Safety Rounds in Ambulatory and Inpatient Settings Wednesday, October 25, 2006 12:00 1:00 p.m. EDT

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Safety Rounds in Ambulatory and Inpatient
SettingsWednesday, October 25, 20061200
100 p.m. EDT
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• Moderator
• Uma Kotagal, MD, MBBS, MSCE, FAAP
• Vice President for Quality and Transformation
• Director, Center for Health Policy Clinical
  Effectiveness
• Cincinnati Childrens Hospital Medical Center
• Cincinnati, Ohio

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This activity was funded through an educational
grant from the Physicians Foundation for Health
Systems Excellence.
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Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME
Activities Grid

• The AAP CME program aims to develop, maintain,
  and increase the competency, skills, and
  professional performance of pediatric healthcare
  professionals by providing high quality,
  relevant, accessible and cost-effective
  educational experiences. The AAP CME program
  provides activities to meet the participants
  identified education needs and to support their
  lifelong learning towards a goal of improving
  care for children and families (AAP CME Program
  Mission Statement, August 2004).
• The AAP recognizes that there are a variety of
  financial relationships between individuals and
  commercial interests that require review to
  identify possible conflicts of interest in a CME
  activity. The AAP Policy on Disclosure of
  Financial Relationships and Resolution of
  Conflicts of Interest for AAP CME Activities is
  designed to ensure quality, objective, balanced,
  and scientifically rigorous AAP CME activities by
  identifying and resolving all potential conflicts
  of interest prior to the confirmation of service
  of those in a position to influence and/or
  control CME content. The AAP has taken steps to
  resolve any potential conflicts of interest.
• All AAP CME activities will strictly adhere to
  the 2004 Updated Accreditation Council for
  Continuing Medical Education (ACCME) Standards
  for Commercial Support Standards to Ensure the
  Independence of CME Activities. In accordance
  with these Standards, the following decisions
  will be made free of the control of a commercial
  interest identification of CME needs,
  determination of educational objectives,
  selection and presentation of content, selection
  of all persons and organizations that will be in
  a position to control the content, selection of
  educational methods, and evaluation of the CME
  activity.
• The purpose of this policy is to ensure all
  potential conflicts of interest are identified
  and mechanisms to resolve them prior to the CME
  activity are implemented in ways that are
  consistent with the public good. The AAP is
  committed to providing learners with commercially
  unbiased CME activities.

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DISCLOSURES
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DISCLOSURES
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DISCLOSURES
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CME CREDIT

• The American Academy of Pediatrics (AAP) is
  accredited by the Accreditation Council for
  Continuing Medical Education to provide
  continuing medical education for physicians.
•  
• The AAP designates this educational activity for
  a maximum of 1.0 AMA PRA Category 1 Credit.
  Physicians should only claim credit commensurate
  with the extent of their participation in the
  activity.
•  
• This activity is acceptable for up to 1.0 AAP
  credit. This credit can be applied toward the
  AAP CME/CPD Award available to Fellows and
  Candidate Fellows of the American Academy of
  Pediatrics.

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OTHER CREDIT

• This webinar is approved by the National
  Association of Pediatric Nurse Practitioners
  (NAPNAP) for 1.2 NAPNAP contact hours of which
  0.0 contain pharmacology (Rx) content. The AAP
  is designated as Agency 17. Upon completion of
  the program, each participant desiring NAPNAP
  contact hours should send a completed certificate
  of attendance, along with the required recording
  fee (10 for NAPNAP members, 15 for nonmembers),
  to the NAPNAP National Office at 20 Brace Road,
  Suite 200, Cherry Hill, NJ 08034-2633.
•  
• The American Academy of Physician Assistants
  accepts AMA PRA Category 1 Credit(s)TM from
  organizations accredited by the ACCME .

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• Featured Speaker
• Kathy N. Shaw, MD, MSCE, FAAP
• Chief, Division of Emergency Medicine
• The Childrens Hospital of Philadelphia
• Philadelphia, Pennsylvania

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OBJECTIVES

• Upon completion of this activity, participants
• will be able to
• Describe the process and explain the rationale
  for senior leader-driven Safety Rounds in
  ambulatory and inpatient settings.
• List the types of safety issues identified on
  Safety Rounds, and distinguish similarities and
  differences between safety issues in ambulatory
  and inpatient settings.
• Select and apply at least one strategy to ensure
  issues identified on Safety Rounds are
  efficiently and effectively discussed with all
  appropriate individuals and improvements are
  implemented.

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The Childrens Hospital of Philadelphia Emergency
Department Unit-Based Patient Safety WalkRounds

• Kathy N. Shaw, M.D., M.S.C.E.
• Chief, Division of Emergency Medicine
• Professor of Pediatrics at CHOP
• University of Pennsylvania School of Medicine
• The Nicholas Crognale Endowed Chair
• in Pediatric Emergency Medicine

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Purpose of WalkRounds

• Mechanism for communicating with staff
• about safety issues
• Signal staff on the front lines that there is
• commitment to a culture of safety
• Foster open communication and
• a blame-free environment
• Gather ideas to take action to make
• a safer work place

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Unit-based PSWR

• Stakeholders vs. visitors
• Ubiquitous vs. sporadic
• Rapid response and dissemination
• of information vs. not . . .

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When Unit-based PSWR

• Minimum of 2 times / month
• All days of the week
• All times of the day

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Participants Unit-based PSWR

• Team leaders
• PEM attending / 2 RNs
• Staff Participants
• Resident
• ED nurse
• Clerical staff
• Social worker or Child Life therapist
• Respiratory therapist or Radiology tech
• Environmental Services or ED tech

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Where Unit-based PSWR

• CQI in patient care area of the ED (15-20 min)
• Group meeting in the ED conference room (15-20
  min)

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Tool Kit Unit-based PSWR

• Step by Step Guide to Conducting PSWR
• Quality Improvement Indicator Tools
• General Questions for Group Discussion

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ED Based CQI Activities

• 4 team members complete CQI tools in ED
• Clinical observations
• Interviews with staff / parents
• Review of chart, electronic tracking and
• ordering system

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Quality Improvement Tools

• 1. Accuracy of weight and allergy documentation
• RN or tech joins PSWR
• Appropriateness of patient monitoring
• and alarm parameters / central monitoring
• RN joins PSWR
• 3. Reasons for prolonged ED length of stay 3
  hrs
• Resident joins PSWR

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Quality Improvement Tools

• Accuracy of medication orders, administration,
• and documentation
• ED RN or MD joins PSWR
• 5. Compliance with hand washing
• RN joins PSWR person from Environmental
  Services identified to complete room check part
  of QI
• 6. Patient / family communication (directed at
  patient/caregiver)
• Clerk or Social Work / Child Life or RN join PSWR

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Conference Room Discussion

• Review purpose of PSWRs
• Open-ended general questions and discussion
• with 5 individuals chosen from clinical area
• Discussion / information is reported without
• identifiers to an individual

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General Questions for PSWR Participants

• In your last few shifts, have you experienced any
  near misses that almost caused patient harm but
  were avoided? Have you noticed any incidents
  that actually did result in patient harm?
  (please describe)
• What should be done to encourage reporting of
• near misses events?

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General Questions for PSWR Participants

• Based on discussion of near misses, please
  provide suggestions on how we could improve the
  safety of patients in our ED.
• Have you developed any personal practices to help
  
• you prevent making errors in the ED?
• If you could fix one thing in the ED to make it a
  safer
• place for patients, what would it be?

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PSWR Follow-up

• Multidisciplinary team meets twice per month
• - Reviews latest PSWR data and IRs
• - Follow-up report generated regarding issues
• observed, resolution, and who is accountable
• Dissemination of ideas / results to staff

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Our Experience(First 9 Months)

• 20 Unit-based PSWR
• 30 on weekends,
• 65 on evenings / overnights
• 99 staff members participated

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Lessons Learned

• 20 aborted and rescheduled
• Orientation and Communication are Essential
• General each group of constituents
• Individual leaders prior to PSWR

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Discoveries and Actions

• Numerous issues identified
• Action items involved
• - Multiple services
• - Education of staff
• - New policies and procedures
• - Occasional quick fixes

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Patient / Family Communication Tool

• Systems Issue
• Families could not identify staff roles
• Solutions (unit-based)
• Dry erase board in each room
• with providers names
• Bedside report and rounding

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Hand-Washing Tool

• Systems Issue
• Lack of alcohol hand-rub in each room
• Solutions (multiple services)
• Environmental Services
• Environmental Health and Safety
• Purchasing

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Monitoring and Alarms

• Systems Issue
• No standard for initiating CR mentoring
• Lack of age-appropriate alarm parameter
• Inaudible alarms
• Solutions (unit-based and hospital-wide)
• Standards established
• Mandatory education on age-based parameters
• Biomedical engineering to increase alarm volumes

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Patient Safety Discussion

• Systems Issue
• Staff unclear as to when or why to complete
  incident reports tattling vs. identification
• and prevention
• Solutions
• Staff communication (emails, meetings)
• Emphasis on systems issues and solutions
• Praising near-miss reporting
• Feedback on PSWR / IRs monthly

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Medication Near-Miss Incident Reports
Rate per 1000 ED Patients
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Conclusions Unit-based PSWR

• Inspire staff to participate in making their unit
  safe
• Identify multiple issues not reported
• by usual practice
• Lead to multiple systems improvements
• to improve patient safety

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Further Information

• Creating Unit-based Patient Safety Walkrounds in
  a Pediatric Emergency Department
• Kathy N. Shaw, MD, MSCE
• Jane M. Lavelle, MD
• Kelly Crescenzo, RN, BSN, CEN
• Jacqueline Noll, RN, BSN, CEN
• Nancy Bonalumi, RN, MS, CEN
• Jill Baren, MD
• Clin Pediatr Emerg Med, December, 2006, Elsevier,
  Inc.