Apathetic and aloof with an unlit cigarette tucked behind her ear, "Nurse Nasty" sat in jeans with her MP3 player, not wanting to be bothered. Unfortunately, her frightening attitude directly reflected what was going on inside the room which, by strict nursing standards, was nothing short of a nightmare.

Step Inside If You Dare

Step inside and you find an unresponsive patient whose chart says he had a below-the-knee amputation, but in reality both legs were amputated. His armband does not match the name on his chart, which is open for all to see. His oxygen has run out, but he still has the mask on. IV fluids are expired. His call bell is too far for him to reach. And while he is on fall precautions, his bed is unlocked in a high position without side rails.

How many patient safety errors can you spot in Beebe Medical Center's Room of Horrors?

But that's not all. Electrical cords snake across the floor. A urine specimen sits uncovered, and uncapped needles, garbage and dirty gloves are scattered about. The bathroom is "absolutely horrific," according to one nurse who refuses to go into details because it's too painful for her. Plus, a shriek-inducing cockroach has taken up residence in the room.

Yet the most alarming finding may be the feeding tube inserted into the patient's arm, noted Celeste Daigre, BSN, RN, case manager at Beebe Medical Center in Lewes, DE.

Can This Be for Real?

Scary and surreal? Yes. Thankfully, it's not real. Daigre and more than 100 others who were equally shocked and horrified were taking part in a recent simulation activity at Beebe Medical Center. (A smaller-scale activity was first held June 19 at the Rehoboth Beach, DE, Tunnell Cancer Center facility).

This "Room of Horrors" was the brainchild of the Periodic Performance Review (PPR) team, responsible for monitoring Joint Commission National Patient Safety Goals (NPSG) and developing programs to educate staff about NPSG. Using NPSG as a guide, the PPR team created the patient room with specific examples of violations to patient safety like infection prevention, patient identification, fall prevention, medication safety and safety-risk identification.

How It Worked

Through e-mail announcements and flyers, every hospital staffer was invited by the PPR team to walk through the room and jot down as many things as possible that were wrong or unsafe in 5 minutes. For those who couldn't attend that day, a PowerPoint presentation was created, viewable on the medical center's intranet.

"We wanted to stress that while a lot of education is mandatory we can actually make it fun, have a good time and learn something," said Corey Esposito, MPA, BSN, RN, clinical education specialist at the medical center and in charge of the Room of Horrors.

Nurses were encouraged to visit the room during their shift while managers covered patients. When those nurses returned, they in turn covered patients for other participating nurses.

While nurses were allotted only 5 minutes in the room, there was a lot to digest with nearly 70 errors in practice, safety or infection control in the scenarios. No one was penalized for not spotting everything, but those who did well received prizes like gift baskets and gift certificates to local eateries. Awards were handed out for both the clinical and nonclinical staffer who found the most mistakes in the room or in the PowerPoint presentation.

"They had a blast," said Esposito. "We always see the big picture but sometimes don't notice the finer details, so it was an opportunity to improve our skills. And it was a fabulous opportunity for staff to come together."