$25,000 Award

Project Overview

Gaps in processes related to invasive bedside procedures can lead to patient harms and other safety challenges, including central line insertion complications (e.g. retained guidewires, infections), mislabeled or lost specimens, inadequate supervision of proceduralists, and inconsistent timeouts. Our multidisciplinary project team aims to target these gaps though a pilot program on bedside procedure expected standards of care using interprofessional education (IPE) didactic/skills lab and a safe procedures in-service education cart. The emphasis will be on the use of standard operating procedure (SOP) for a variety of different bedside procedures. 

Project Team

  • Jason Custer, MD, Director of Patient Safety
  • Nikia Herold, MSN, RN, CCRN, Patient Safety Coordinator
  • Margaret Murphy, MBA, Program Manager
  • Emma Lima, BSN, RN, CCRN, Patient Safety Coordinator 
  • Maureen Archibald, MS, RN, Director of Clinical Education and Professional Development
  • Carolyn Harris, MSN, RN, Clinical Practice and Professional Development Coordinator
  • Benjamin Neustein, MAT, Paramedic, CHSOS, Training and Simulation Manager

June 2022 Updates

We have successfully onboarded our Pilot Units, CCU and SICU, and continue to meet regularly with Unit Leaders as we develop our education plan and auditing tools. Our team has trained 5 Interprofessional Unit Instructors with 2+ more to be trained. We are preparing to launch our frontline staff interprofessional education.

Our full go-live with auditing tool will be ready to begin September 1, 2022.

Project Outcomes

The team successfully created and published hospital policy and standard operating procedures (SOP) to address a standardized bedside procedure process. The team created SOP checklists for best practices, trained unit-based interprofessional leaders and frontline staff members, and completed retrospective chart reviews to audit for timeout documentation compliance.

Training and implementation of the SOP have shown significant results. The team plans on integrating the SOP into routine education for new staff, as well as adding to clinical documentation.

The project and outcomes were proudly presented at the 2022 Maryland Critical Care Conference. This project was also submitted to the Maryland Patient Safety Center in consideration for the 2023 Minogue Awards.

Chart showing how often a Timeout is completed before every procedure

Chart showing how often Debrief is completed after every bedside procedure