Improving Patient Safety in 20 Minutes or Less:
Using TWI to remove the dodginess in pressure ulcer prevention
Ellen Noel

Significance Pressure ulcers (i.e. bed sores) are the fourth leading cause of preventable error in the United States adding between 10.5-17.8 billion dollars in cost to our national health care. Bed sores cause pain and suffering for patients, extend their hospitalization, and create a financial burden for patients, organizations and society. Despite nursing practice standards and advances in technology to help prevent pressure ulcers, many institutions find that reliably getting to zero hospital acquired pressure ulcers is unachievable.

Methods In January 2009 Virginia Mason Medical Center (VMMC), a 292 bed facility located in Seattle, Washington, recommitted to their pursuit of zero facility acquired pressure injury. Outcome analysis confirmed variability in nursing practice regarding the execution of a standardized pressure ulcer prevention bundle. The Critical Care Unit, home to our sickest patients was the highest offender with a 44 % increase in pressure ulcers in 2011.

Root cause analysis and documentation review showed that despite an increase in defects the prevention bundle was documented as in place. The investigation team was puzzled and questioned the quality and frequency of patient turning, the critical element in pressure ulcer prevention. The only way to confirm or deny adequate turning practices was through observation. Using the tools of the Virginia Mason Production System, turning observations showed a 32 % defect rate, confirming that the process remained unreliable.

Implications The Training Within Industry method of improvement was employed to teach critical care nursing staff about the science of the Perfect Turn. This learning provided a simple, sequenced, quality standard that was repeatable and observable. The Perfect Turn job instruction focused on an economy of words and movement and leveraged simple tactile, visual, and auditory learning through repeat back demonstration. TWI learning techniques can alter habitual practice patterns with the ability to positively influence patient safety training.

Upon completion of this session, participants will learn…

• Describe the techniques and application of root cause analysis as a set up strategy for Training Within Industry pressure ulcer prevention instruction.
• Discuss the implications of combining the Virginia Mason Production System and the Training Within Industry methods to accelerate patient safety pressure ulcer prevention.
• Discuss the results, lessons learned, and next steps needed to ensure sustainability of the science of the Perfect Turn

About the Presenter(s)

Ellen Noel MN, RN-BC, is the Adult Medical- Surgical Clinical Nurse Specialist for Virginia Mason Medical Center. She received her Bachelor of Science in Nursing in 2001 from the University of Washington and her Masters in Nursing from the University of Washington in 2005.

Ms. Noel has 25 years of diverse nursing experience. In her current role as Clinical Nurse Specialist she provides a platform for evidence- based process improvements in the areas of patient safety and quality. She is a graduate of the 2006- 2007 Virginia Mason Production System Fellowship Program and has led numerous organizational improvement workshops. Additionally, she has provided process improvement consultation internationally through partnerships forged through the Virginia Mason Institute. She has lectured for a variety of academic and safety organizations during her career, holds a nursing faculty position at the University of Washington and is a contributing textbook author.