PICU Safety Stand Down Sessions*
Sunday, June 12th, 3:00-4:30 p.m.
Wednesday, June 15th, 9:30-11:00 a.m.
Monday, June 20th, 5:15-6:45 p.m.
Look
, focusing
on safety
issues and providing
training to improve communication and to reduce preventable
accidents/errors in the PICU!
Difficulty hearing
handoffs
due to equipment
on the fly
Fighting the hand hygiene
alarms
? Giving
? or
battle
alone?
These & other safety concerns will be the topics of discussion during our safety
stand down!
*Total time for each Safety Stand Down will be 90 minutes. The safety stand down is mandatory for
all PICU nursing staff members, PICU RT staff members, and PICU physicians (attendings, fellows and
current residents). PICU team member from other areas are encouraged to attend.
PICU Safety Stand Down
Facilitator Agenda
Overall Purpose and Introduction – 30 minutes
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Review how others see the PICU, tell stories about how we have heard from internal and external
sources. We are the ones that get it right. We should be proud of that fact since we all have joint
responsibility for the performance of our unit.
It is extremely hard to keep our gains – especially when we are working on many things at once and
often feel overwhelmed.
It is the most important aspect of our jobs to make sure the patients are safe and receive the highest
quality care. The only way to make sure our system is the right one for the patients is to have that
shared vision.
We have seen subtle and not so subtle areas of safety concerns. We are here today to talk openly and
honestly about how we can refocus on these topics and provide the needed support to make this focus
successful.
What we work on today will not fix everything but at least bring this to the forefront and give us a
platform to work from
Illustrative Stories and Examples
Likely topics for stories include:
Alarm fatigue and complacency with general room safety
Complacency with teamwork tools
Frustrations with asking others to comply with isolation signs
Hand off errors
Interactive Discussion (everyone)
Ask for stories from the audience. Ask the audience about barriers and things that prevent us from keeping our
gains. Let them know that we are taking notes and will try to work as a team to eliminate barriers. Safety again
is top priority so we will continue to work on this after the safety stand downs.
Divide into 3 teams for rotation through stations
Station 1: Alarm Fatigue/General Room Safety (20 minutes)
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Review of General Room Safety --- What to consider? Why it is important? Who is responsible?
Why we have alarms? Why they fail? What is alarm fatigue?
History of alarm fatigue in the literature? What causes alarms fatigue? Joint Commission national
patient safety goals. Reports in the literature and outcomes….Examples from our unit.
Lead group participation/input on what makes us ignore our alarms in the PICU?
Followed by ideas on how we combat alarm fatigue and become more sensitive/responsive to alarms?
Station 2: Patient advocacy and infection prevention/difficult situations during advocacy (20 minutes)
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Review Hand Hygiene Compliance and Observation Tool
Present and Discuss JCAHO Disruptive Behavior
Interactive discussion – include personal perspective related to asking others to be compliant with
infection prevention and stories. Consider role play exercises, if time permits.
Station 3: Communication/Hand Offs/Checking (20 minutes)


Review importance of accurate handoff-correct information and active check of all equipment attached
to patient.
Present and discuss the handoff tools for RN, RT and MD.
PICU Safety Stand Down Feedback Survey
1. To what extent did the safety stand down raise your awareness of safety issues in
the PICU?
Not at all
(1)
Very little
(2)
Somewhat
(3)
A great deal
(4)
2. How helpful/ meaningful/ useful were the discussions?
Not at all
(1)
Very little
(2)
Somewhat
(3)
Very helpful/
meaningful/ useful
(4)
3. What did you like best about the safety stand down?
4. What are your suggestions for improvements?
5. List additional ideas for improving safety in the PICU.