Author(s): Kristina Davis, MS, MPH, RN, CNL, CPHQ, CLSSBB
Director
Stanford Healthcare

Kristina Davis is a nurse leader whose career started in public health policy development and implementation. She currently serves as the Director of Nursing Quality for Stanford Healthcare. Prior to her current role, she was Director of Quality & Patient Safety at VHC Health. Her work is driven by curiosity for the multi-faceted nature of health. Kristina takes pride in leading innovative quality initiatives grounded in nursing theory and evidence-based practice while passing that knowledge on to the next generation of nursing and public health professionals. Kristina has been recognized as a 2020 Mazda Hero, an Illinois 40 Under 40 Nurse Leader, and an AONL Emerging Nurse Leader. She holds an MSN from Rush University and an MPH from Benedictine University. When she isn't working, Kristina enjoys ice skating, farmer's markets, and getting to know her sewing machine better.

Competency Domain: Patient Safety

Description: Most care delivery in the US is provided in ambulatory settings, yet quality improvement and patient safety efforts are heavily weighted towards inpatient settings. It is estimated that 5% of outpatient encounters result in an adverse event, however, efforts to better understand patient safety in our ambulatory departments have been limited by the dearth of reported events. A nursing-led council sought to understand reporting practices to guide fall prevention efforts. This session will discuss the findings from this survey and suggest ways findings can be used by others to help promote patient safety event reporting in the ambulatory setting. Problem: An ambulatory nursing shared leadership council reviewed safety events during project planning and found a limited number of events reported. This did not align with anecdotal evidence and lived experiences. To understand potential reasons for the disconnect, we looked at reporting barriers and facilitators in this setting. Measurement: A online survey was designed by the Ambulatory Nurses Shared Leadership Council Falls Taskforce. The questions focused on barriers and facilitators of safety event submission including behavior, perceptions, knowledge, and support. This survey was shared with nurses practicing in all ambulatory settings via email and was open for one month. Analysis: Descriptive analytics and basic statistics (chi-square) were used to assess findings and their statistical significance. Results were shared with the committee for feedback and identification of priority areas. Implementation: Ambulatory nurses work across diverse service lines, physical spaces, and schedules. They often have closer connections to their interdisciplinary colleagues than nursing leadership. Collecting survey data required word-of-mouth, email campaign and engagement of the leadership council for success. Frequently clustered responses developed once a local stakeholder was identified. Results/Discussion71 nurses from 25 unique clinics responded. Over half had not reported a safety event even though 79% knew events should be reported through the system. 80% acknowledged management and colleagues encourage safety event reporting. Tops barriers to reporting included: beliefs reporting is punitive, cumbersome, and linked to employee record.

Evaluation: Complete Poster Evaluation