Earlier identification of patient risks enables nurses to anticipate better and avoid some adverse events. The unit’s sickest patients consistently receive a high level of care, but patients identified as ‘stable’ can still experience serious yet preventable adverse events, including falls, ventilator disconnection, and inadvertent tube and line removals.
A multidisciplinary team devised the PICU Risk Matrix, which is based on six patient risk factor categories identified by Incident Information Management System (IIMS) data. The tool targeted assessments of risk, matching of nursing skill with patient requirements and the handover of risks during the shift. A formalised system was devised, with the goal of improving the culture of patient safety in PICU and risk mitigation.
A demonstrated change in handover practices and organisation of meal reliefs has occurred. The team collected data relating to patient acuity and nursing workload which has ongoing implications for planning of safe staffing levels.
