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Spring 2009 Council Meetings
1. Principles for Pressure Ulcer Reduction
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Welcome
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Georgia, how are we doing?
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you compare?
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Georgia, how do we rate?
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How do you compare?
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Can we do better?
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7. Where have we been
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and where are we going?
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What will it take?
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Learning the Lessons?
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The Sue Sheridan Story
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Strategies and
TeamSTEPPS Tools
to Enhance
Performance
and Patient Safety
For Today’s
Hospital’s and
Nursing Homes
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Building Trust:
Enhances Quality Care
Spring 2009
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Objectives
Recognize that mistrust and poor communication are
contributors to medical errors and increase staff and
resident dissatisfaction
Learn how to increase trust, mutual support and
communication among your team
Practice techniques that support a ―safety culture‖
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Exercise
What drives you crazy at work?
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Things that drive us crazy……
"That's all I
What is your Popeye moment can stands, cuz
I can't stands
―That’s all I can stands, n'more!"
cuz I can’t stands n’more!‖
Or makes you say
―It doesn’t have to be like
this‖
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What drives you crazy at work?
List 2-3 things that drive you crazy at work
Share them with a small group
Within the small group, agree on the top 1-2 items
Report back to larger audience
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Typical Issues Identified
Poor quality of care
Staff who don’t show up for work
―Not my job‖
Low staff morale
Complicated process that no one follows
Risks to patient safety
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Great leadership does not mean running away from
reality. Sometimes the hard truths might just demoralize
the company, but at other times sharing difficulties can
inspire people to take action that will make the situation
better.”
John Kotter
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What’s wrong in healthcare today?
Root Cause Analysis (RCA)
At the root, is ―every man for himself‖
At the root of ―every man for himself‖ is a profound
lack of trust
If we, the leaders of a healthcare community can’t
earn the trust of each other – how can we
systematically improve safety, quality, and
outcomes
Excerpt from: ―Optimizing Work Environments‖; Brian Wong, MD; Georgia Patient Safety Summit
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Defining Trust
Think of a person whom Think of a person whom
you really trust you do not trust
Write down some Write down some
descriptors descriptors
Share with small group Share with small group
Within small group arrive at a consensus on
2-3 things in each category
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Defining Trust
Qualities of High Trust Qualities of Low Trust
Integrity Misgiving,
Strength Suspicion,
Ability Suspect
Surety No confidence
Hope Undependable
Follow-through Unreliable
Reliable
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Attributes of Trusted Colleague
T = Team Player
R = Respectful and Responsive
U = Understanding
S = Safe
T = Talented
E = Executes
D = Dedicated
Excerpt from: ―Optimizing Work Environments‖; Brian Wong, MD; Georgia Patient Safety Summit
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Trust
Trust is both an emotional and logical act.
Trust helps you predict what other people will do
Trust is certainty based on past experience
Help begets help just as trust begets trust.1
Trust is the ability to act on what you see and
trusting that you are trained to see what is right or
wrong in a situation.
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Common Approaches That May
Impact Trust Adversely
Often used to manage conflict; however, typically do
not result in the best outcome—
Compromise—Both parties
settle for less
Avoidance—Issues are
ignored or sidestepped
Accommodation—Focus is
on preserving relationships
Dominance—Conflicts are
managed through directives
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Collaboration
Achieves a mutually satisfying solution resulting in
the best outcome
All Win! Patient Care Team (team members, the
team, and the patient)
Includes commitment to a common mission
Meet goals without compromising relationships
Creates Trust!
“True collaboration is a process, not an event.”
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Mutual Support Tool
Mutual support is the essence of teamwork
Protects team members from work
overload situations that may reduce
effectiveness and increase the risk of error
Team members foster a climate in which it
is expected that assistance will be actively
sought and offered as a method for
reducing the occurrence of error.
“In support of patient safety, it’s expected!”
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Enhancing Mutual Support Builds
Team Trust and Improves Safety
Foster an environment where you seek the
support of others and offer assistance to team
members
Provide feedback to team members to improve
performance
Be assertive if safety is at risk
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Please Use CUS Words
but only when appropriate!
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When is CUS appropriate?
CUS is a signal phrase
Other signal words
Danger
Warning
Caution
Used to draw attention to the magnitude of
the issue.
Not to be used casually
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Your turn to CUS
Take a card
Find the person with your same card but
the opposite color
Role play the situation using CUS
Switch and role play again
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Communication
Distractions
Assumptions
Stereotypes
Fatigue
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Real World Communication
Both the receiver and sender may have barriers
that prevent effective communication including:
Language barriers
Distractions
Physical proximity
Stereotypes
Personalities
Assumptions
Workload
Fatigue
Hierarchy
Professional Standing……….
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Phrases that Signal
Bad Communication
Whatever you want to do is fine – Complacency/Apathy
You need to run that up the chain of command, have you spoken to
your supervisor? – Hierarchical
You are just a CNA, get the nurse to call me –Professional
Standing
We always do it this way – Conventional Thinking
We will get around to it later – Time/Fatigue/Workload
Why do you ask? No one ever told me that –Defensiveness
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Overcoming Barriers to
Communication
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Standards of
Effective Communication
Complete
Communicate all relevant information
Clear
Convey information that is plainly understood
Brief
Communicate the information in a concise manner
Timely
Offer and request information in an appropriate timeframe
Verify authenticity
Validate or acknowledge information
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Communication Check List
Get the person’s attention
Make eye contact, face the person
Use the person’s name
Express concern
Use the communication technique (e.g., SBAR)
Verify that they understand the message
Re-assert as necessary
Decision reached or Escalate if necessary
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Structured Communications
A framework for team members to effectively communicate
information to one another
Hand-Offs
SBAR
Closed Loop
Communications
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Communicate in a structured way all
the time and it will become common in
the case of an emergency
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Handoff
Relevant Information
Responsibility– Accountability
Reduce Uncertainty
Verbal Structure
Checklists
Electronic Records
Acknowledgement
Great opportunity for quality and safety
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Handoff
Point of danger
---AND---
Opportunity for error detection and
recovery
Great opportunity for quality and safety
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Effective Handoff Strategies
Interactive communications
Include up-to-date information
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Effective Handoff Strategies
Limited Interruptions
Verification Process Required
Receiver has opportunity to review relevant data
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Situation
What is going on with the patient?
State your name and unit
I am calling about (patient name)
Patient age
Gender
Mental status
Patient stable/unstable
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Background
What is the clinical background or context?
Pertinent medical history
Allergies
Sensory Impairment/Disabilities
Interpreter required
Religion/culture
Family location
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Assessment
What do I think the problem is?
Vitals
Isolation required
Skin
Risk factors
Issues I am concerned about
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Recommendation/Request
What would I recommend?
Specific care required immediately
or soon
Priority areas
Pain control
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SBAR
Exercise
Form groups of 4-5 people
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Scenario #1
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Scenario #2
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Scenario #3
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Debrief the Exercise
Was it easy for you to organize the information you
were given into the SBAR?
This question is for the listeners:
How clear did the information seem to you?
Did it seem that you were missing out on any of
the information you needed to proceed?
Did it prompt you to action?
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Was there anything missing?
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Check-Back is…
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In Summary
Recognize that mistrust and poor
communication are contributors to medical
errors and increase staff and resident
dissatisfaction
Learn how to increase trust, mutual support and
communication among your team
Practice techniques that support a ―safety
culture‖
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The Challenge
Pick one tool
Pick one unit or neighborhood in your facility
Pick one shift
Find one champion for change
Teach the staff how to use the tool
Commit together to implement that one tool
for one month
Evaluate for effectiveness at the end of the
month and adjust if needed.
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In review of the data, let’s look first at how we are doing in regards to Low Risk Pressure Ulcers as compared to the national rate and you can see that Georgia is doing better but has been edging back up from a low of 1.5% in Q1 2008 to about 1.6% in Q3 2008.
We are in Region ___________________ represented by the _________ line. The State average and the National Average are the dashed and dotted lines respectively and your region is doing ____________________ but by no means is the process in control. Next, let’s look at High Risk Pressure Ulcers ---Change Slides
Georgia is above the national average in High Risk Pressure Ulcers but the gap has narrowed significantly since about Q4-2007. The last 2 quarters show a leveling out while the national rate continues to decline, a run started in Q1-2008. For Georgia, Q3- 2008 the rate was 12.2%.Next, let’s look at the regions – change slides here
You are in region _______________________ and the state and national rates are dashed and dotted respectively. Your region is ________________________ the state average.Next, we can look at restraints --- Change Slide Here
Now, this is a great trend dropping from 7.5% to 4.4% in 11 quarters. On top of that, the trend line is declining faster for Georgia than for the national restraint numbers. If you keep up the good work, you will dip under the national level within 2 years. What do the regional graphs look like? Change the slide here.
Again, you are in region _______________________ and the state and national rates are dashed and dotted respectively. Your region is ________________________ the state average.Next, we can look at Post Acute Care Pressure Ulcers--- Change Slide Here
Georgia has narrowed the gap between the national rate and the state rate here again and quarter after quarter, you have been working hard to improve. The national average is under 15% now and the Georgia average is very close to that however what if that 15 % included your mother or grandmother, would it still be too high then? Change Slides Here
Again, you are in region _______________________ and the state and national rates are dashed and dotted respectively. Your region is ________________________ the state average.Overall Georgia is improving but there is still opportunities to do better. Are there any questions or comments on the data before we move on. Use parking lot here if unrelated and be sure to explain parking lot concept.Next, for those of you that were here in the Fall that remembers the video we played at the end of the presentation, -- Change Slides Here
Recognize that mistrust and poor communication are contributors to medical errors and increase staff and resident dissatisfactionLearn how to increase trust, mutual support and communication among your teamPractice techniques that support a “safety culture” by:Improving understanding in communications.Improving respect and trust among team members.
This is that tipping point that we all encounter. We sometimes feel that we are forced to make a choice between:Quitting because we can’t take it anymore and we start to believe we cannot make a differenceCommitting to make it betterIgnore it and hope it goes away– or at least try to until we give into 1 or 2
Say:So, to summarize, a Trusted Co-worker, colleague or friend is Always a team player Respectful and responsive, that means timely or the opposite of a procrastinator Understanding, an empathize with what you are going through Safe—Not prone to overreact or judge you with extreme prejudice, you can share with confidence that it will “go no further” – not prone to gossip Talented– skilled in facilitating collaboration and agreement Executes– When given something to do, you can be sure it will be done and done well. Dedicated – Another word for this is faithful
1. The Leadership Challenge – Kouzes and Posner p. 268 “ If we could offer one bit of advice on how to start the process of creating a climate of trust it would be this: be the first to trust. Building trust is a process that begins when one party is willing to risk being the first to open up, being the first to show vulnerability, and being the first to let go of control” 2. Blink, Malcolm Gladwell– p.119-”Trust means allowing people to operate without having to explain themselves constantly enables rapid cognition.” Collaboration is the key to trust
We are building on the concept of trust and collaboration to move into the next set of tools, Mutual Support.Balancing the workload requires trust, Trust that you can give responsibilities to others, and they can handle it without being overwhelmed and trust that there will be no compromise in care or safety.
But have you ever had a problem getting the support you need when you need it? How many times in your home life, with your kids or at work do you or people you work with seek out assistance and don’t seem to get it.Have you asked yourself “do they just not hear me or do they just not care?”How do you take your passion or “Righteous indignation” and make it contagious, drawing others into your cause?We are about to work on a tool for that. Many of you may have seen before if you came to the 2008 Fall Council meetings.
Please Use CUS Words but only when appropriate!We are now going to watch a video clip of the CUS tool in action.DO: Play the video by clicking the director icon on theslide.DISCUSSION:• How was the “challenge” presented?– In the form of a statement, “I am concerned …” and thenfollowed up with additional patient vitals.– The nurse was uncomfortable with the late decelerations– She became concerned and uncomfortable that thepatient’s safety may be at riskAnother way:Some healthcare providers are spelling Cus with two U’s I’m Concerned…I’m Uncomfortable...This is Unsafe...I’m Scared..
Have an idea of how many in the group there are (i.e. if 30, have them count off 1-15 twice) then have them pair up in twos. Can be done with playing cards eg. If you have 2-26 people use half the deck 13 red and 13 black. Hand them out randomly and have them find the other opposite colored matching card. Just be sure you do not have cards that do not match. The facilitator can set this up in advance.Pairs are given a situation to CUS one to anotherPairs will practice as the cus-er and swap to be the cus-eeDebrief- Did it seem the point of the problem was grasped the first time? How about the second time, did the cus-ee feel like their attention was more drawn to the cus-er? Are there times you could have used this at work or at home in the last few months?Situations do not need to be detailed: Notice bald tires on family car Notice a display of can goods at the grocery store that seems a little unbalanced for your 4 year old to be near it and you want to tell the manager One of your residents seems to be in pain and is not sitting still in her wheelchair You notice a frayed wire on a lamp in a new resident’s room You notice that the pills you remember giving Mrs. Jones was a different color than the ones you just received from the pharmacy You notice that every time Mrs. Smith’s daughter is visiting, Mrs. Smith’s bed is all the way up when your policy is to minimize restraints and all beds are to be lowered to minimize the injury if a resident falls, you need to talk to Mrs. Smith’s daughter. You notice the Mr. Albert is in bed with a wet sheet that extends up his back, he is very overweight and you need to change his sheets but you need someone’s assistance if you do not want to hurt yourself. It is shift change and you are the CNA assigned to Mr. Beckle. He is acting differently from the last time you had his assignment and you are not sure this is normal. Your 15 year old has just gotten her learner’s permit and you are driving down a disserted road a little out of control
Some things to consider when communicating:• The audience—How might your interaction with a lab technician be different from that with a physician?• The mode of communication—Verbal, non-verbal, written, email• Standards associated with the specific mode of communication (e.g., use of "do not use" abbreviation as prescribed by JCAHO) – Non-verbal communication requires verbal clarification to avoid making assumptions that can lead to error. The simple rule is, "When in doubt, check it out, offer information or ask a question.“• The power of non-verbal communication—The way you make eye contact and the way you hold your body during a conversation are signals that can be picked up by the person with whom you are communicating, although powerful, nonverbal communication does not provide an acceptable mode to verify or validate (acknowledge) information.
ASK:• What are some barriers to communication that can lessen theeffectiveness of teams?SAY:Challenges may include:• Language barriers—Non-English speaking patients/staff poseparticular challenges• Distractions—Emergencies can take your attention away fromthe current task at hand• Physical proximity• Personalities—Sometimes it is difficult to communicate withparticular individuals• Workload—During heavy workload times, all of the necessarydetails may not be communicated, or they may becommunicated but not verified• Varying communication styles—Healthcare workers havehistorically been trained with different communication styles• Conflict—Disagreements may disrupt the flow of informationbetween communicating individuals• Verification of information—Verify and acknowledge informationexchanged• Shift change—Transitions in care are the most significant timewhen communication breakdowns occur
Whatever you want to do is fine – Complacency/Apathy You need to run that up the chain of command, have you spoken to your supervisor? – Hierarchical You are just a CNA,get the nurse to call me –Professional Standing We always do it this way – Conventional Thinking We will get around to it later – Time/Fatigue/Workload Why do you ask? No one ever told me that –DefensivenessCan you think of any other signals? How about at home? With your teenagers?
What causes medical errors? The Joint Commission, which accredits the majority of hospitals in this country and some nursing homes and other facilities, analyzes the root causes of sentinel or critical events. Miscommunication is the most common cause of patient injury or death. Some forms of Structured Communications that address one of the most problematic areas is handoffs and how SBAR applies along with Closed Loop Communications to assure that the message was received.
HANDOFF CommunicationSAY:Key Forces Driving Handoff ChangesPatient HarmJCAHO timelineOpportunity to design handoffs based on quality and safety principlesSAY:JCAHO NPSG 2E requires facilities to implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions. The rationale is stated by the Joint Commission: “The primary objective of a handoff is to provide accurate information about a patient's/client's/resident's care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a handoff must be accurate to meet patient safety goals.”A proper handoff includes the components listed on this slide.• Responsibility—When handing off, it is your responsibility to know that the person who must accept responsibility is aware of assuming responsibility.• Accountability—You are accountable until both parties are aware of the transfer of responsibility.• Uncertainty—When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before the transfer is completed.• Communicate verbally—You cannot assume that the person obtaining responsibility will read or understand written or nonverbal communications.• Acknowledged—Until it is acknowledged that the handoff is understood and accepted, you cannot relinquish your responsibility.• Opportunity—Handoffs are a good time to review and have a new pair of eyes evaluate the situation for both safety and quality.
Say:Interactive communications: questions between giver and receiver of informationInclude up-to-date information regarding care, treatment, services, condition, recent or anticipated changesSome observed handoff strategies used to enhance effectiveness includeFace-to-face verbal updates with interactive questioningLimiting any interruptions during update
Say:Interruptions limited (to prevent information loss) and sufficient time allocated for handoff process Require verification process: repeat-back or read-back as appropriateReceiver has opportunity to review relevant historical data, including previous care, treatment, servicesIn Summary, the best most effective observed handoff strategies include:Face-to-face verbal updates with interactive questioningLimiting any interruptions during updateAdditional updated information from teammates (other than one beingreplaced)Topics initiated by oncoming as well as outgoingLimit initiation of operator actions during update (wait until after handoff)“Check-back” to ensure that information was accurately receivedInclude outgoing team’s stance/opinion toward (oncoming’s) changes to plans and contingency plans
SBAR (Pronounced S-Bar) is a formalized method of communicating with other healthcare practitioners that is sweeping the country. Its use is spreading within hospitals, and may soon become so commonplace that it will be recognized as close to, if not a standard of care. SBAR was developed by Kaiser Permanente of Colorado, and has been increasingly adopted by hospitals through the United States. SBAR is used to report to a healthcare provider a situation that requires immediate action, to define the elements of a hand off of a patient from one caregiver to another, such as during transfers from one unit to another or during shift report, and in quality improvement reports. Liability issues may surround the communication that occurred in any clinical situation, but particularly when unexpected changes in a patient’s condition occur. It is often difficult to determine what the healthcare prescriber (physician, physician assistant, nurse practitioner) was told. An inexperienced or fatigued nurse may omit specific important information. One of the goals of SBAR is to provide a structure for such communication. The elements of SBAR are explained below and applied to contacting a prescriber.http://www.medleague.com/Articles/medical_errors/sbar.htm
CHECK-BACK IS… CommunicationSAY:A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.Typically, information is called out anticipating a response on any order which must be checked back.Example:• Information call-out “BP is falling, 80/48 down from 90/60.” The sender expects the information to be verified and validated and to receive a follow-on order that must be acknowledged with a check-back.DO: Play the video by clicking on the top director icon on theslide.DISCUSSION:• Identify the sender and receiver?– Pharmacist was the sender– Resident was the receiver• How did the sender and receiver “close the loop?”– The doctor says “Correct”.• What communication errors were avoided?– Pharmacist did not rely on memory to give correct dosing information– Resident wrote the exact dosing instructions to avoid dependence on memory and was able to check-back using notes since the dosing was more complicated by dilution – Similar sounding drugs errors as well as dosing units of measure errors are avoided using this tool
Give a quick rundown of what they were taught todayRemind them of Sue Sheridan's experience and challengeIf time, ask them to share any experiences with any of these tools or tools that were presented in the Fall of 2008.Let them know, they can make a differencePrepare them for the challenge on the next slide.