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Things That Work: Patient Safety Walk Rounds

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Things That Work: Patient Safety Walk Rounds Marlene R. Miller, M.D., M.Sc. Karen Frush, M.D. Safety Walk Rounds Organizations improve upon safety only when ... – PowerPoint PPT presentation

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Title: Things That Work: Patient Safety Walk Rounds


1
Things That WorkPatient Safety Walk Rounds
  • Marlene R. Miller, M.D., M.Sc.
  • Karen Frush, M.D.

2
Safety Walk Rounds
  • Organizations improve upon safety only when
    leaders are visibly committed to change, when
    they enable staff to openly share safety
    information, and when staff feel that their
    comments are heard and acted upon. When an
    organization does not have such a culture, staff
    members are often unwilling to report adverse
    events and unsafe conditions because they fear
    reprisal or believe reporting wont result in
    change. www.ihi.org

3
The Hopkins Experience
4
Childrens Center Safety Rounds
  • Every Wednesday 1000 AM (since 2003)
  • Every Tuesday 1000 AM (since 12/2004)
  • Covers all Childrens Center units and outpatient
    clinics and Emergency Dept and Pediatric Pharmacy
  • C9, 8W, PICU, RR, C6, C4, 3E, PCRU, NICU, Peds
    ED, HLPC, Pharmacy, JHOC Specialty Clinics
  • Senior Leaders (Chairman, Chief of Surgery, Board
    of Trustees)
  • Focus on proactive safety concerns

5
Scope Impact of Safety Rounds
  • Total issues/projects 145
  • Active issues/projects 43
  • Completed issues/projects 102
  • Each unit/clinic has 3-5 active issues/projects
  • At first, much low hanging fruit issues are
    more complex now
  • Units now keep lists and wait for us
  • ¾ of units had Safety Climate scores gt60

6
next patient will be harmed by 4 vials
7
New Products
8
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9
Zofran/Anzemet
  • JHH therapeutic interchange made Anzemet first
    drug of choice for nausea
  • It is not uncommon for patient to not respond to
    Anzemet and need Zofran
  • Zofran needed to specially come up from Pharmacy
  • WHAT ABOUT THE RECOVERY ROOM?
  • Worked with PT Committee to place Zofran in all
    Recovery Rooms

10
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11
Safer Outpatient Prescribing
  • No requirement to record a weight on pediatric
    prescriptions
  • Without a weight, an external pharmacy that
    wanted to dose check was powerless
  • Revamped all ambulatory prescription pads to
    include a line for recording weight
  • Required that JHH Pharmacies perform a
    weight-based dose check before dispensing

12
Safety Needles.safer for whom?
  • Entire hospital changed to safety needles
  • HLPC found over several months that 8 25G
    needles had no holes bored
  • (HLPC does gt150 immunizations a week)
  • Worked with JHH, pulled needle from CC,
    substituted new safety needle, no further problems

13
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14
The Duke Experience
15
Tools to Improve the Culture of Safety
  • Voluntary Reporting System
  • Non-punitive reporting policy
  • Team training Crew Resource Management
  • Unit based safety teams
  • Safety walk rounds

16
Goals of Safety Walk Rounds
  • Identify procedures or processes that could put
    patients at risk
  • Identify opportunities to improve care and reduce
    risk
  • Close the gap between leadership and frontline
    perspectives on safety
  • Allow executives opportunities to model safety as
    a priority, provide appropriate resources to
    improve care

17
Safety Walk Rounds
  • Initiated in Childrens Hospital January 2004
  • Included all areas caring for children
  • Intermediate care, ICN, PICU, BMT, FTN, ED,
    Psychiatry, Radiology, CHC (outpatient)
  • Improvement in hospital safety survey noted by
    October 2004
  • Expanded to Duke University Hospital January 2005

18
Identifying Problems Whats the Next Thing To
Harm a Patient?
  • Medication safety
  • PICU - expired syringes
  • PBMT late medication delivery
  • Home Health pump labeling

19
Identifying Problems Whats the Next Thing To
Harm a Patient?Medication Safety
20
Identifying Problems Whats the Next Thing To
Harm a Patient?
  • Environment of care
  • Patient security
  • Unrestricted access
  • Hazardous environments

21
Identifying Problems Whats the Next Thing To
Harm a Patient?Environment of Care
22
Identifying Problems Whats the Next Thing To
Harm a Patient?
  • Patient identification
  • ID bands
  • Name changes

23
Solving Problems Patient Name Changes
  • Safety risk name changes in patients, especially
    from ICN, lead to incorrect radiographic
    study/procedure performed
  • Approximately 40 events in past year
  • Unnecessary exposure to radiation
  • Potential risk of complications associated with
    unnecessary procedure
  • Initial interventions
  • Limited in scope (Peds Radiology and ICN)
  • Policy and procedure focused errors still
    occurring
  • The problem is unsolvable

24
Impact of Safety Walk Rounds
  • Concern raised during walk rounds with Chief
    Patient Safety Officer and hospital executives
  • Other departments experienced similar issues
  • RCA gt 3000 potential entry points to change name
  • Required IT, Medical Record solution

25
The Solution
  • Employees with ability to change patient names
    reduced from 3000 to 10
  • Patient data computer system does not allow
    unauthorized employees to change names provides
    a true hardwired system solution
  • Education for staff, patients, families included
    in process
  • Ongoing monitoring and control
  • Medical Records performs audits of all name
    changes
  • All inpatient name changes are reviewed by
    Childrens Safety/Quality Core Team

26
Next Steps
  • Expansion to Health System level
  • Academic medical center
  • Community hospital
  • Clinics
  • Incorporation of patients and families
  • Youre the generalist, Im the specialist
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