ALWAYS Making Patient Safety a Priority

Lenox Hill Hospital (Manhattan, New York)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Project Topic:

Decreasing “never events” through systematic nursing-lead risk-rounding

Hospital Unit:

Cardiothoracic Intensive Care Unit (CTICU)

CSI Participants:

  • Ivis Cassius-Linval, BSN, RN
  • Catherine Kim, BSN, RN
  • Jenna Maizes, BSN, RN
  • Madison Montague, BSN, RN, CCRN-CMC-CSC

Video Presentation

View this CSI team's project presentation video to earn CERPs.

Project Goals/Objectives:

  1. Standardize safe room setups
  2. Decrease patient harm and never events
  3. Reinforce culture of safety
  4. Create a safe space for having patient safety conversations
  5. Decrease knowledge gap between nurses

Project Outcomes:

  1. Decreased never events 50% in 2021 (compared to our projected 40% decrease)
  2. Progressed in eliminating mortality from coronary artery bypass graph (CABG) surgery patients in 2021
  3. These outcomes resulted in an estimated annual fiscal impact of $92,544.

Project Overview:

Our CTICU at Lenox Hill Hospital reported six “never events” between January and June 2021: three pressure injuries, two falls and one occurrence of C-Diff. To address this problem, the nurses of our CSI team focused on implementing systematic nurse-led rounds to reduce patient harm using the acronym ALWAYS (Airway, Lines, Walking, Alarms, whY the lines & Skin).

Our CSI team introduced the new approach to rounding during daily huddles. Many staff members were in favor of our project and were eager to participate. We also incorporated information about the nurse-led rounds and our project during nursing orientation to establish an expected culture of safety in our unit. In addition to nurses, our unit’s physicians, PAs and PCAs also saw the benefit of our program.

By incorporating an adaptable model of nurse-led rounds, we were able to standardize a safe environment in patient rooms, give impactful voices to nurses about patient safety and ultimately decrease never events 50% by the end of our project.

Our team created the ALWAYS risk-rounding tool to be adaptable to many patient populations and easy to use by novice nurses. We hope to incorporate this approach throughout various ICUs in the near future.

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The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.