Things That Work: Patient Safety Walk Rounds

1. Things That Work:Patient Safety Walk Rounds Marlene R. Miller, M.D., M.Sc. Karen Frush, M.D.

2. 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 won’t result in change.” www.ihi.org

3. The Hopkins Experience

4. Children’s Center Safety Rounds • Every Wednesday 10:00 AM (since 2003) • Every Tuesday 10:00 AM (since 12/2004) • Covers all Children’s 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

5. 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 >60%

6. “next patient will be harmed by 4 vials…”

7. New Products

9. 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 P&T Committee to place Zofran in all Recovery Rooms

11. 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

12. 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 >150 immunizations a week) • Worked with JHH, pulled needle from CC, substituted new safety needle, no further problems

14. The Duke Experience

15. 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

16. 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

17. Safety Walk Rounds • Initiated in Children’s 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

18. Identifying Problems: What’s the Next Thing To Harm a Patient? • Medication safety • PICU - expired syringes • PBMT – late medication delivery • Home Health – pump labeling

19. Identifying Problems: What’s the Next Thing To Harm a Patient?Medication Safety

20. Identifying Problems: What’s the Next Thing To Harm a Patient? • Environment of care • Patient security • Unrestricted access • Hazardous environments

21. Identifying Problems: What’s the Next Thing To Harm a Patient?Environment of Care

22. Identifying Problems: What’s the Next Thing To Harm a Patient? • Patient identification • ID bands • Name changes

23. 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”

24. Impact of Safety Walk Rounds • Concern raised during walk rounds with Chief Patient Safety Officer and hospital executives • Other departments experienced similar issues • RCA: > 3000 potential entry points to change name • Required IT, Medical Record solution

25. 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 Children’s Safety/Quality Core Team

26. Next Steps • Expansion to Health System level • Academic medical center • Community hospital • Clinics • Incorporation of patients and families • “You’re the generalist, I’m the specialist”