National Nursing Ebook Continuing Education

○ Human resources : Sarah delegated tasks and assessments to all the members of her team that were present during the emergency. ● Situational awareness : Sarah was aware that there was a situation and she needed to be a leader, assigning tasks and anticipatory planning for further escalation (need for evacuation of certain residents). She used data given to her from the team members — the inability to contain the fire and the potential risk to some of the patients located close to the fire – to further her decision-making. Question: What could have been done differently in the above scenario to improve the response to the emergency? Discussion: Areas for improvement based on the different components of CRM: ● Leadership : Sarah realized she was the leader, but she did not explicitly state this to her coworkers, who had varying levels of experience and may not have been aware that the charge nurse assumed leadership during an on-unit crisis. ● Role assignment : Sarah assigned Helen a specific role, and herself the role of getting the fire extinguisher. She should have delegated this to a team member. She did not explicitly state who should call 911 or shut all the patient doors, and her staff responded by all moving to close doors and no one called 911. She also did not assign anyone to pull the fire alarm, which may have alerted internal responders sooner. Without naming a specific person to carry out an important task, the task may not be completed at all or in a timely manner. ● Communication : ○ Closed-loop : Sarah should have used closed-loop technique to ensure her role assignment was conveyed. By making eye contact or asking the person if they understood her ask, the loop would be closed. Any person completing a task must close the loop by stating that the task is completed. Sarah also should have verified, verbally, that someone called 911 if she did not get confirmation from the person assigned. ○ State of the union : If Sarah had done a brief state of the union with her staff earlier, she likely would have realized more quickly there was an evacuation plan for the unit. She should have asked at the end of the state of the union, “Does anyone have anything to add?” Jeanne would have then mentioned the evacuation plan. Cognitive aids : The institution where this fire occurred had a mnemonic tool (cognitive aid) to follow in case of a fire. ○ ● Resource allocation : ○ R.A.C.E. : The R stands for Remove or Rescue. There was no one in the room of the fire to remove or rescue. However, nearby patients and those with respiratory compromise may need evacuation. A is for activation. Sarah did ask for activation – calling 911 – but did not assign someone which resulted in a delay, and she did not assign anyone to pull the fire alarm. C is for contain. Sarah did have Helen contain the fire to the kitchen by closing the door. E is for extinguish/evacuation. The decision that the fire was too large to extinguish was explored and made early. Sarah was in the process of deciding on evacuation when the supervisor arrived, discussing the need to move some at-risk residents with Jeanne and Dotty and remembering and obtaining the evacuation plan (cognitive aid). ○ Equipment : In this scenario, specific equipment that team members would need to know how to use include timely use of the fire extinguisher, knowledge of the different types and when to deploy and use the correct one. The fire was considered too large for a fire extinguisher, but Sarah ran for the extinguisher later in

all stable, and the shift has been uneventful so far. At around 3 a.m., there is a burning odor coming from the kitchen area on the unit. Helen yells out that the coffee maker is on fire and that the flames are all over the table in the middle of the room. She runs into the hall and leaves the kitchen door open. As the charge nurse, Sarah knows that she has a lead role in this emergency and has responsibilities related to fires. She cannot remember the specifics of her responsibilities but recollects that there is a manual on the unit at the nurse’s station that has the disaster plans. As she runs to the desk, the R.A.C.E mnemonic immediately comes to mind. The following dialogue starts among the team: Sarah calls out to Helen : Is the fire small enough to use a fire extinguisher on? Sarah : Can someone call 911? Let’s all shut the patient doors. Jane and Ken start running down the hall shutting doors. Dotty and Jeanne also start closing all the other doors. Sarah runs for the extinguisher. It is another minute before Sarah realizes that the call to activate 911 did not occur. At the same moment, Ken realizes that no one activated the fire alarm and pulls the alarm. Smoke is starting to fill the hallway near the kitchen. Jane : Do you think we need to move the residents in the two rooms near the kitchen? Sarah : I think we might need to. Where do we move them to? Jeanne : In orientation, they told me that there is an evacuation route for each unit, and it should be located at the nursing station. Dotty hears this and runs to get the evacuation plan. The night supervisor arrives after hearing the fire alarm and, realizing that there is a fire, asks what the situation is. Sarah immediately tells the night supervisor that they smelled smoke and Helen noticed the fire in the kitchen. The fire was too big to extinguish, so they closed the doors to all the rooms and pulled the fire alarm. She explains that they were just deciding if they need to move the residents in the rooms near the kitchen and where to move them. Question: What actions in the above scenario would be classified as components of CRM? Discussion: The scenario in the case study included the following components of CRM: ● Leadership : Sarah realized that she was the charge nurse and had a role as leader in situations such as a fire on the unit per the institution protocol. Helen : No, it is all over the room. Sarah : Helen, please shut the door. ● Role assignment : Sarah was aware as the charge nurse/ leader that she needed to make sure that certain roles were filled to complete the necessary tasks. She assigned Helen to close the door to the kitchen, and asked that other tasks be attended too, such as calling 911 and shutting patient doors. ● Communication : ○ Closed loop : Sarah initiated closed loop communication with Helen, asking her specifically if the fire was too large for the extinguisher, and, based on her response, assigning her the additional task of closing the kitchen door. ○ State of the union : Sarah demonstrated a state of the union communication when she filled the nursing supervisor in on what actions had occurred up to that point in a succinct manner.

● Resource allocation : ○

Cognitive aids : Sarah remembered that there were resources available for her to use during this type of emergency. She remembered that there was a manual for fires, the R.A.C.E. mnemonic, and Jeanne mentioned there was an evacuation plan for the unit.

Book Code: ANCCUS2423

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