Safety: Safer Care in 30 Minutes or Less

Patient Safety

By: Amy Brunson

Published: 3/19/2020

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Meet as a team to discuss how to prevent patient harm.


It's not that difficult to learn from your mistakes. All it takes is gathering your nurses and surgical techs for a half-hour meeting every few months to talk about errors that occurred and what can be done to make sure they don't happen again.

Surgeons do it all the time. They meet to comb over the details of a surgical error, discuss what could have gone differently, and update policies and procedures to ensure they don't repeat the same mistake. The forums, called morbidity and mortality meetings, have been extremely successful in improving the practice of experienced physicians and the training of med students and surgical residents.

When several of our nurses who were involved in an adverse event participated in a surgeon-led morbidity and mortality meeting, I thought: Why shouldn't other members of the surgical team benefit from the same frank conversations about ways to improve patient safety?

We now gather members of the surgical team to discuss incidents that occurred, including near misses or complications that can be avoided. The meetings are held once a quarter, lasting no more than 30 minutes (see "Stick to a Specific Patient Safety Agenda"). Each conference involves a 15-minute presentation by staff members followed by a question and answer session. Our department has realized several benefits since we started holding the meetings:

  • It's constructive to have members of the surgical team gather with their peers to have honest discussions about errors and near-misses in order to define exactly what happened.
  • The meetings are relevant learning opportunities for staff based on real-life events their colleagues experienced or safety-related issues the entire team needs to solve.
  • Staff appreciate the opportunity to openly share how they can improve their practices, are more aware of incidents that occur and learn how they can prevent them.

Managers can conduct retrospective reviews of safety incidents, but they don't have an intimate knowledge of the root causes or what team members involved were thinking. Plus, staff would rather hear from peers than managers. It's a powerful message when colleagues can share what happened, admit the mistakes made and lead an open and honest discussion about how the team can ensure something similar won't happen again. That's a far better approach than having a manager stand in front of the group to reprimand them for their performance.

Interestingly, staff told us they want to hear from surgeons involved in events. We've invited several surgeons to join us, but they've declined for numerous reasons, including their busy schedules. Staff also shared in the meetings that they wanted to hear from management about policies and procedures relevant to the adverse events discussed. They often knew what needed to be done to prevent patient harm, but didn't always understand the reasoning behind the correct actions to take.

Better prepared

We polled staff about their perceptions of our patient safety efforts before and after implementing the safety meetings. They said the meetings improve the way they practice and they're now more aware of patient safety protocols, better informed of the facility's policies and procedures, and enjoy increased communication with their peers.

To develop a culture of safety, you must promote non-punitive learning opportunities. Remember, you're not trying to play the blame game. You're trying to figure out why a mistake occurred and take the necessary steps to ensure it doesn't happen again. OSM

MEETING PLANNER
Stick to a Specific Safety Agenda
TIME WELL SPENT Set aside a half hour to discuss safety-related incidents that need to be addressed.

Have a plan in place when gathering staff to discuss safety-related matters. Check your incident reports to look for trends or commonly occurring events you feel need to be addressed. Focus on one topic or event per meeting so there's ample time for learning and discussion. Have the staff involved in a specific incident present to the rest of the team. During the meeting, follow this basic format:

  • Present a brief patient history. Establish the patient's ASA rating, comorbidities and other relevant details of their physical status.
  • Discuss the event. The staff who worked the procedure have a firsthand account of the events and background knowledge of the process breakdown that occurred. They should outline how the case proceeded and the events that ultimately led to the error.
  • Review relevant policies. Talk about the protocols you currently have in place that could have prevented the error from happening. If your facility's protocols stopped an error from causing patient harm, highlight that success.
  • Touch on process improvements. This is perhaps the most important part of the meeting. Discuss adding new protocols that will enhance patient safety. Ask the staff members who are presenting to share relevant research that supports the protocols you want to put in place.
  • Assign action items. Summarize the facts of the case, what went wrong and the steps your team will take moving forward to prevent similar errors from occurring.
  • Save time for Q&A. This is one of the most productive parts of the meeting. We've seen lively discussions take place among our staff. They give suggestions based on their past experiences and question why we're doing things a certain way, or why we're not.

Announce at the beginning of each meeting that the team has gathered to learn from each other. Emphasize that the meeting is non-punitive. You want to foster an honest discussion where staff feel comfortable opening up about what went wrong and what can be done differently moving forward without fear of punishment.

— Amy Brunson, MSN, RN, CNOR

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