key: cord-0027212-yezoit5h
authors: Warner, Karin E.
title: Getting to Zero - Part One
date: 2022-02-15
journal: J Radiol Nurs
DOI: 10.1016/j.jradnu.2021.12.009
sha: 0aa08eb2d351be116a023be82ea2aec864bb648a
doc_id: 27212
cord_uid: yezoit5h

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Regardless of the type of facility that we practice indambulatory care center, in-patient hospital facility, behavioral health facilitydwe should be continually assessing our work processes and environment. By looking for and identifying areas for improvement we can make necessary and appropriate changes. The safety of our patients and staff members in our work processes, and the resultant quality of the care we deliver depends upon many converging processes and issues. Consequently, we should be continually monitoring, measuring, evaluating, and improving.

Within the evolving worldwide COVID-19 pandemic, frequent turnover of staff and reliance on temporary staff to fill shifts present an even greater challenge than normal. Responsible leadership at all levels of our organizations is essential to ensure that proper orientation to all elements of the environment of care, standard operating procedures, and safety protocols are accomplished with all staff to ensure patients are shielded from harm in clinical environments.

Are there current competencies for all levels of staff working in your clinical workspace? Are job descriptions accurate for the work that each staff member is expected to do? Have staff members been trained to do the jobs they are expected to perform and is this documented? Have any deficits in knowledge and learning needs been addressed, and is there a plan to ensure all staff are properly trained to perform their duties? Are licensed staff performing within the scope of their licensure in the state or jurisdiction that they are working?

If any of those questions are answered with a "no," then there are opportunities to improve. Regardless of which agency accredits your organization to provide healthcare services to your patient population, all staff members should have position descriptions that accurately describe the work they are hired to do, and there should be evidence that this set of knowledge and skills has been assessed, and that staff are competent (and licensed if required) to perform this work. Leadership has the responsibility to ensure staff are adequately oriented to all equipment, policies, and procedures for performing work in their clinical settings. Moreover, there should be an appropriate climate in the workplace that allows staff to self-assess, document, and speak up if they need additional training or do not feel comfortable performing the job functions they are assigned. There should be evidence that all staff members have received orientation to all aspects of the environment of care in the work area. Knowledge is essential about equipment, computer systems, communication systems, emergency systems and protocols, policies and procedures for the unit and facility, and reporting methods for alerting staff and leadership of problems identified in the clinical space. Do a quick scan of your work area, and ensure levels of competence are established and maintained, and appropriate and effective processes are in place.

Additionally, think about the periodic performance reviewdif everyone has a current job description and staff have been properly oriented to their work and the environment of care, then the assessment of performance of those duties is straightforward. If these administrative elements are not in place for each staff member, then evaluation of job performance is difficult. How can staff be evaluated on performance of their duties if the specific roles and job functions have not been adequately expressed to them and evidence documenting their competence or certification to do those job functions is either lacking or absent?

Why is this important? Consider a recent unfortunate incident of a patient suffering harm (death) in the magnetic resonance imaging (MRI).

In October 2021, it was reported that "A 60-year-old man at a South Korean hospital was killed in an MRI accident when an oxygen cylinder was carried into the scanning suite during his exam, [which]…was sucked into the device, killing the patient…" (Anonymous, 2021). A similar incident had occurred in a hospital in Mumbai in 2019 when a man carrying an oxygen cylinder for a sick relative was sucked into the MRI machine. In this case, the cylinder was ruptured, and the man died of an oxygen overdose (Diebel, 2018) .

Apparently, in both cases the patient was in critical condition and needed oxygen, but with knowledge of the safety issues regarding electromagnetic pull and the MRI, how was this allowed to happen? Were staff working in and around the MRI suite properly trained in that environment of care? What safety protocols were in place that should have questioned if not prohibited bringing a metal oxygen cylinder into the room? Are there explicit rules to establish best practices for safety and prevention of harm in the MRI? What leadership oversight of these clinical areas existdand how do we ensure rare events of this kind NEVER happen again?

The author has no relevant disclosures. There was no grant funding or financial support for this manuscript. Massin & Loeb (2013) describe principles of Highly Reliable Organizations and suggest ways that healthcare facilities can apply the five components of safety culturedtrust, accountability, identifying unsafe conditions, strengthening systems, and continual assessmentdto our healthcare organizations (Anonymous). If we put these practices into action, we can strive to achieve ZERO Harm to our patients (see Figure 1 ) (The Joint Commission, 2017). Our next "Shielding from Harm" column will focus more on these components of safety culture.

If you have suggested topics or ideas that you would like me to cover in future "Shielding from Harm" columns, please contact the publisher at kathleen.gross@arinursing.org.

Oxygen cylinder kills South Korean man in MRI accident

Indian man dies after being sucked into an MRI machine while carrying an oxygen cylinder USA TODAY

High-Reliability Health Care: Getting There from Here

Zero Patient Harm Is Achievable