FINAL SUMMARY REPORT 1

Final Summary Report

NURS 4242

Bon Secours Memorial College of Nursing

Kamari Parris, RN

April 1, 2018

“I Pledge…”
FINAL SUMMARY REPORT 2

Final Summary Report

The purpose of this project is to improve the patient safety practices in the Emergency

Department (ED) by educating the staff on the importance of releasing sign and held orders on

patients who are being held in the ED as inpatients. Sign and held orders can be defined as an

order that the physician has written in the electronic medical record, but has not been released by

the nurse. Sign and held orders are only written once a patient receives an inpatient status. In

order for these orders to be seen or carried out by the nurse, they must physically be released so

that they are displayed on the electronic medical record. The reason this project is being

conducted is because it was communicated by the nurse educator at St. Mary’s Hospital that staff

are forgetting to release these orders. Studies have shown that by developing and maintaining a

culture of safety, you are less likely to experience adverse events that result in harm (Farmer,

2016).

The culture of the ED and inpatient nurse is already strained by the sometimes rocky

handoff from ED staff to the floor nurse and this addition to that stress is not a positive

reinforcement for their relationship (Farmer, 2016). Staff members are forgetting to release

orders for patients who are being held in the ED as inpatients. The result of this includes, but is

not limited to, an increase of delay of care which has the potential to lead to serious negative

patient safety events. Some examples of safety events that took place due to sign and held orders

not being released are: an EKG was missed, a troponin was not completed and finally, an entire

order to prepare a patient to have surgery was missed. Although these omissions didn’t cause

harm to the patients, they have the potential to if this is done repeatedly.
FINAL SUMMARY REPORT 3

This issue could be improved because nurses in the ED are not ordinarily accustomed to

having to do this in their practice and neither are float pool nurses. These orders are not

normally released until patients have reached inpatient status. Therefore, ED and float pool

nurses are having to change their scopes of practice to accommodate the increasing amounts of

ED holds. Patients have suffered delays in receiving important test or procedures which then

result in an extension in their length of stay.

The improvement to be implemented is an awareness and reduction of nurses forgetting

to release sign and held orders in the ED. The week prior to this study, there was an average of

2-4 occurrences per week of missed sign and held orders. A PSDA cycle was completed the

during the first week of April to organize, plan and implement this process. Being a nurse that

doesn’t necessarily belong to a particular unit was a barrier that was encountered prior to this

process, and it made it difficult to have full access to the area of concern. Another issue that

was faced was this is not a “reportable” action so the only way to measure a decrease in this

issue is by counting the number of days in between occurrences. Other topic specific barriers

include an increase in the inpatient census, staffing shortages, patients being held in the ED for

an extended amount of time and the lack of visual reminders to release these orders. Lastly, the

nurse educator provided some information to help shed some light on the capacity of the number

of patients that are being held in the ED. For the month of February, the total volume that was

seen in the ED was 3,919 patients; from that number, 1,034 were admitted; 855 were held in the

ED and of those holds 5,211 hours were spent holding them. In addition to patients being held as

inpatients and risking the occurrence of safety events, the hospital was also placed on diversion

for a total of 8 hours and 32 minutes in February (Smith, 2018). The ED is known for being a
FINAL SUMMARY REPORT 4

fast paced environment that is efficient but is at high risk for the development of mistakes so it is

important that we take time to address this problem (Farmer, 2016).

The implementation plan included making my nurse manager aware of the issue and

having her educate the float staff on the importance of releasing these orders through an email

reminder. Secondly, six visual reminders were made and posted in the ED to remind staff to

release sign and held orders on inpatients. In addition to this implementation, the following

questions were answered to further grasp the issue at hand: What are the average number of

holds projected to be in the ED per week? What are the reasons why these orders are missed?

How many non staff nurses are floated to this unit on a weekly basis? What is the best way to

ensure compliance amongst staff?

Some useful background information to consider about the ER environment that was

studied is : 1) the average number of patients that were held in the ED during this cycle was 20;

2) reasons staff gave for these orders being missed were physicians not making the decision to

admit patients in a timely manner, staff being selective on which orders they chose to release

based on the importance, and staff not being educated on how to care for an inpatient; 3) the

average number of non-permanent nurses that were floated to the ED for the week was between

5 and 6. After polling staff and the nurse educator, it was determined that the best way to ensure

compliance of releasing sign and held orders was through continued education, continuing to

support staff and giving them the resources to perform these orders.

In conclusion, the expected outcome was partially met, which resulted in an increase in

the culture of safety in the ED. There was only one occurrence of a missed sign and held order

at the completion of the cycle. There was a decrease in the average number of missed orders so

there was an increased awareness made which will eventually lead to an increase in throughput
FINAL SUMMARY REPORT 5

of the patients held in the ED. One thing that could strengthen this project is if a second PDSA

was completed and focused on a way for physicians to alert nurses when they have transitioned a

patient from ED to an inpatient.

FINAL SUMMARY REPORT 6

References

Farmer, B. (2016). Patient Safety in the Emergency Department. Emergency Medicine,48(9),

396-404. doi:10.12788/emed.2016.0052

Smith, K. R., RN, MSN. (2018, April 1). Barriers to releasing sign and held orders [E-mail
interview].