Patient Safety
On January 16, 2009, the Minnesota Department of Health (MDH) and the Minnesota Hospital Association (MHA) released the fifth annual report of adverse health events that occurred in Minnesota hospitals, ambulatory surgical centers and regional treatment centers from October 7, 2007 to October 6, 2008. The public report is part of a statewide effort to improve patient safety in Minnesota health care facilities. 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 facilities. 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.
This year, new reporting requirements were enacted which significantly increased the number of events reported by hospitals throughout the state.
North Memorial reported 18 events, which are included in the report. We believe that one of these events 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 event from reoccurring. As a result of the law, these plans are 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 some 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
- Refined 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
- 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 special red slippers and have a falling star placed outside their hospital room door to alert staff to the patient's risk of fall. Gait belts are available in patient rooms.
- 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.
- Hourly rounding has been implemented to assure that patients' are toileted, repositioned and have their needed possessions and equipment (telephone, call light, water, etc.) within easy reach.
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
- Preparedness for biological incidents, including pandemic influenza
- Robust safety first reporting system in place
- A response team with emergency code is in place to locate wandering confused patients or other patients who do not have the capacity to leave on their own.
Care Management
- Participation with 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
- Education has been presented on pressure ulcer prevention including identification of high-risk patients and early intervention
- Working with hospital bed manufacturers to determine if improvements in bed design can help minimize occurrence of pressure ulcers
- Evaluating mattresses to assure adequate pressure redistribution
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
Criminal
Preventing Hospital Acquired Infections (HAI):
- Enhanced surveillance for surgical site infection to include all clean surgeries.
- Monitoring of ventilator and central venous catheter bundles.
- House-wide surveillance of catheter-associated bloodstream infections.
- Active surveillance cultures for MRSA in all patients admitted to critical care units.
- Surveillance of ventilator-associated pneumonias on all critical care units.
- Participation in statewide committees addressing MRSA and reporting of HAI.
- Implementation of antiseptic-coated urinary catheter to reduce device-associated, hospital-acquired urinary tract infection.
