The low volume of patients with PACs in the ICU is a challenge for clinicians to gain or maintain competencies, placing patients at risk for PACs related injury or sentinel events. Online learning, simulation, and checklists are tools for clinicians to acquire/maintain PACs care KSAs and competencies. The Low volume of patients with Pulmonary Artery Catheters (PAC) in the ICU is a challenge for clinicians to gain or maintain competencies, placing patients at risk for PACs related injury or sentinel events. A chartered RCA help improve the quality of care among patients with PACs that were impacted by the COVID-19 Pandemic and magnified by the low number of patients with PACs in the ICU. The project’s purpose is to avoid patient injury and sentinel events related to the use of PAC in the ICU. The project seeks to define multifactorial root causes and provide Actions, and Outcome Measures.
Problem: Avoiding Pulmonary Artery Catheter (PAC) Related Injury and Sentinel Events Among Intensive Care Unit Patients
Measurement: The RCA team conducted Safety GEMBA walks/observations to illustrate a final understanding of the PSe. A Cause-and-Effect diagram was used to identify root causes. Cause, Effect, and Event statements were formulated to state five RCAs and later provided with corresponding Actions and Outcome Measures
Analysis: Registered Nurses in the ICU assumed leadership roles in a chartered RCA to improve the quality of care among patients with PACs. PAC care was impacted by the COVID-19 Pandemic which was magnified by the low number of patients with PACs in the ICU
Implementation: Aligned to the five root causes, the RCA team implemented PAC online learning and collaborative didactic for RNs and MDs, situation-based simulation training, real-world patient should-to-shoulder interdisciplinary training, PAC competency checklists, development/implementation of PAC Order Set, bedside PAC Checklists, and Standard Operating Procedure in ICU bedside management of PACs
