 28-bed convalescent unit is to provide restorative care to primarily geriatric patients. Many of these patients are at high risk for falls, mostly due to weakness and balance impairment. From January 1 to October 31, 2015, a total of 124 falls were recorded.

“When we began the mistake proofing process, we discovered that 25 out of 28 beds were not displaying a TLR (transfer, lifting and repositioning) card,” Manager Bryan Jorgensen said.

When admitted to the unit, all patients receive a mobility/TLR assessment. A TLR card is then supposed to be placed on a whiteboard at the patient’s bedside to inform all staff of the patient’s mobility status.

“Although the whiteboards beside patient beds often contained mobility instructions, they were cluttered and most did not have the TLR card or the patient’s name and date on the card,” said Jorgensen.

To solve the problem, the mistake proofing team developed standard work that clarified the roles of all bedside staff (e.g., registered nurses, physical therapists, clinical coordinators), including where to place the TLR cards when a patient is admitted and when to update them (i.e., weekly at interprofessional rounds and as otherwise indicated). They also trained staff on the new standard, made larger TLR cards, and determined a standard location to place the TLR cards – at the head of the patient’s bed by their name tag, similar to what’s done on the rehabilitation unit at SCH.

As a result of the changes, after one week, the unit had just one out of 28 beds not correctly displaying the cards.

“Up-to-date TLR cards are ensuring both patient and staff safety,” said Jorgensen. “We’re really pleased with the results and will continue to seek out opportunities to improve processes, communications and training for staff.”

The second team looked to mistake proof the placement of call bells at a long-term care home.

St. Mary’s Villa in Humboldt has 85 residents with a variety of physical and mental needs. Prior to the mistake proofing project, the Villa did not have standard work for call bell placement in each resident room.

Call bells are used by residents to let the nursing staff know when they need assistance. Not placing call bells within reach of residents has the potential to increase risk of falls, urinary tract infections, incontinence and potential violence.

The goal of the mistake proofing team was to ensure that call bells are within reach of residents at all times. Prior to the mistake proofing, the team noticed a number of problems: the colour of the call bells blended in with the wall and bedspread, some of the call bell cords were inadequate in length, there was a lack of clips to affix bells to ensure they are placed near residents, there was no visual cue to remind staff to place call bells within reach of residents, and there was a lack of consistent placement of bells by staff when residents were out of their room.

“We created a visual cue to remind staff to ensure that call bells are within reach of residents at all times,” said Care Team Manager Britany Silzer, explaining that a card was laminated and placed in each resident’s room to the side of the call bell cancellation box. A black tape border was also placed around the card to ensure that it was seen by staff.

The team also created an education package that included standard work regarding call bell placement, a presentation with six basic slides, a flyer that included helpful tips (i.e., clip call bell to fitted sheet not top sheet) and a quiz to ensure that staff read the material.

The team has only seen positive results with one of the five residents with whom they trialed the new standard work; however, they are hopeful that the mandatory learning package for staff will improve call bell placement.

“Safety is everyone’s responsibility, and resident safety needs to be at the forefront of our everyday work,” said Silzer.

The third team focused on mistake proofing response times to urgent client referrals to Mental Health and Addictions Services.

Of the nearly 550 mental health and addictions clients referred to Community Addiction Services from January 1 to October 28, 2015, 13 were assessed as urgent, and all 13 should have been offered an initial appointment within seven calendar days. However, only seven (53.8 per cent) were actually offered this appointment according to the Addictions and Mental Health Information System (AMIS).

The goal of the mistake proofing team is to ensure that 100 per cent of clients assessed as urgent are offered an appointment within seven days, which is above the provincial goal of 85 per cent.

“We learned that data tracking problems are responsible for the majority of defects, rather than clinician error,” Manager Greg Pauli said, explaining that the client’s date of assessment is not always correctly recorded in AMIS.

“We also determined that the definition of urgent was not universal,” he added.

In response, the team created a visual cue in the form of a flow chart that clearly and universally defines urgent clients (i.e., pregnant women, people waiting for a liver transplant, individuals assessed as medium risk for suicide and those who have received a score of 20 or higher on the Severity Index Rating Scale). The standard work also includes an explanation about AMIS and how it works, so that clinicians know when and how to enter the client’s date of enrollment and the subsequent appointments that are expected to follow.

With an average of only one urgent client per month, the team plans to examine the AMIS data in six months to determine its effectiveness.

The final team focused their efforts on preventing mistakes in client activation data errors in AMIS entry. A total of 95 errors have been in made the past when entering client activation dates into the system.

“When entering dates, it’s important for the date of the first visit and the activation date to match,” Manager Michelle Robson said, explaining that monthly mistakes consistently occur. Reasons for entry errors range from lack of awareness by staff about the importance of matching dates, a high number of people entering the data (i.e., 32 clinicians, five support staff), inconsistent communication between clinicians and support staff, and variation in practice due to a lack of visual cues to prompt correct data entry.

The team’s goal is to correct the 95 past errors that occurred and to eliminate errors to all new entries by January 31, 2016.

“Support staff is spending two hours a week correcting the 95 errors. By December 1, we were down to 49,” Robson said, adding that for the month of November, zero new errors were recorded.

The team is on their way to achieving their goal through the implementation of a visual cue that is now placed on client folders. The cue, a rectangular paper about the size of a mobile phone, contains a checklist prompting staff to record matching dates and to file the folder only after clients have shown up for their appointments. The team has also created an admission package for staff that includes standard work and is in the process of working with the Information Technology department to upgrade AMIS so it no longer accepts entries that do not have a matching date.

The importance of continuous improvement

“All of you have made the connection that the data you have been analyzing is not just numbers, it’s the people you serve who you’re responsible for. This is what continuous improvement is all about: respect for people,” Dr. Shaw said at the end of the presentations.