NUR 4450 Module 2 Safety and Quality Competencies Example

Proving Safety on a Phone Line: Safety and Quality Competency Statements Backed by Audit Results and a Near Miss

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4450: Validating Nursing Competence

Mentor Name

Month Day, Year

Proving Safety on a Phone Line: Safety and Quality Competency Statements Backed by Audit Results and a Near Miss

In the first module I chose the six QSEN competencies as the framework for my portfolio and identified safety as the competency that telephone triage tests most severely. This paper writes my safety and quality competency statements and supports them with evidence measured against published standards rather than my own sense of how well I work. The evidence comes from two years of de-identified peer audit results on my recorded calls, one near miss I reported, and the triage literature. Both statements end with what the evidence does not yet show.

The Standards I Am Measured Against

The safety competency, as Cronenwett et al. (2007) framed it, is about keeping harm away from patients and staff, and it treats that as a job for well-designed systems as much as for careful individuals. Its listed skills include using technology and standardized practices that support safety, communicating observations or concerns about hazards and errors, and participating in analyzing errors and designing system improvements. The quality improvement competency asks the nurse to use data to monitor the outcomes of care and to apply improvement methods to make care safer. Both competencies were influenced by the argument in To Err Is Human that most harm comes from faulty systems rather than careless individuals, and that the solution lies in designing systems that make errors harder to commit and easier to catch (Kohn et al., 2000).

On a triage line, those standards translate into three observable behaviors: following the protocol consistently, recognizing when a caller's presentation exceeds the protocol, and reporting weaknesses in the system rather than working around them. The published evidence explains why the second behavior matters most. In their review of out-of-hours telephone triage, Huibers et al. (2011) found that triage performed well for most callers but much less reliably for high-urgency callers and poorly in tests using simulated high-risk patients. A nurse who follows protocol perfectly can still miss the call that matters.

Evidence From Two Years of Call Audits

Our service audits five recorded calls per nurse each month using a twenty-item checklist that covers identification, use of the correct protocol, asking every required question, selecting the right disposition, giving care advice, confirming the caller's understanding and documenting accurately. Over the past twenty-four months my average score was 94 percent, with no month below 88 percent. The team average over the same period was 91 percent. These figures are evidence of consistent performance on the standardized parts of the work, which is what the safety competency means by using standardized practices. They were produced by someone other than me, using a checklist I did not design, on calls I did not choose, which is what makes them worth more than my own account of how carefully I work. The audit is also blind to the nurse's mood or the night's volume, so it captures ordinary performance rather than performance on good days.

The audit also shows a weakness. The item I miss most often is confirming the caller's understanding of the disposition, which I completed on 81 percent of audited calls. That matters for safety. Purc-Stephenson and Thrasher (2012) pooled studies of patient compliance with telephone triage advice and found that callers followed the recommendation only about 62 percent of the time, and that some noncompliant callers said they had heard a different disposition than the one given. A caller who misunderstands go to the emergency department now as see your doctor tomorrow has received unsafe advice, however correct the triage decision was.

Evidence From a Near Miss

Last winter I took a call from an adult child reporting that a parent in their seventies had become newly confused two days after a fall. The fall protocol I opened was based on the injury, and the patient had no visible injury and no pain. The protocol's disposition was to call the primary care office within twenty-four hours. Two details did not fit: the confusion was new, and the caller mentioned in passing that the parent took a blood thinner. I overrode the disposition to send the patient to the emergency department, where imaging showed a subdural hematoma. Afterward I reviewed the protocol and found that the anticoagulant question appeared only in the head injury protocol, not in the general fall protocol, so a nurse who chose the fall protocol might never ask it.

I reported the gap through the service's safety reporting system and joined the review with the clinical director. The protocol vendor's version could not be edited locally, and waiting for the vendor's annual update would have left the gap open for months, so the service added a required screening question about blood thinners at the start of every injury call, regardless of protocol. That change addressed the system rather than relying on the next nurse to notice. It is evidence of the skills the safety competency lists: recognizing a hazard, reporting it, and participating in a system fix.

What the Evidence Does Not Show

The audit shows consistent protocol use, and the near miss shows that I can recognize when a protocol fails, but neither shows how often I miss the call that does not fit. A near miss I caught is, by definition, not one I missed. The only way to know the miss rate would be to follow up on a sample of calls I managed at home or with a next-day appointment and check whether any led to an emergency visit within forty-eight hours, which our service does not yet do. For the quality competency I can show that I use audit data to improve, since my understanding-confirmation rate has risen over the last six months after I started using a teach-back phrase, but I cannot yet show outcomes for callers. I will propose an outcome follow-up audit as part of my final portfolio.

References

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D. T., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. https://doi.org/10.1016/j.outlook.2007.02.006

Huibers, L., Smits, M., Renaud, V., Giesen, P., & Wensing, M. (2011). Safety of telephone triage in out-of-hours care: A systematic review. Scandinavian Journal of Primary Health Care, 29(4), 198-209. https://doi.org/10.3109/02813432.2011.629150

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press. https://doi.org/10.17226/9728

Purc-Stephenson, R. J., & Thrasher, C. (2012). Patient compliance with telephone triage recommendations: A meta-analytic review. Patient Education and Counseling, 87(2), 135-142. https://doi.org/10.1016/j.pec.2011.08.019