SEPTEMBER 2013

Patient Safety Partners With Security

At Brigham and Womens Faulkner Hospital, we have both a Patient Safety Committee as well as a Safety Committee that meets on a monthly basis. The task of each group has some overlapping goals in terms of creating a safe environment within the hospital and using the analysis and trending of incidents to prevent future incidents from occurring. Ashley N. Ditta, Director of Police, Security, Safety and Parking, and Kelly Mitchell, Patient Safety Specialist decided that from a process improvement standpoint, it would be ideal to align and aggregate similar data in the rL Solutions database with the Security database. They now meet monthly to review all safety and security incidents to ensure they are properly represented in both databases as necessary. In addition, the Safety and Security, Patient Safety, and Risk Management departments began meeting on a monthly basis to discuss concerns related to safety for patients and staff. Both have been instrumental in reviewing past incidents in order to create process improvement strategies for prevention. The group reviewed both data sources. Ditta noted that the number of potentially violent persons reported in the security data base is increasing in all areas of the hospital, which is consistent with local and national trends. However, despite this increase, the number of restraints remains relatively at. This is illustrated well in the data from the Emergency Department, (see graph) which appears to reect the de-escalation skills of the Security and Nursing teams who are able to mitigate potentially violent persons often without the application of restraint. The monthly meeting serves to ensure that any restraint that is reported in the security system is reported in rL solutions and vice versa to ensure consistent and quality reporting. Ditta expressed her own patient safety message, mentioning that she is dedicated to protecting the patients as well as staff here at BWFH. Ditta added, I am eager to continue utilizing this data to identify our highest risk areas so we can mitigate those risks and keep BWFH patients, staff, and visitors safe and secure. The Security, Patient Safety, and Risk Management departments monthly meeting allows for in-depth analysis of data and the ability to work together towards process improvement strategies for all of BWFH.

New Falls Safety Precaution Measure

The Patient Safety Department utilizes data from our safety reporting system, rL Solutions to identify problems and then propose possible solutions. A recent example of this chain of events occurred when a patient fell on one of the medical units. The patients PCA was helping the patient pivot to the commode. When the patient stood, her PCA noticed that her sock had become turned around and was placed with treads on the top of her foot and the smooth sock surface on oor. The PCA tried to prevent the patient from slipping, but ultimately resorted to lowering her to the oor to avoid an injury. A team of nurses and PCAs brought the patient back to bed safely and implemented additional fall precaution protocols. Following this incident, the team reviewed the contributing factors. The team believed that this fall could have been prevented had the non slip treads of the socks been properly in place on the patients feet. In working to prevent similar falls in the future, Nursing collaborated with Materials Management to nd new socks with treads on both top and bottom to prevent sock alignment related problems. The Products and Technology committee readily approved the alternative two sided tread sock to support patient safety and prevent falls. Analysis of all the details of a safety event can be used, as in this incident, to nd contributing factors and potential solutions to prevent reoccurrence.

EDITORs: Christi Barney, RN, Director of Quality Improvement, Patient Safety, Accreditation, Infection Control Kelly Mitchell, Patient Safety Specialist

Follow @FaulknerHosp for #PatientSafety Updates!

We will be trending #PatientSafety on Twitter to keep you updated on the latest Patient Safety initiatives at Brigham and Womens Faulkner Hospital. Check out an interesting perspective from Health Affairs: Seven Policy Recommendations to Improve Quality Improvement. Check it out here: http://healthaffairs.org/blog/2013/05/22/ seven-policy-recommendations-to-improve-quality-measurement/

Scanning the Decks: Patient Safety Walk Rounds

Patient Safety Walkrounds are designed as a tool to connect senior leadership to patient safety and reinforce the importance of safety within an organization (Frankel et. Al 2003). Approximately twice a month, Chief Operating Ofcer Michael Gustafson and Christi Barney make a tour of an area within the hospital to meet with staff to hear directly from them about patient safety issues and safety concerns. In Quarter 1 of 2013, they toured the ED, GI, Radiology, Lab and OR areas. In Q2 of 2013 they visited PT, 6 South, Pharmacy, and also met with the staff of Patient Transport and Environmental Services. Often they hear about team work and safe practices on these tours. The Patient Transport staff for example, were very complimentary in describing how staff of many disciplines, but particularly nursing staff, work together to help move a patient from a stretcher to a bed on the inpatient units. They noted the collaborative teamwork and the respectful communication between the healthcare members. They also identied a potential safety concern. They noted that sometimes patients who were waiting for transport back to the units might be waiting on a stretcher in a hallway. The patients sometimes were left with the stretcher in the high position used for the test/exam and the brakes were not locked. They voiced concern that if the patient tried to get off the stretcher in this scenario, the patient could easily slip and fall as the stretcher moved out from under them. Following this Patient Safety Walkrounds, a reminder to keep waiting patients on stretchers in the low position with brakes locked was sent to leaders in the areas where the staff had observed this problem. The information was then relayed to the staff of the areas. This is a powerful example of staff identifying a potential safety issue before an incident occurred. In the language of Patient Safety reporting, this is near miss or good catch reporting where potential problems are identied and then corrected before ever impacting a patient. Identifying problems before they impact patients is an important aspect of robust Patient Safety Culture in a high reliability organization. Hospitals have worked to incorporate best practices from other industries where safety is consistently implemented. On Naval Aircraft Carriers, the entire team is empowered to speak up about safety and to work together following specic patterns to ensure uniformity and safety around complex tasks. Prior to aircraft taking off from the ight deck, the team forms a human chain and they scan the decks for any small material that could alter a safe takeoff or landing of a plane. At BWFH we are working together to scan the decks for anything that could potentially disrupt safe patient care. Walkrounds are a tool to identify concerns and nd good catch ideas to improve safety. * Frankel, A., E. Graydon-Baker, C. Neppl, T. Simmonds, M. Gustafson, and T. K. Gandhi. 2003. Patient Safety Leadership Walkrounds. Joint Commission Journal on Quality and Safety 29 (1): 16-26.

Patient Safety Proles: Joe ODay

This month we would like to recognize Brigham and Womens Faulkner Hospitals Director of Pharmacy Services, Joe ODay for his commitment to patient safety. As co-chair of the Patient Safety Committee at BWFH, ODay not only works to promote patient safety in the pharmacy, he leads discussion surrounding patient safety issues in all areas of the hospital. Christi Barney, Director of Patient Safety noted, Joes passion for the safe care of our patients shows in his tireless efforts to improve system issues. He actively seeks to implement best practices around medication safety at BWFH. From left to right: Chief Operating Joes advocacy for safe IV Ofce Michael Gustafson, MD, pump design impacts the MBA, Lab Director Frank Giacalone, BWFH patient daily, but Joe ODay, and Chief of Pathology also pushed our vendor Stephen Pochebit, MD. to create a safer product. He cares about the broad design of safe patient care as well as the safety of each individual patient. Recently, ODay received the Susan Bezanson Patient Safety Award which is presented annually to a BWFH staff person who demonstrates superior levels of excellence and the same dedication to patient safety and quality assurance that Bezanson herself exhibited.

Patient Safety Award Winner

A Patient Safety Award was presented to Sam Koroma this month. Koromas recognition of a patient safety issue serves as a true example of the culture of safety that we strive to achieve here at BWFH. Mr. Koroma is a food service worker who works in the dish room at BWFH. Mr. Koroma noticed some dinner trays that were being returned from the units carried unused thickening agent packages. He recognized that these thickening agents are vital for our dysphagia patients who have difculty swallowing and run the risk of aspiration when plain liquids are ingested. This group of patients are on special nectar thick or honey thick diets. He brought his observations and concerns to Sue Langill, Director of Food and Nutrition. The Nutrition team investigated further. It appeared that when the patient trays were brought to patients bedside, there was a brief gap before the nursing team could come in and mix the thickening agent for patients on this special diet. Some hungry patients were going ahead before the nursing staff could assist with the thickening agents. The Dieticians evaluated several options and decided that the safest course would be to thicken all liquids prior to leaving the kitchen. Sam Koroma exemplies the true meaning of patient safety at BWFH. He understood that at the heart of all that we do, in every job location at the hospital, we are thinking about the best care and safety of our patients. We are proud to award him with a Patient Safety Award for his efforts.