I Am Patient Safety 2018: Innovation Award

Carol Mathews, BSN, RN, CWOCN; Cecilia Zamarripa, MSN, RN, CWON; Lisa Donahue, DNP, RN, CPPS; Sarah Martin-Cua, MBA, MSN, RN; Kristian Feterik, MD, MBA
UPMC Presbyterian Shadyside
I Am Patient Safety 2018 winner of the "Innovation" award.

Nurses develop creative ways to manage their patients' symptoms, especially when they involve bodily fluids such as diarrhea. The hospital found that nurses were using nasopharyngeal airway devices as off-label rectal trumpets to manage fecal incontinence. However, unintended problems developed, including patients experiencing rectal mucosal injury, bleeding, or perirectal injuries. A team was convened with the goals of promoting best patient-care outcomes, eliminating serious events related to rectal injury, and more effectively managing diarrhea in hospitalized patients. The revised fecal containment policy now includes a focus on assessing reversible factors that lead to diarrhea and initiating nursing interventions to address those factors. For example, dietitians are consulted to evaluate enteral feeding formulas to address the diarrhea. In addition, medical evaluation of the diarrhea is encouraged, including testing for infection. When a fecal management system is ordered now, the wound, ostomy, and continence (WOC) nurse must assess the patient and rule as to whether a device can be used. The WOC nurse provides a detailed explanation to staff nurses with each case and a rationale if using the device is disallowed. The medical provider may override the WOC nurse's refusal for the benefit of the patient. But the revised care protocol specifies that a formal patient consent must first be obtained and verified. In the year before the revised policy and care protocol were implemented, there were 18 adverse fecal-containment-related events. The hospital had only a single adverse event in the eight months that followed.

©2018 Pennsylvania Patient Safety Authority