Patient Safety Observations | Safe Surgery Initiative | TeamStepps | Bar-code Medication Verification | Engagement | Additional Safety Initiatives
“To do good and to do no harm” is the foundation of medical ethics. As we provide quality care, we take reasonable measures to protect patients against harm. National studies estimate that:
- More than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries10.
- One in 20 patients contract hospital-acquired infections11.
- Medication errors12 harm an estimated 1.5 million Americans each year, resulting in about $3.5 billion in extra medical costs.
Texas Health Resources is committed to the health and safety of our patients. We work tirelessly to refine our practices, reduce risks, and promote a safe treatment and healing environment, while aligning our patient safety goals with the goals of The Joint Commission.13
Identifying Opportunities for Improvement
It is Texas Health’s philosophy to continuously improve. Our patient safety program is designed to reduce patient injuries and improve performance.
Patient Safety Observations
We turned to a unique resource to help develop the patient safety observation program: nuclear power engineers. After all, few are better qualified to monitor and manage exceptional safety risks. They advised that to achieve optimal performance, our clinicians must pause and consider each action they take when interacting with a patient.
Each quarter, trained staff observers monitor how often staff appropriately use hand hygiene, identify patients correctly and assess patient needs using checklists before procedures or surgery. These observations help us identify best practices and opportunities for improvement, which are then shared with board members and hospital leaders.
Additionally, we conduct weeklong observations every other year in each hospital to assess communication, medication safety, fall safety, and other patient and environmental safety practices.
Safe Surgery Initiative
The Safe Surgery Initiative calls for clinical teams to take a timeout immediately before surgery to confirm patient identity, the procedure to be conducted, location of surgical site and any unique patient needs.
Today’s complex medical care requires high-functioning teams. Teamwork is created through purposeful communication, training and leadership, and is sustained through shared knowledge, skills and attitudes.
Beginning in 2011 every wholly-owned Texas Health hospital implemented TeamSTEPPS,14 a nationally recognized program to strengthen teamwork and communication among health care workers. Since implementing this program, communication failure has dropped from being the top contributing factor to serious medical error to sixth.
We also ensure caregivers understand patients’ medical history and treatment plans to better deliver safe and quality care. We are achieving this by:
- Implementing electronic health records and other technology to enable caregivers to securely review patient records remotely or even from a smart device.
- Enabling hospital caregivers to facilitate the transfer of information to other facilities.
- Deploying advanced practice nurses into patients’ homes when a follow-up visit to the physician’s office cannot be scheduled shortly after discharge from the hospital.
Bar-code Medication Verification
Medication administration errors can put patients at risk of adverse reactions or even death. In response, Texas Health Resources implemented a systemwide program in 2011 called Bar-code Medication Verification. This technology helps the clinician know if the right patient receives the right medication at the right dose via the right route at the right time.
All medications are bar-coded either by the manufacturer or by the hospitals’ pharmacy department. Prior to administering medication, caregivers scan the patient armband and then the barcode on the medication. Our electronic health record (EHR) immediately verifies if it is the correct medication. If a discrepancy occurs, the caregiver is alerted so the process can be stopped and corrected. As a result of this technology, medication errors have been reduced by 55 percent at Texas Health.
Another notable EHR-based safety program is an early warning system that notifies caregivers that a patient’s vital signs have changed and attention is needed. These alerts may prevent life-threatening emergencies.
Patients with special needs or with communications impairments may need specialized care or services during their stay to ensure their needs are met. It is critical we identify these during the intake process to deliver appropriate care during their stay and upon discharge.
We deploy both formal and informal methods of identifying patients’ requests and quality of care standards. These vary from discussing treatment plans and ways we can improve, to requesting that our 24-hour interpretation service delivers clear and accurate information to diverse patients.
Health system leaders also make rounds to ensure our caregivers meet communication expectations.
Additional Safety Initiatives
Texas Health takes additional precautions to protect patients from harm. We:
- Assess skin breakdown and intervene to prevent pressure ulcers.
- Implement evidence-based practices to prevent central line infections.
- Identify why and where falls occur, as they are the most frequent cause of patient injuries while in a hospital.
- Review and administer influenza and pneumococcal vaccinations.
- Require annual influenza vaccinations for all Texas Health employees.
- Reduce elective inductions15 before 39 weeks gestation to reduce pre-term births and improve perinatal care.
- Reduce hospital-acquired infections or dangerous blood clots.
- Use smart pumps for intravenous administration of medications and fluids, which provide an added level of safety. They work together with bar-coded medication verification to avoid serious human errors.
These patient safety initiatives have helped us achieve internal targets on our safety goals16.
10 According to the National Patient Safety Foundation.
12 According to the Institute of Medicine’s July 2006 report, Preventing Medication Errors.
13 TJC’s 15 National Patient Safety Goals are designed to ensure safer care and better patient outcomes. The TJC independently assesses how well health care organizations adhere to its goals, and accredits and certifies those that do.
14 Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based program developed by the U.S. Department of Defense, with research and education provided by the Agency for Healthcare Research and Quality (AHRQ).
15 Aligns with the March of Dimes prematurity campaign, and our own commitment to reducing low birth weight babies, c-sections and medical expenses in this setting.
16 According to the U.S. Centers for Disease Control. The 2012 national average for positive patient identification is not available.