For Patients

Patient Safety

On January 17, 2008, the Minnesota Department of Health (MDH) and the Minnesota Hospital Association (MHA) released the fourth annual report of adverse health events that occurred in Minnesota hospitals from October 7, 2006 to October 6, 2007. The public report is part of a statewide effort to improve patient safety in Minnesota hospitals. Legislation was signed into law on July 1, 2003, which created a system for hospitals to report and share information regarding adverse health events at their facility. This legislation was supported by the MDH, MHA and hospitals across the state. The intention and goal of the legislation is for hospitals to share information, allowing implementation of best practices to improve on processes already in place.

North Memorial reported six events, which are included in the report. We believe that one medical error is too many, which is why we have a long-standing policy to conduct a root cause analysis following any adverse health event. This analysis helps determine what happened, why it happened, and allows us to develop a corrective action plan to prevent the error from reoccurring. As a result of the new law, these plans are now being shared with other hospitals so facilities can benefit from each other's learning.

We are committed to the care and safety of our patients and are very concerned about the events that occurred at North Memorial. To create the safest possible environment for our patients, we have implemented numerous patient safety initiatives. Some of these initiatives have been in place for years while other initiatives are ongoing and have just recently been implemented. Examples of these initiatives as they relate to the Adverse Health Event report include:

Surgical

  • Use of two patient identifiers for patient identification
  • Site marking protocols in place
  • Refining surgical count process
  • Staff uses a reporting tool that alerts the team of any potential problems so action can be taken to prevent mistakes before surgery is performed
  • Stop for Safety" protocol implemented and routine audits conducted to ensure we are compliant with JCAHO protocols
  • New audit tools being developed for medication safety, documentation and instrument management
  • Quality improvement teams formed to implement IHI surgical protocols
  • Special clinical practice council created to be involved in patient safety efforts across surgical services
  • Improve printed materials to include all patient identifying information
  • Established a "hard stop" for site marking and final verification. This process stops to assure correct patient, correct procedure and correct site.
  • Enhanced surveillance for surgical site infection to include all clean surgeries

Environmental Events

  • A hospital-wide team including nurses, physical therapists, pharmacists, geriatric nurse practitioners, nurse managers and physicians are working to improve falls prevention in the medical/surgical areas.
  • Special ceiling-mounted lifts designed for moving and transporting bariatric patients have been installed to provide enhanced safety. Additional special lift equipment is available for staff to use throughout the hospital.
  • A fall prevention protocol is used to assess the risk based on medications, mobility, confusion, etc. Patients at risk of falls wear green arm bracelets and have a falling star placed outside their hospital room door to alert staff to the patient's risk of fall.
  • Posey Sitter II: a device used on beds and chairs that senses when the weight of the patient is removed. It can be programmed with familiar music or the gentle reminding voice of a loved one.
  • Regular toileting and availability of walkers and canes if the patient used them before admission. A patient safety video is available for patient and family viewing.
  • We have acquired beds that can be lowered within seven inches of the floor to reduce injury. These beds also have specially designed mattresses that make it more difficult for patients to get out of bed without help.
  • Multiple efforts are in place to reduce the use of restraints and bedrails as restraints. Very specific conditions must be in place before used and many alternatives must be attempted. Physician orders are required for specific time periods and continued assessment and intervention during use is required.

Patient Protection

  • Mother/Baby Unit, Pediatrics, Patient Care Center: North Memorial uses a four-band identification system that requires the mother and the nurse to verify the identity of the infant. Even in cases of adoption, Child Protection, or foster care, the mother must validate with the staff the identity of the infant via the bands.
  • Family-centered care model encourages that infants be with their families for a majority of the time while in the hospital
  • Missing infant/child prevention and alert activation program in place. Drills conducted periodically to test process, staff knowledge level and effectiveness.
  • Surveillance cameras in strategic locations
  • Card accessed doors to Labor/Delivery unit, Mother/Baby Unit, Nursery, NICU and Pediatrics
  • Upgrading of Airborne Isolation Rooms to prevent disease transmission
  • Enhanced surveillance and preparedness for biological incidents, including pandemic influenza
  • Patient Safety WalkAbouts take place throughout the hospital
  • Robust safety first reporting system in place

Care Management

  • Participation with Safest in America and National Patient Safety Goals to reduce medication errors
  • Rapid response teams in place
  • Dedicated teams established to implement IHI safety protocols (part of IHI's "Save 100K Lives" initiative)
  • Standardized IV solution concentrations.
  • Use of "smart" IV pumps.
  • 24 hour pharmacy services.
  • Pharmacists decentralized to the nursing units.
  • Computer maintained medication profiles with printed medication administration records.
  • Pharmacy technology upgrades provide improved drug information availability for health care professionals
  • Additional drug monitoring services available for patients on specific medications
  • Increased access to pharmacy staff, including the addition of a Clinical Pharmacy Specialist in critical care areas of the hospital
  • Drug storage improvements separate high-risk medications, specifically those that sound alike and look alike
  • Drug dispensing machines have been upgraded to ensure access to appropriate medications

Pressure Ulcer Prevention:

  • Specific pressure ulcer prevention protocols have been redesigned and now include specific interventions for high-risk patients
  • Patient care staff use aggressive turning schedules to minimize the occurrence of pressure ulcers
  • Devoted skin teams have been formed to identify patients who may be at risk for developing pressure ulcers and ensure appropriate protocols are followed
  • Staff has adopted set of recommendations for skin protection and pressure reduction when using specialty beds
  • Working with hospital bed manufacturers to determine if improvements in bed design can help minimize occurrence of pressure ulcers

Product or Device

  • Required evaluation of devices and staff education before use. We have an active problem reporting process for any patient care equipment including internal evaluation by our Biomedical Engineering Department and consultation with the nationally known independent biomedical engineering organization, ECRI
  • Response protocols for manufacturer recalls and alerts
  • All explanted devices are returned to the manufacturer
  • Enhanced surveillance of critical care patients for ventilator-associated pneumonia with multi-disciplinary case review
  • New surveillance program for non-critical care patients to detect central line associated bloodstream infection
  • Multi-disciplinary teams have helped create dramatic reductions in ventilator associated pneumonia and in central line associated bloodstream infections for critical care patients
  • Evaluation with planned implementation of antiseptic-coated urinary catheter to reduce device-associated, hospital-acquired urinary tract infection

Criminal
Workplace violence Prevention and Intervention Policy and Procedure has been in place. It includes the development of the Response Team-a team of specialists made up of Security staff, Crisis Intervention Unit nurses, and administrative managers that go to the scene of behavioral disturbances or escalating disruptive behavior. Debriefing and audits are conducted after each activation of the Response Team.