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Sight gags abound in patient safety "room of horrors"


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Sight gags abound in patient safety ‘room of horrors’

Propped up on a pillow, wearing a baseball hat and a pink cast on his ankle, the patient is perfectly still, unmoving as nurses and other staff members walk through jotting notes on identical forms. Tucked between the patient’s lips is … an unlit cigarette.

Fortunately, the patient is made out of rubber and plastic.

This was just one detail among dozens used for a training exercise in a mocked up “hospital room of horrors” at Shriners Hospitals for Children in Erie, PA, explains Jean Tauber, FACHE, director of performance improvement, risk manager, and patient safety officer.

The exercise was part of the hospital’s patient safety awareness week.

“Nurses created the room—volunteers,” says Tauber. “Night shift nurses volunteered. Getting staff involved made the creation of the room as much an exercise as having staff run through.”

It really is a simple concept, says Celia Goers, RN, CPUR, director of care management services at Perry Memorial Hospital in Princeton, IL, who ran a similar training exercise with the facility’s safety officer. Rather than during national Patient Safety Week in March, Perry Memorial held its “hospital room of horrors” program at the other highly appropriate time of year: Halloween.

“It was pretty easy. We met a few times, put a few ideas together, discussed some basic safety concepts,” says Goers.

Perry Memorial’s safety officer is also the facility’s EMS coordinator, so she was able to pull together the necessary materials, including a wounded dummy. The dummy was on the receiving end of much medical attention, and real IVs and tubing were used to illustrate safety errors.

“We focused on hot topics along with the basics,” says Goers. “Restraints, issues with IV medications, patient identifiers.”

Shriners also included some tricky areas such as dietary dangers.

“We included food allergies, expired milk cartons,” says Tauber. “You’d need to look at the patient information board to learn that the patient was NPO, and yet there was a tray of food for the patient.”

Shriners also incorporated elements that are distinct to its patient base. “We have a strong patient component that is latex-sensitive,” says Tauber. “We put things in the room to trigger that. The clinicians noticed.”

Less subtle but also challenging items included outdated inspection stickers on hair dryers.

“We wanted to appeal to everyone that you may not have hands-on patient care, but you care for patients,” says Tauber.

Perry Memorial set up two rooms—one for clinical and one for nonclinical staff members—although they were invited to work their way through both rooms to look for errors.

Shriners was able to use a lower-census week to set up a stand-alone patient room for the project. Perry Memorial used rooms that were undergoing repairs and unusable for patients at the time.

“We had an old patient care area that was being rehabbed, which still had a bed, bedside table, chair. We didn’t have to take up any space in patient care areas,” says Goers.

Because the room was being rehabbed, there were opportunities for staff members to catch unexpected errors and violations as well.

“They caught everything, including things that weren’t intentional on our part,” says Goers.

This included a broken switch plate cover on the wall, which was broken before the contest and hadn’t been repaired in anticipation of the renovations and was not on the list of items for staff members to catch. Amusingly, it was this accidental item that acted as a tiebreaker between two teams.

Broken equipment, brought into the room because it could not be used for patient care, ended up being used the same way.

“We had an IV pump set aside to be fixed, with a sign on it stating this,” says Goers. Several teams going through the room spotted this accidental inclusion on the list of violations.

Sometimes, things were added to the list through accidents during the set-up process.

“The call bell was tied to the rail, and when I put the rail down, it yanked the call bell out of the wall. I decided to add it to the list to see if anyone would notice,” says Goers.

Tip: Announce the winners and list the violations in the room, but make sure everyone knows the room was doctored up intentionally. “We put it in our newsletter with a list of correct answers, and administration [got nervous] that laypeople might not realize we were talking about a doctored room,” says Goers.

Alternatively, make the answers available immediately following the tour through the room. “Before you left the room, you were supposed to find everything,” says Tauber.

Fun and voluntary

The exercise was not required by either organization, yet they both had high staff member attendance.

Perry Memorial had set two- or two-and-a-half hour intervals to allow all shifts an opportunity to run through the rooms during the course of two days. Even with limited available timeslots, the hospital garnered more than 50% attendance. Shriners ran its program one full week and managed to achieve almost 100% attendance.

“I’ve heard of places doing similar programs but focusing on clinicians,” says Tauber. “We had everyone go through the room—maintenance, housekeeping, everyone.”

“Putting it all together on display to make it fun—it was silly but effective,” says Goers. “We’re dealing with true issues.”

The trick is to choose memorable sight gags that, although over the top, will trigger responses when staff members encounter future real-life, more subtle incidents.

The hospital also incorporated hand hygiene training and education into the exercise.

“We were just starting to increase our hand hygiene education” to the next level, says Goers.

Organizers tied this into the contest by picking one staff member six times per day to have his or her hands tested with Glo Germ, a commonly used substance for identifying bacteria on hands.

“It’s worth doing because it’s a very low-investment project in terms of time and cost, but very high return if you make it fun enough that they’re going to remember the core of it,” says Tauber.

It can be done with minimal time and items as long as you have a location to hold it, says Goers. “It’s surprising how easy it is to bring this sort of project together.”