Things That Work: Patient Safety Walk Rounds

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Things That WorkPatient Safety Walk Rounds

• Marlene R. Miller, M.D., M.Sc.
• Karen Frush, M.D.

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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

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The Hopkins Experience
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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

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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

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next patient will be harmed by 4 vials
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New Products
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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

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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

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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

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The Duke Experience
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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

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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

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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

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Identifying Problems Whats the Next Thing To
Harm a Patient?

• Medication safety
• PICU - expired syringes
• PBMT late medication delivery
• Home Health pump labeling

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Identifying Problems Whats the Next Thing To
Harm a Patient?Medication Safety
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Identifying Problems Whats the Next Thing To
Harm a Patient?

• Environment of care
• Patient security
• Unrestricted access
• Hazardous environments

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Identifying Problems Whats the Next Thing To
Harm a Patient?Environment of Care
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Identifying Problems Whats the Next Thing To
Harm a Patient?

• Patient identification
• ID bands
• Name changes

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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

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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

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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

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Next Steps

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