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Story Care

The following stories are avaiable to TTUHSC faculty via the StoryCare website.For detailed information and outcomes, please visit the StoryCare website.

Contact Jarrod Jones for login access to StoryCare

 

#216 - The Patient Traveled To Africa … What’s Next? Healthcare facilities and especially Emergency Departments need to be prepared to implement administrative and precautionary procedures to treat potentially infectious patients, but more importantly they need to protect their healthcare workers as well.

#215 - SBAR As Though Your Life Depended On It Having a structured format for giving reports between clinical staff members leads to increased efficiency and enhanced safety. One such structured format is SBAR, which stands for Situation, Background, Assessment, and Recommendation. The SBAR tool can be easily learned, readily applied, and will lead to more accurate, professional, and mistake-free communications.

#214 - Debrief or Perish…Ebola Risk Teams often fail to learn as much as they can from critical incidents. By not taking adequate time to report, discuss and examine near-misses and other errors in patient care, teams are destined to repeat the same mistakes. Team debriefs have proven to be an effective team learning and self-correction strategy.

#213 - To Monitor or To Observe … That is the Question The overall safe care of patients being investigated for Ebola exposure must be overseen by an onsite manager. Strict adherence to PPE donning/doffing procedures must be supervised by a trained observer in order to prevent risk of self-contamination.

#212 - Can You Hear Me…Ebola Risk Handoffs are the single most error-prone events in the patient continuum of care. Ineffective communication, coupled with distractions and an incomplete patient assessment can lead to a sentinel event. In fact, sentinel events most often occur as a result of a series of errors.

#211 - Yes, I’ve Been To Africa Recently Treating patients with possible deadly viral infections with respect and dignity while keeping them and their family members fully informed and as comfortable as possible during the observation and treatment processes can be difficult and challenging when staff are not prepared.

#210 - I'm Alright, Really It is difficult to be objective about the well-being and fitness to work both about ourselves and our co-workers. The TeamSTEPPS IMSAFE tool is meant to be a helpful checklist for assessing different dimensions of our own and others ability to deliver safe patient care.

#209 - First Baby STEP This story is about the loss of situation awareness as the root cause of many serious medical errors and sentinel events. A team's ability to maintain situation awareness depends on having good tools to use, and using those tools consistently and skillfully.

#207 - Let’s STEP Back This story is about how training for situation awareness can prevent many serious medical errors and sentinel events. A team's ability to maintain situation awareness depends on having good tools to use, and practicing the use of those tools.

#206 - That One Little Thing Each contact with the patients in a healthcare facility creates an opportunity to satisfy or dissatisfy that patient as a consumer. If careful attention is not paid, small incidents can color the overall perception of care.

#208 - Check Back For a Good Outcome This story is about how using check backs to ensure communication exchanges between the sender and the receiver can impact the accuracy of patient safety-critical information.

#205 - The Sound Resounds This story is about a very important part of the patient experience is that the environment be clean, orderly, and quiet. Staff members can become desensitized to noises over time that disturb and annoy patients.

#204 - Fearing No Pain This story is about how communication about pain medications can be just as important as the selection, dosage, timing, and administration of the medication itself. Patients need to understand pain management as well as any the pain medications they may be taking.

#203 - I Have Nothing More Important Than You! This story is about how contact with nurses will often be the primary difference in patients being satisfied with their care or not. Consistently caring, empathetic response are absolutely necessary for a highly satisfying patient experience.

#201 - Conduct Unbecoming This story is about what happens when an incidence of unprofessional behavior happens. If team members aren't equipped with the tools to diffuse conflict or the ability to deal with unprofessional conduct effectively and quickly, the consequences for staff and patients can be harmful in more ways than one.

#200 - When Egos Clash, It's the Patients Who Lose This story is about how unprofessional conduct is a major cause of compromises in patient safety and affects the morale of the entire clinical team. All parties, regardless of role, seniority, or skill level, need to treat each other with respect and dignity.

#202 - How could this happen? This story is about ensuring a safe and satisfying experience for mother and baby during the rapidly changing environment of Labor and Delivery. To prevent harm, use structured and reliable communication protocols.

#179 - A Fatal Interruption This story is about minimizing distractions during medication administration to prevent adverse drug events. Rigorously following patient identification protocols using the “5 Rights” is crucial to ensure the right patient receives the right medication dose at the right time.

#178 - If Only... This story is about the lack of preparedness of teams to handle out-of the-ordinary emergent events, and the dire consequences for patients of the failure of teamwork within and across hospital units.

#151 - CUS-sing for Safety's Sake This story is about CUS, a TeamSTEPPS® tool that helps care providers find the right words to express their concerns when they become aware of something they think will compromise patient safety.

#198 - Empathize to Deescalate This story is about the challenge of diffusing a patient's upset or anger, and how important it is for every team member to maintain an even keel when dealing with conflict, find ways to empathize with patients no matter how combative, and to listen with compassion.

#197 - Toxic Handoff This story is about how a poor patient handoff can result in crucial information about the patient's condition not being communicated, resulting in incomplete or inappropriate care decisions that can seriously endanger the patient's safety.

#196 - Close the Loop! This story is about patient discharge as a crucial activity to ensure their safety. It's not enough for caregivers to simply communicate instructions—we must ensure that the patient and their family fully understand every detail using the check-back process.

#195 - Question Everything! This story is about a patient who is prescribed an inappropriate and dangerous dose of a drug, and how no one from the nurse carrying out the order to the pharmacist filling the order challenged the dosage that could have resulted in patient harm.

#193 - Safety Depends on Feedback This story is about how patient safety is everyone's responsibility, and how all staff members are accountable for giving fellow team members feedback when their practices diverge from accepted safety norms and practices that have been adopted by the unit or the hospital.

#194 - When There's a Conflict, DESC It! This story is about dealing with difficult interpersonal conflicts that can often become personal if not properly managed. Using the DESC tool, even difficult situations that have the potential to become inflamed can be appropriately managed in a manner that is respectful, yet still assertive.

#190 - Safety Practices Depend on Advocacy and Assertion This story is about when we witness team members depart from evidence-based safety practices designed to minimize risk, and how we can best intervene when it's often difficult or uncomfortable to speak up assertively to confront unsafe practices.

#187 - Those Who Don't Debrief Are Destined... This story is about the importance of team debriefs. Teams often fail to learn as much as they can from critical incidents by not taking adequate time to report, discuss and examine errors in patient care. Teams are destined to repeat the same mistakes if they fail to debrief.

#185 - When in Doubt, Use the 2-Challenge Rule This story is about when safety protocols in any area are not being followed and patient safety is at risk. It is the responsibility of all team members to speak up and challenge the direction the patient’s care is taking to ‘stop the line’ if their concerns can’t be quickly resolved.

#182 - Trust Your Instincts: Cross Monitor! This story addresses the issue of cross monitoring as it relates to error prevention. A work environment that encourages staff to openly share concerns related to the safety of the patients is necessary for optimal patient care and experience.

#169 - Are You Challenging Me? This story is about what happens when team members express their concerns about the safety and well-being of a patient twice, and if the concern is not alleviated, it is their responsibility to escalate the conflict to someone who has authority to resolve the situation.

#188 - Advocate for a Smooth Delivery This story is about an expectant mother and the timing of a scheduled C-section delivery. The physician's schedule, not the gestation age of the fetus, becomes the primary scheduling concern. Reducing or eliminating early elective deliveries has been shown to be safer for newborns.

#177 - The Burden of VTE This story is about when healthcare team members are acutely overburdened at work, the potential for error rises and patient safety is put at risk, especially for VTE. Most hospitalized patients have at least 1 risk factor for VTE, however, appropriate prophylaxis is applied only 39.5% of the time.

#174 - It's Not That Obvious This story is about how when team members don't communicate effectively with each other and patients about their actions, patient input is sidelined, patients lack sufficient information to make informed choices about their care, and safety can be compromised.

#175 - No One Is Exempt This story is about how there is often an implicit assumption that Patient Satisfaction is predominantly a function of nursing, whereas these problems may be caused by everyone but nursing. One of the best ways to get to the source of poor ratings is to listen to your patients’ stories.

#186 - When Concerned, It's Time to Huddle This story is about a patient who is allowed to leave a cardiac clinic without critical test results being examined and resolved because the protocols for allowing a patient to leave were either non-existent or not followed by the staff. If only the caregivers had taken the time to huddle.

#189 - Your Patients and Family See What You Can't This story is about the impacts of medication errors. Distractions and interruptions can cause human error that may not be caught by other team members. Patients and family members are witnesses to their care and can provide cross monitoring to prevent errors from occurring.

#191 - Cross Monitor to Address Adverse Drug Events This story addresses the issue of cross monitoring as it relates to adverse drug events (ADEs). Proper communication protocols between physicians and nursing staff are essential to prevent patient ADEs.

#153 - No One Sits Until Everyone Sits This story is about mutual support and task assistance, and how offering assistance to other team members when your workload permits promotes patient safety, mutual trust, efficiency, productivity, and service excellence.

#172 - Checklists—Check! This story is about how all staff members are accountable for following safe practices. When team members diverge, others need to be able to call them on it in a respectful, non-threatening way, without being made to feel uncomfortable.

#167 - Did You Remember to SBAR It? This story is about SBAR, a TeamSTEPPS® tool that helps care providers through the use of a structured format for giving reports between clinical staff members leads to increased efficiency and enhanced safety.

#181 - Advocate for Patient Safety This story addresses the importance of effective and consistent forms of team communication. Staff should feel empowered to speak up, assert, and advocate on behalf of the patient and the team regardless of perceived organizational hierarchies.

#180 - Cross Monitor for Patient Safety This story is about how cross monitoring helps maintain situation awareness and prevent errors. Commonly referred to as “watching each other’s back,” it allows team members to self-correct their actions and provides a safety net or error-prevention mechanism for the team.

#159 - Brief to Set the Tone Team leaders must set the tone for service excellence. Without collective decision-making, targeted goal setting and clear roles and responsibilities, team performance suffers. This has a negative impact on patient satisfaction and safety.

#147 - Can You Suggest A Solution This story is about how you can put the emphasis on respectful problem-solving and building buy-in and responsibility-taking when disruptive or unprofessional behavior affects patients by slowing their care, thereby increasing the risk of error or omission.

#184 - Step Up to Safety This story illustrates how adherence to protocols, closed loop communication, documentation, and building time for improved decision making are important strategies to safely manage spikes in workload.

#183 - I'M SAFE When I Reach Out This story focuses on care for the caregiver, sometimes referred to as resilience. The stress of caring for patients can lead to chronic fatigue, burnout, and unprofessional behaviors. All team members have a responsibility to recognize and respond when team members becomes overwhelmed.

#171 - A Question of Timing This story is about the failure to give antibiotic prophylaxis on time which can contribute to SS and can be averted with a pre-op briefing.

#173 - Transferring Blame This story is about implementing a follow-up plan when patients are transferred across hospital units or discharged to ensure that that their care history is documented and passed on. It also highlights the importance of listening to what patients tell you about their care.

#176 - Word of Mouth This story is about including patients' families as members of the healthcare team. Evidence suggests that when they are contributing to the care of their loved ones, risk for VAP will be reduced and VAP rates will decrease. Plus, they will be more satisfied with their care.

#163 - We Need 100% of You Now! This story is about how distractions can cause serious compromises in patient safety and need to be consciously controlled. Some teams have devised approaches to prevent distractions, similar to how the airline industry has created “sterile cockpits” that keep the team focused when it counts.

#152 - Let's Huddle Up Here This story is about illustrates the importance of the TeamSTEPPS® “huddle”tool to keep everyone on the same page and allow for brief problem-solving before continuing the treatment plan as a patient's conditions changes.

#146 - Hidden in Plain Sight This story is about how healthcare as seen through the patient's eyes is often perceived as serving the staff's needs instead of the patient's. The cumulative effect of many small issues can make the care look disjointed and unprofessional.

#168 - Step Up To Rounding This story is about falls which are three times more common in hospital and nursing home settings where they result in higher injury rates. But they can be reduced through a number of simple solutions, such as tweaking hourly rounds to make them more meaningful.

#166 - Prioritizing Pressure Care Using a pressure prevention bundle can reduce the risk for pressure ulcers. Unfortunately, even though nurses understand its importance, it's associated with low status work and they often don't make it a priority, falsely assuming that LPNs are performing skin care/PU prevention.

#164 - Who Knows Best? This story is about mutual support, especially when it comes to preventing VAP. A team-oriented approach to patient care requires that each team member's expertise is respected, and differences of opinion about the direction of care are worked out in a mutually supportive manner.

#162 - Aware of the Situation This story is about an elderly woman being cared for in a nursing home who is incontinent and catheterized despite new criteria for catheterization, because indwelling urinary catheters cause up to 80% of hospital-acquired infections, 30% of which are unnecessary.

#137 - Vigilance Is Never In Vain This story highlights the importance of Venous Thrombosis Embolism (VTE) prevention protocols. Signs and symptoms of VTE are frequently silent and can lead to fatal pulmonary embolism. All team members are responsible for VTE prevention.

#165 - Walking Into Risk This story is about how most VTEs in the ambulatory setting occur within 1 month of discharge and are preventable, but oncologists' adherence to VTE assessment/prophylaxis guidelines is suboptimal and a major barrier to implementing VTE protocol.

#161 - Dial "I" for Ignore This story is about the importance of hand washing. Failing to wash hands between each patient visit can result in CLASBIs. According to a recent CDC report, the majority of CLABSIs are now occurring outside of ICUs, especially in outpatient dialysis clinics.

#160 - Admission of Failure This story is about preventable readmissions. They may result from incomplete treatment or poor care of the underlying problem, or may reflect poor coordination of services at the time of discharge. Every team member is responsible for the discharge process.

#158 - The Tiger Gets New Stripes This story is about the deviation from safety protocols. It is a leading cause of patient harm. Executive leaders must hold all providers and staff accountable for safe practices and protocols. Coaching for engagement is a strategy for gaining buy-in and behavior change.

#157 - Improving Medication Safety This story is about how labor nurses are at risk for professional liability when titration results in uterine tachysystole aren't recognized in a timely manner, and how effective nurse-doctor communication is crucial to provide an outstanding patient experience.

#156 - Everyone Is A Monitor This story is about the impacts of adverse drug events (ADEs). Proper communication protocols between physicians and nursing home staff are essential to prevent patient ADEs.

#155 - No Shortcuts To Risk Reduction This story is about surgical site infections. According to the CDC, SSIs are the second most common healthcare-acquired infection. Following evidence-based perioperative practices - such as using precautions to prevent contamination of sterile equipment - can prevent the risk of SSI.

#154 - Patients Are People Too The story illustrates how knowing about being patient-centered, and actually doing it, are two different things, and that staff must be intentional and self-aware about engaging the patient.

#150 - See You Soon This story illustrates the likelihood of readmission in the absence of a coordinated care plan for the patient. Readmissions are often caused by preventable complications that occur during a transition from one care setting to another and may reflect poor coordination of care.

#149 - Room for Improvement This story addresses patient falls. According to reports by the IHI, Robert Wood Johnson Foundation and several studies, falls are three times more likely in hospitals and nursing homes than in the community. It is every team member's responsibility to help prevent falls.

#148 - One Big Team This story demonstrates the benefits of a care team functioning as a unified whole where everyone assumes responsibility for every job getting done when it comes to the patient's safety and satisfaction.

#145 - Are We Sure This Is Necessary? This story is about the fact that indwelling urinary catheters cause up to 80% of hospital-acquired infections, with 30% being unneeded in the first place, and how a nurse reviews a patient's chart and challenges the catheterization.

#144 - Putting Safety on the Line This story is about the importance of following protocols, particularly those pertaining to central venous catheters (CVCs). Prevention of CLABSI is mandated by legislation. Therefore, it it every team member's responsibility to speak up when procedures are incorrectly performed.

#143 - Got Clutter? This story is about facility cleanliness. It is a key patient and family satisfaction performance indicator. Facilities that are cluttered, unorganized, and generally untidy form negative patient perceptions. This could also impact safety, efficiency and organizational effectiveness.

#141 - Code of Silence This story highlights the importance of a nonjudgmental culture. Every human makes mistakes or poor decisions. A culture of denial, shame, and fear of litigation prevents providers from admitting and discussing mistakes openly, or using them to learn and improve.

#140 - Sailing on a Healing Tide This story is about the importance of listening for understanding. The messages we communicate come across in both verbal and non-verbal ways. We must be aware of the messages we are sending, and must decide if those are the ones we want to be sending.

#138 - The Pressure's On Pressure ulcers are common in patients with spinal cord injuries due to lack of mobility. Evidence-based protocols for pressure ulcer prevention must be developed, trained, and followed across teams to prevent patient harm. Effective handoffs are essential to ensure continuity of care.

#136 - Heading in the Right direction Lack of clear roles and responsibilities for Head of Bed (HoB) elevation reduces the likelihood that HoB is elevated to recommended angle to prevent ventilator associated pneumonia (VAP). All members of the team are responsible for initiating HoB elevation.

#135 - If It Was Your Mom This story is about the impacts of medication errors. Distractions and interruptions can cause human error that may not be caught by other team members. Patients and/or family members are witnesses to their care and can provide cross-monitoring to prevent errors from occurring.

#132 - Debrief or Perish This story is about the importance of team debriefs. Teams often fail to learn as much as they can from critical incidents by not taking adequate time to report, discuss and examine errors in patient care. Teams are destined to repeat the same mistakes if they fail to debrief.

#142 - Teamwork Starts Here This story is about the role senior leadership plays in effective teamwork. A top-down and control leadership style among senior leadership teams creates a climate where members don't feel respected or empowered to perform, whereas psychological safety creates trust among all teams.

#139 - Nature to Nuture This story is about bullying and hazing practices often associated with a healthcare's indoctrination. These practices cause both unnecessary stress and premature abandonment of the field, and often compromise both the satisfaction and safety of patients.

#134 - In Whose Time? This story is about an expectant mother and the timing of a scheduled C-section delivery. The physician's schedule, not the gestation age of the fetus, becomes the primary scheduling concern. Reducing or eliminating early elective deliveries has been shown to be safer for newborns.

#133 - They Come and Go This story is about the patient experience as seen through the eyes of the patient. The patients in this story view their care as competent yet disjointed especially at shift changes. Bedside handoffs are one technique to make the transitions of care both satisfying and safer for the patient.

#131 - Between the Cracks This story demonstrates the importance of improving team communication, developing effective cues, re-engineering processes and promoting coordination between units to reduce Emergency Department length of stay (LOS) to improve patient safety, efficiency, and satisfaction.

#130 - Sound the Alarm This story is about how staff response to safety alarms and patient call lights is essential to ensure patient safety. Preventing patient harm due to falls requires effective strategies and protocols in addition to team vigilance.

#129 - The Floor's Open This story is about the importance of patience, flexibility, adaptability and prior planning during the 'learning curve' to manage the changes related to team processes, workflows, and practices when any new technology or information system is introduced.

#128 - Welcome to the Team This story is about how bullying, hazing and lateral violence are frequently part of a healthcare professional's indoctrination. These practices cause both unnecessary stress and premature abandonment of the field, and often compromise both the satisfaction and safety of patients.

#127 - Caution for CAUTI This story describes the importance of following best practice protocols, such as the IHI bundle, to prevent urinary catheter associated infections. Use of a daily checklist ensures appropriate practices and guidelines are followed to decrease the potential for infection.

#126 - Almost Routine Central Line-Associated Blood Stream Infections (CLABSIs) cause up 60,000 preventable deaths in the U.S. each year. This story highlights how deviation from evidence-based protocols and checklists can place the patient at risk for CLABSI.

#125 - These Things Happen This story is about how human error is common during 'workload spikes' due to monitoring failures, multitasking, distractions, deviations, or interruptions. Cross monitoring and team 'backup behaviors' are essential safety practices for managing such workload threats.

#123 - A Tale of Two Patients This is a story about how excellence in healthcare delivery requires attending to the needs, wants, feelings, insecurities, and anxieties of each and every patient and their families in addition to treating their medical problem.

#122 - The Rule of Six This story is about a patient being discharged following a readmission for pneumonia. A Care Transitions nurse uses patient coaching skills and motivational interviewing techniques with the patient to focus on important aspects of caring for himself at home to prevent readmission.

#119 - Diagnosis: Organizational Antibodies This story is about how one IT director learned through trial and error to gain the support of medical staff through carefully orchestrated EMR implementation planning, a must for any change initiative to succeed.

#124 - No One Thing Killed Elias Smith This story is about how healthcare organizations are often ill-equipped to effectively respond to the crisis following the unexpected death or harm to a patient due to medical errors, and how an organization can establish an effective crisis management team to transparently respond to the family.

#121 - It's Dangerous To Judge This story is about how persistent negative labeling can become ingrained in a culture,making it an acceptable norm. The end result can be poor quality or inappropriate, even unsafe care, misdiagnosis, and significant patient dissatisfaction, for which the patient may be blamed.

#120 - Doctor, I'm Concerned... This story is about what happens when a patient is allowed to leave a cardiac clinic without critical test results being examined and resolved because the protocols for allowing a patient to leave were either non-existent or not followed by the staff.

#118 - The Perfect Storm This story is about how handoffs are the single most error-prone event in the patient continuum of care. Ineffective communication, coupled with distractions and an incomplete patient assessment, can often lead to a sentinel event.

#114 - Reaching Out This story focuses on care for the caregiver, sometimes referred to as resilience. The stress of caring for patients can lead to chronic fatigue, burnout, and unprofessional behaviors. All team members have a responsibility to recognize and respond when team members become overwhelmed.

#116 - Why Not? This story is about how patient choice can improve the patient experience by better meeting patients' emotional needs. To do this, healthcare professionals must see exceptional care from the patient's perspective and act as a patient navigator of the system of care.

#113 - Getting to the Heart of the Matter This story is about the importance of recognizing that performance data reports alone may not tell the whole story. Leaders must assess multiple problems and challenges on a unit face-to-face, using walk-rounds and 'adhoc' informal rounding.

#117 - Empowered to Challenge This story is about how retained foreign objects (RFOs) during surgery can result in significant harm due to infection and other complications, and speaking up is crucial when the instrument count is inaccurate.

#115 - Shortcutting Safety This story illustrates how adherence to protocols, closed loop communication, documentation, and building time for improved decision making are important strategies to safely manage spikes in workload.

#110 - Double Check Three Times This story addresses the issue of double checking and verifying patient identification before administering medications while dealing with fatigue, and simultaneously anticipating family needs when moving a patient to a new room.

#109 - Seize the Moment This story is about how every staff members' job is to recognize that what we experience as routine is for the patient a journey that is filled with fear and concern. It emphasizes the positive impact staff members have on patients when they provide reassurance and support.

#112 - Trusting Enough To Do the Right Thing This story addresses the issue of cross monitoring as it relates to error prevention. A work environment that encourages staff to openly share concerns related to the safety of the patients is necessary for optimal patient care and experience.

#111 - When Shared Mental Models Shatter This story addresses the impact disruptive behavior has on teamwork, communication, patient safety, and patient satisfaction. Each person involved in patient care, regardless of position, must conduct themselves in a professional manner.

#108 - Decision to Incision This story addresses the importance of effective and consistent forms of team communication. Staff should feel empowered to speak up, assert, and advocate on behalf of the patient and the team regardless of perceived organizational hierarchies.

#107 - Anything Else You Want to Tell Us This story is about bedside handoffs and the opportunities they present to share and receive information with the patient and the family. When done well, trust and connections will be established, resulting in staff members meeting the patients’ needs more efficiently.

#106 - Missed Our Chat Today This story is about making a human connection with a patient and how small personal touches and recognizing the needs of others are the key to an exceptional patient experience.

#105 - The Courage to Make the Call This story is about questioning written physician orders that don't seem to make sense clinically and illustrates the value of cross monitoring.

#104 - You Tell Me All About It This story is about going beyond our roles and seeing the person, not just the patient, in order to deliver an excellent patient experience.

#103 - You're Part of Our Care Team Now This story is about how prior planning and coordination are essential for successful handoffs in emergent situations.

#101 - Lead or Follow, But Don't Interrupt This story highlights the importance of communication to build cohesive teams sharing the same mental model regarding each of the patients in their care. The team brief at the start of each day can prevent errors and ensure that patients’ needs are anticipated.

#102 - The Hard Way This story addresses the issue of hand hygiene, as well as the importance of including patients and family members as valued members of the care team. and how anyone on the healthcare team should feel comfortable questioning hand hygiene for patient safety.

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