Prior to having a team of peer safety coaches, adverse patient events experienced at the Dell Children’s Medical Center Pediatric Intensive Care Unit (PICU) were reported using a hospital-wide online reporting system that flowed to leadership, with nurse managers or educators conducting individual counseling with ‘offending’ nurses when considered necessary.
This traditional system of error response has several shortcomings, including:
- Temptation to prioritize staff privacy (and the emotional needs of a staff member who has made an error) over the need to inform all staff about errors.
- Subjective prioritization by one or two leaders (the educator or manager) of which adverse events would merit follow-up education for all staff.
- Fostering a punitive environment where the shame that staff feels about errors combined with loyalty to coworkers incentivizes under-reporting of errors.
In 2015, staff nurses in the Dell Children’s PICU took the initiative to change the unit’s error response strategy, emphasizing collective responsibility for all adverse events and collaborative solutions.
The staff nurse’s goals were to prevent future errors and encourage a culture of safety by increasing nurse awareness and reporting of safety events, supporting non-punitive corrective measures and responding to errors using a framework of collective education rather than individual counseling.
Dell Children’s created Peer Safety Coaches to review unit-level safety events reported in the PICU and encourage nurses to openly report medication errors without fear of individual punishment. Some of the key activities led by the Peer Safety Coaches include:
- Tracking the frequency of observed safety behaviors and meeting with the individual nurses involved in safety events to identify safety and knowledge gaps.
- Posting a safety and education bulletin board in the break room to educate staff on recent safety events occurring in the PICU, along with methods to prevent the recurrence of similar events.
- Creating and emailing a PICU-specific safety bulletin to all staff summarizing the prior month’s safety events in the PICU.
- Distributing “safety snacks” to PICU nurses in order to recognize and thank them for safe actions observed by the safety coaches that shift.
- Conducting intentional rounds each month with the PICU clinical pharmacist and the PICU medical director.
- Recruiting two additional nurses to the safety coach role: one nurse to cover safety auditing responsibilities and one nurse to represent the peer-coaching safety committee on the night shift.