School of Nursing Capstones
Permanent URI for this collectionhttps://hdl.handle.net/10877/17201
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Browsing School of Nursing Capstones by Author "Burgoon, Courtney"
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Item An Interprofessional Quality Incident Review Team: Effects on Reporting and Resolution [paper](2019-12) Burgoon, Courtney; Dolan, Diana; Willson, PamelaBackground: Since the Institute of Medicine's (IOM) report, To Err is Human, there has been increased focus on patient safety, to include use of incident reporting systems for gathering data to improve knowledge and decrease e1rnrs in the hospital. With increased pain and suffering, and cost associated with errors, the justification for these processes are clear. It is known that underreporting of incidents continues. There is a need for reporting systems, with available research focusing on organizational safety culture, ba1Tiers to reporting, and the acceptance of reporting systems in practice. Process improvement methods to increase incident reporting, and resolution of incidents is lacking in literature. Method: A descriptive repeated measures quality improvement project was undertaken at baseline, 3-months, and 6-months post intervention. Quality metrics were number of patient safety incidents and time to resolution of incident review. The intervention consisted of the development of An Interdisciplinary Quality Incident Review Team (QIRT) at a 147 bed acute care hospital in central Texas, U.S. A. The QIRT process, involved education of staff and managers on the new processes of reporting, evaluating, and completing incident reports. Results: Implementation of the QIRT process resulted in an increase in overall reporting of patient safety incidents in the categories of medication errors, hospital, nursing, and safety. At 3- months and 6-month post intervention, incident reports increased by 41% (n=21) and 59% (n=30). Hospital Incidents made up greatest increase in rep01i types, while Medication Errors had the fewer rep01is. Time to resolution of Nursing Incident reviews had the largest decrease in resolution time with an average of 11 days. Nursing Incident reporting demonstrated that consistency lead to sustainability over time, as the number of reported incidents continued to increase during the 6-month follow-up. Conclusions: Implementation of the QIRT, including educational materials and expectations for nursing staff and managers, increased incident reporting in all areas. Education regarding rep01iing, awareness ofrep01ied events, and follow-up from the QIRT were shown to increase reporting across the organization. Nursing incident rep01is were the only category where the time from the incident was reported, to resolution of the incident in the rep01iing system decreased.Item Implementation of a Quality Incident Review Team: Effects on Reporting and Resolution [poster](2019-12) Burgoon, CourtneyBackground: Incident reporting systems (IRS) are used for gathering data to improve knowledge and decrease errors in the hospital. There is an established need for reporting, with available research focused on patient safety culture, barriers to reporting. Process improvement methods to increase incident reporting, and follow-up for of incidents is lacking in literature. Method: In April, an Interdisciplinary Quality Incident Review Team (QIRT) was implemented. The QIRT, involved education of staff and managers, incident assignment, and follow-up for resolution. Three measurement times were (1) Baseline (pre-implementation –January through March 2019), (2) 3-month post-implementation data (April through June 2019), and (3) 6-months post-implementation. Results: Implementation of the QIRT and associated interventions resulted in an increase in overall reporting of patient safety incidents. During the implementation measurement period, there was a 29% increase over the pre-implementation period, and a 37% increase during the post-implementation period. Nursing incidents had the largest decrease in resolution days to an average of 11 in the post-implementation period. Conclusions: Implementation of the QIRT, increased incident reporting in all areas. Nursing incidents showed the only significant decrease in resolution time. Limitations included involvement of leadership in morning huddles, and knowledge of new leaders in use of the IRS, may have impacted the ability for some managers to complete their incidents.