It's a Crime to Risk Patient Safety


Poster Presentation

Purpose for the Program

Patient safety was defined by the Institute of Medicine as “the freedom from accidental injury due to medical care or from medical error.” Creating a culture of safe patient care is leading the healthcare industry in terms of quality of care, medical reimbursement, patient outcomes, patient satisfaction, and nursing education. The purpose of this innovative education is to enhance the critical thinking skills of perinatal direct care nursing staff on patient safety hazards with the intent to decrease adverse patient outcomes. The Crime Scene Investigation (CSI) education program was implemented to improve an overall safe environment that reduces the rate of adverse obstetric safety events.

Proposed Change

Traditional nursing education includes self-study packets, written examinations, online learning modules, and didactic oral presentations. As nurses we routinely use psychomotor skills; however, traditional nursing education fails to address how we perform and critically think. A CSI room was created to have the direct care nurses physically identify safety hazards in an obstetrics’ patient room.

Implementation, Outcomes, and Evaluation

A patient's room was simulated into a crime scene with a low fidelity mannequin and more than 35 patient safety hazards with various maternal education competencies, including invasive lines, wound care, sepsis, respiratory, blood administration, medication safety, and falls. Neonatal patient safety hazards included patient identification, safe sleep, and radiant warmer equipment. The nurses received information about the crime scene through a case study and then entered the room to investigate for patient safety hazards. The investigating enhanced critical thinking skills and awareness of patient safety hazards. Direct care nurses engaged in communication about the safety hazards and discussed process and flow in the patient's room. Direct care nurses were able to identify areas of risk on the obstetric unit and implement ideas for process improvement.

Implications for Nursing Practice

The CSI project affected nursing care because it created a new type of learning environment that enhanced critical thinking skills and psychomotor skills. Minimal cost was associated with the project as everything was preformed on the unit during the staff's scheduled shift. This CSI education project is adaptable to any health professional education. Avoiding preventable injuries to mother and neonates improves a patient's outcomes and is on the forefront of staff education and awareness.