Putting a Human Face on Harm: Reducing Patient Adverse Events through Story-telling

Abstract

Patients are unintentionally harmed in healthcare settings across the country every day. This evidence-based quality improvement project was designed to decrease the total number of patient harm events and increase nurse engagement in the problem-solving process by using patient stories to change human behavior. The project organization had embarked on a journey to zero avoidable harm events through the implementation of a Quality Management System that encourages frontline staff to actively participate in problem-solving experiments to learn from adverse events and prevent future injury. The utilization of story-telling during post-harm huddles was implemented across three intermediate-care units who had utilized the post-harm huddles, without story-telling over the previous 12 months. A pre-and post-survey was administered to measure nursing engagement in the problem-solving process as it specifically relates to the post-harm huddle. Avoidable patient harm events were also captured and the project focused specifically on the harm events of central line-associated blood stream infections, catheter-associated urinary tract infections, hospital-acquired pressure injuries, and falls with injury. Findings included a total of 18 harm events across the three project units as compared to 10 events in the comparison period. Nurse engagement scores increased by a mean of 0.2 points across the three project units combined. While the incremental increase in engagement was small, sustaining story-telling beyond the three month implementation period may result in a decrease in total numbers of patient harms and an increase in nursing engagement, resulting in improved quality outcomes for the organization.