Mitigating Adverse Events with Patient Handling Equipment: A Photo-Narrative Project

The VA has invested substantially in a Safe Patient Handling Program at all VA medical centers. Despite the obvious success of this program, there have been adverse events and near misses associated with patient handling equipment. The purpose of this quality improvement project was to document the adverse events with patient handling equipment. VA Facility Champions were asked to take photos that would represent the most important issues related to adverse patient events with patient handling and movement equipment. They were also asked to write short descriptions of the issue with the equipment. The photographs and brief narrative descriptions of each were discussed in facilitated conference calls with participants and made accessible to the participants via a secure SharePoint site. The summarized results of the photo narratives and those conference call discussions are presented in this article. This preliminary information indicates the need for further study of factors or causes related to adverse events or near misses, as well as preventative actions.

Rugs D, Elnitsky C, Lind J, Powell-Cope G

Keywords: safe patient handling, adverse events, preventative actions, patient safety and staff safety