ALWAYS Making Patient Safety a Priority

The cardiothoracic intensive care unit at Lenox Hill Hospital, Manhattan, New York, reported 6 “never events” from January through June 2021: 3 pressure injuries, 2 falls, and 1 occurrence of Clostridium difficile. To address this problem, the nurses of the Clinical Scene Investigator (CSI) team focused on implementing systematic nurse-led rounds to reduce patient harm, using the acronym ALWAYS (Airway, Lines, Walking, Alarms, whY the lines, Skin). The CSI team designed a rounding tool that could be adapted to a variety of patient populations and was easy for novice nurses to use.

The CSI team introduced the new approach to rounding during daily huddles. The team members also incorporated information about nurse-led rounds during nursing orientation to establish an expected culture of safety in the unit. In addition to nurses, the unit’s physicians, physician assistants, and patient care assistants were also introduced to the program.

By incorporating an adaptable...