EP - Exemplary Professional Practice

EP32:  Culture of Safety-Describe and demonstrate the nursing structure(s) and process(es) that support a culture of safety.

Brenda Hall MS, RN, NEA-BC, Senior Vice President of Quality, Safety and Regulatory Affairs
 Brenda Hall MS, RN, NEA-BC, Senior Vice President of Quality, Safety and Regulatory Affairs  

Safety is one of the organizations core values and a pillar of excellence.  Brenda Hall MS, RN, NE-BC, Senior Vice President of Safety, Quality and Regulatory Affairs, as well as Chief Patient Safety Officer, is a nurse and is passionate about patient safety. Ms. Hall has designed a comprehensive program that addresses many safety issues.

Ms. Hall Chairs an interdisciplinary Patient Safety Committee which is a forum for the collection and analysis of risks to patient and employee safety and for the dissemination of information on identified risks for the purposes of improving care and services.  The committee designates an Adverse Event Response Team to perform root cause analysis and develop and implement action plans for gaps in safety.  Sources used to identify adverse events and near misses include but are not limited to:

  • Anonymous reporting
  • Safety Hotline
  • Complaints
  • Infection Control surveillance
  • Performance Improvement data
  • Patient Satisfaction Surveys                                                 
  • Retrospective Medical Record Reviews
  • Clinical Triggers (return to the OR for example)
  • Licensure/Accreditation Survey reports

An example of a case, reviewed by the Adverse Event Team, consisted of poor communication between nursing and the healthcare team, which contributed to the patient staying in the wrong level of care. The case was reviewed by the Adverse Event Team, which is comprised of primarily nurses.  See table below for the nurses’ names.    


After reviewing the case, the team made recommendations, such as Senior Management facilitating communication when needed, updating the physician call list, and handing off the same physician beeper at the end of shift.  These recommendations continue to reinforce a culture of safety.     

Ms. Hall has also established a Patient Safety Leadership Walkrounds process which includes all members of the executive team.  Ms. Hall and Ms. Smith take part in Patient Safety Leadership Walkrounds.  Due to their clinical nursing background they are able focus in on particular potential nursing and patient safety concerns.  These safety rounds are performed on a weekly basis to all of the clinical areas.  Safety concerns raised by the nursing staff on rounds are followed-up immediately with the responsible managers via e-mail with a request to follow-up and expected date of resolution.  Results are shared with the Administrative Conference Team and the Board of Trustees. 

Key questions asked of staff include but are not limited to the following:  See appendix for complete survey (Appendix EP32-A).  

  1. What do you think this unit could do on a regular basis to improve safety
  2. Are there specific measures the leadership team can take to make the work you do safer? 

Ms. Hall also developed a brochure that is entitled Patient Safety:  Leadership “Walk Rounds,” which she gives to staff and also includes a Safety Hotline Number to report issues/problems related to safety (Appendix EP32-B).  See categories of safety concerns below:




 Safety concerns are trended and shared with leadership.  Another way that nursing supports a Culture of Safety is by our Shared Governance Council; Nursing Quality and Patient Safety Committee.  This Council is chaired by Erin Salmond BSN, RN, Charge Nurse in Intensive Care Unit and facilitated by Claudia Garzon-Rivera MSN, RN, CNL, CCRN Clinical Nurse Leader in the ICU.  The Table below depicts membership:


This Council is charged with the development of the annual nursing quality/safety program and monitors and tracks initiatives on the overall nursing report card.  Each unit has specific initiatives that they monitor depending on the specialty.  For example, such safety initiatives such as hand-off, restraints, wounds, falls, RRT, and Code Blues are reported at this Council.  At one of the most recent meetings, Shirley Espejo BSN, RN, CNN, Staff Nurse in Renal reported that a patient fall prevention module is being conducted.  Evangeline Cagas BSN, RN Staff Nurse from the Cardiac Catheterization Laboratory (CCL) detailed a patient safety initiative which entails the proper completion of the Preoperative check list for inpatients who have procedures in the CCL. (SE1) 

Safety Awareness

The Quality and Safety Council also added 3% Sodium Chloride drip to the double check policy.  This proposal came about as a result of a Root Cause Analysis.  The committee agreed to add this hypertonic solution to the High Risk Double Check medication policy.  Ms. Garzon-Rivera presented the policy to the Professional Practice Nursing Council for approval.

Safety Boards on medical/surgical units 

Safety boards are placed on all the medical/surgical units so that staff nurses can review at a glance falls data, to include numbers of falls year-to-date on the unit, the number of days that they were falls free and those patients that are a risk for falls. Additionally noted on the safety board are skin and nutrition monitoring which includes repositioning times, feeding schedules and complete care patients.  Restraints are also noted as well as core measures.  The safety boards are an important part of the hand-off process as well as the safety huddle. 

Perinatal safety rounds 

Every morning the Perinatal team, which includes:  Lillian Reyes BS, RN Nurse Manager of Mother/Child Health, Rachele Dalalian RNC, CLNC Performance Improvement Specialist, Randa Francis MSN, RN, CNM, Mother/Child Health Educator, Dr. Bimonte MD, Chairperson of Mother/Child Health, the Charge Nurse for the day as well as the senior Resident make rounds on all of the patients in Labor and Delivery (L&D) and all the Antenatal patients.  Each patient is individually assessed for problems/issues and a plan of care is developed.  

Patient safety on 7 East and West (Medical-Surgical Units) 

Colleen Calero BSN, RN and Helen Im BSN, RN  both Charge Nurses on 7 East were instrumental in the inception of “Patient Care Technician of the Day” which is a method used by our nurses to engage the PCTs in efforts to prevent patient falls.  The role of this person is to assure that the falling star is in place outside the patient’s room if the patient is on the Falls Prevention Program.  He/she also insures that the patients at risk for falls are identified on the assignment board.  This teamwork approach to preventing falls is another example of instituting best practices to promote patient safety.

Unit safety huddles 

The Patient Centered Family Focused Care model provides structure for ensuring a culture of safety during patient care delivery.  It does this through clearly defined roles and responsibilities for all team members (registered nurses, Patient Care Technicians, physician, manager, director) as well as processes that enhance patient safety.  One of these processes central to patient safety is the unit based safety huddle.  These huddles occur at the beginning of each shift and can include anyone that is involved in patient care.  The huddle brings an awareness of possible or actual patient safety incidents that can be prevented.  Patient safety issues which are reviewed include:  patients at risk for falls, pressure ulcers or any other issues related to patient safety.  (See Appendix EP32-C for Safety Huddle Guidelines).  The enhanced teamwork contributes to early identification and intervention for at-risk patients.

See below for staff nurses responses to the effectiveness of safety huddles: 

“Safety huddles are important because it makes you aware of issues with all the patients on the unit and you know which patients to observe for safety issues.”

Swati Patel BSN, RN staff nurse 7 West 

“The safety huddle is a mechanism to prevent error and to keep our patients and the staff safe.”  Yvette Bryant MSN, RN staff nurse 7 West 

“The safety huddle helps us as a team to identify those patients at risk for falls, for example, those patients on anti-hypertensive or anti-depressive medication.”

 Connie Meglioranza BSN, RN staff nurse 6 West 

“The safety huddle helps me to understand the mode of transportation a particular patient needs and the level of their mobility.”  Ingrid Cardinas BSN, RN Medical-Surgical discharge nurse 

“In the Operating Room the huddle helps us to know special equipment or a special supply that’s needed for a particular procedure.”  Pat DiBello MSN, RN, CNOR Charge Nurse Operating Room


Unit Safety Huddles

Cardiac Cath Lab: E. Tasheem RCIS; S. McLendon BSN, RN; E. Bukhtiyaroff Tech; A. Raheem Tech; J Ragussa RT; E. Bahdur BSN, RN;  M. John Lewis BSN, RN; T. Pilgrim BSN, RN, CCRN; E. Cagas BSN, RN

Operating Room: E. Camponella BSN, RN; P. DiBello MSN, RN, CNOR; Madeline Asuncion BSN, RN

7W:  C. Ramirez PCT; S. Copeland PCT;  N. Baffoe; Manan Parikh BSN, RN; Y. Bryant MSN, RN; S. Patel BSN, RN; A. Viray BSN, RN

6W: C. Meglioranza BSN, RN; O. Candalla BSN, RNC; L. Vergara BSN, RNC, A. Blanco BSN, RN; W. Hernandez BSN, RN, J. Moon BSN, RN, C. Alfonso BSN, RN, I. Cardenas BSN, RN