The nurse immediately notified the surgical manager, and they discovered several new nurses were not as familiar with the surgical preparation process as they should have been. All new floor staff were trained again, and there haven't been any quality referrals since. Most of these events involved patients who were admitted through the emergency department. This finding prompted the pharmacist to form a work group, which discovered that routine medications were being held for ED patients until they arrived on their units. As a result, medication-omission errors at the hospital have declined significantly.
Patient falls is another area where detection and prevention have paid off.
The team also discovered that these patients tended to fall on postop day 3, a time when patients are feeling more independent. The data further revealed that the times of the falls corresponded with the busy times on the units-when patients were returning from the operating or procedure room. We began teaching patients to use assistive devices such as walkers when they got out of bed. And we also made a point of leaving those devices in patients' rooms, close at hand. We made scheduling changes on a number of units, too, so that physical therapy staff would be there at busy times so they could assist patients.