Workplace Violence Awareness Month: Reporting

Reporting safety events, big and small, is critical to creating and maintaining a care environment that is safe for everyone. Documenting at-risk patient behavior can help reduce risk during future episodes of care. And understanding safety events is important to continuous improvement in a high reliability organization.

Safety story:

A nurse at C.S. Mott Children’s Hospital partnered with a child’s father to discuss the child’s agitation. The child had a history of developmental delay and aggression. The care team anticipated the child may have agitation or aggression during admission.

The father asked about the child’s first-line medications for agitation. The medication required intravenous administration and the nurse asked another nurse to join them in assessing the peripheral intravenous line to ensure access for any future medication delivery. Upon meeting with the father and the patient attendant in the room, the nurses noted the patient’s bilateral leg splints were not incorporated into guidance on agitation management or the potential for any holds in the future, if needed. 

Although the bedside nurse asked a colleague to join them in assessing the IV line, the nurse was kicked in the face by the child. Following this event, a safety huddle was called with the providers, the father, the two nurses and the charge nurse.

The behavioral health nurse consultant and a member of the psychology and psychiatry team also participated in the huddle. The factors leading to the aggression were reviewed and a plan was made, using historical information and the input of the team, to keep the patient and staff safe.

As-needed medication for agitation was safely administered to the child with no further safety events occurring during this child’s admission. The bedside nurse was ultimately sent to Occupational Health Services for assessment of the injury she obtained when kicked by the patient.

Following the event, a nurse supervisor completed an Apparent Cause Analysis (ACA) with the bedside nurse during their next shift. The bedside nurse was supported with time off service to address the physical and emotional consequences related to the safety event and the nurse received support in processing her feelings related to the incident.

Lessons learned

Understanding risk helps inform proactive care planning:

• Work together with an interprofessional team to proactively assess risk of agitation, particularly in youth with high-risk of agitation or aggression.
• Develop a behavior support plan for all high-risk patients and make sure team members are aware of the plan.
• Before engaging in high-risk activities (when providing care in close proximity to at-risk patients) assure there is pre-planning of care and people understand roles and prevention tactics to reduce potential for injury.
• Be aware of WELLE language, including red scale language, and documentation in nursing flowsheets to anticipate risk of safety events.
• Notice and document evidence of increased agitation or other behavioral escalation in the medical record.
• Think about patient-related, situational, environmental, and care team factors that can aid with maintaining a safe and therapeutic care environment.

Team-based approach:

• Engage other team members, and the family, when the risk of a safety event is increasing.
• Create an opportunity to huddle and debrief following a safety event to understand the situation better, develop a plan, and communicate that plan effectively with the team and the family.
• Be aware of mental health consultants in your care area who can support patients with behavior concerns. Include them in the plan of care.

Learning from experience:

• Report all safety events, even if they are brief or do not result in direct harm, through the RL reporting system.
• Conduct an ACA to better identify gaps in our processes and how we are supporting each other to promote a safe workplace.

Supporting staff after events:

• Be mindful of both the physical and emotional care needs of our staff following safety events.

Additional Tips

Documenting patient behavior in the medical record is essential to care:

• Inpatient teams can utilize flowsheets to document behavior through use of the behavior summary flowsheet documentation, then document behavior under red scale.
• Team members who do not utilize flowsheets can document behavior in any MiChart note function using smartphrase “.behavior”
• Ambulatory care teams can also utilize the smartphrase “.behavior” in MiChart.

For more information on documenting behavior and using flags in the medical record, please refer to the Policy & Procedures to Mitigate Violent and Unsafe Behavior and Support a Therapeutic Care Environment for Patients, Families, Visitors and Staff.