13.1 Protocol or equipment adjustment

LUMC example

Video review revealed a practice that increased contamination risk during sterile line insertions: providers were placing sterile gloves near the sink before washing their hands. This led to the following iterative improvement cycle:

1. Protocol Adjustment: The protocol was revised to prohibit using the sink area for sterile gloves. This change was communicated to the team.

2. Observation & Iteration: Subsequent video reviews showed the practice persisted, indicating a need for further intervention.

3. Reinforcement: The protocol adjustment was reiterated through a team newsletter.

4. Success: Follow-up video reviews demonstrated adherence to the revised protocol, confirming a sustained improvement.

Key Takeaway: Video review offers a powerful tool to identify areas for improvement, implement changes, and evaluate the effectiveness of those changes in a continuous cycle.