Game of Errors: Changing a Culture of Safety by Bringing Errors to the Front Line

Purpose:
Organizations struggle to disseminate critical patient safety information to frontline nurses. An efficient and meaningful delivery method is integral to foster positive practice changes. We created a mobile, incident-specific, and interactive educational experience to improve nursing care quality.

Relevance/Significance:
Clinical nurses are challenged to plan extended educational time away from patient care. Our in-situ, scenario-based Roving Patient of Errors (RPE) simulation created a highly interactive, expedient, and relevant education experience. The RPE uses gaming to innovatively exhibit unit-based incidents and consequential outcomes. This RPE's wide dissemination and immediate application of best practices drives improvement in patient safety.

Strategy and Implementation:
Nursing Quality Council (NQC) members reviewed recent internal patient safety reports and identified trending opportunities for improvement including: mismatched labels on medications, incorrectly programmed pumps, multiple non-matching identification bands, and improperly applied central line dressings. NQC members outfitted manikins with functioning medical equipment and, using stretchers for mobility, created two RPEs. Two teams, each comprised of two clinician presenters and a RPE, visited all patient care areas for four hours during day shift, as well as on night shift. Upon arrival to each unit, presenters called a huddle and simulated handoff report to participants. Over the next three minutes, staff examined the manikin to identify as many errors as possible. A debriefing followed, in which all errors on the manikin were identified. Additionally, presenters explained how the errors originated from recently reported internal incidents. Total time per unit averaged 10-15 minutes.

Evaluation:
Evaluation focused on establishing feasibility and acceptability of the RPE program. Metrics included the number of attendees reached and qualitative participant feedback. Four presenters reached 230 staff over a four hour time period. Qualitative feedback revealed the format was not only acceptable, but appreciated, novel, engaging, insightful, directly applicable, and relevant.

Implications for Practice:
Utilizing recent patient safety incident reports in this mobile education promoted organizational transparency and practice awareness through a more informed staff. This program is generalizable, and can be replicated and customized for any clinical environment to enhance quality patient care.