2012 National Meeting

3003 — Pilot Testing a New Clinical Role: The Patient Safety Professional

Fowler KE, VA Ann Arbor HSR&D Center for Clinical Management Research; Krein SL, VA Ann Arbor HSR&D Center for Clinical Management Research & University of Michigan; Zawol DE, VA Ann Arbor Healthcare System; Saint S, VA Ann Arbor HSR&D Center for Clinical Management Research & University of Michigan;

Objectives:
Patient safety problems remain an important cause of preventable morbidity and mortality for hospitalized patients. Given the lack of effective individual solutions for many endemic patient safety problems and the inability to take advantage of emerging knowledge, we pilot-tested the impact of a new type of clinician: a Patient Safety Professional (PSP). The PSP monitors patients daily in order to enhance their safety by ensuring that evidence-based recommendations to prevent various adverse events are used during hospitalization.

Methods:
We conducted a quasi-experimental study using a before-and-after design with concurrent control wards. A PSP was introduced on one inpatient medical unit at the VA Ann Arbor Healthcare System. She was a Clinical Nurse Specialist who monitored patients daily to ensure all appropriate patient safety practices were implemented to prevent catheter-associated urinary tract infection, falls, venous thromboembolism, and pressure ulcers. Process measures were collected to compare the number of practices that were missed on the intervention unit (both before and after PSP intervention) and 2 concurrent control units.

Results:
Over the 7-month period, patient safety practices were missing on the intervention unit in 45% of the patient days reviewed, compared to 60% on the control units. The PSP was able to correct 49% of the missing practices on the intervention unit (310 corrected of 635 missing practices) so that the proportion of missing practices was significantly lower after PSP intervention compared with the control units (23% missing after PSP intervention vs. 60% missing for control units; P <.001). Time-sensitive practices, such as missing hourly intentional rounding, could not be corrected by the PSP.

Implications:
Preliminary evidence suggests that this new role may help to strengthen the safety net for hospitalized patients and serve as a key resource. If shown to improve outcomes, the role could be tailored to each hospital unit to meet individual needs.

Impacts:
Given the current workload of inpatient providers, it may be impractical to assume that these individuals can consistently ensure that every patient receives the necessary methods to prevent hospital-acquired complications. A PSP can help ensure that patient safety practices are consistently applied to all patients.