Patient Safety Day Strengthens Seattle Children’s Efforts to Improve Medication Safety
October 30, 2010
Over 550 nurses, doctors, pharmacists and staff members gathered to review and recommend immediate and future safety improvements
Link to short video from Patient Safety Day: http://www.youtube.com/watch?v=qejsG0Q0a7s
Seattle Children’s is holding a Patient Safety Day to address concerns that arose after medication errors resulted in two patient deaths over the last 18 months.
“It’s so very important that we never forget that we harmed these children,” said Pat Hagan, president and COO at Children’s. “We were all devastated by this when it happened. It struck us at our core. This has obviously been a great, great tragedy for these families, but it is also a profound tragedy for our staff as well. We never want to forget how this feels. That feeling is going to be what drives us to continue to find ways to improve what we do here.”
Over 550 doctors, nurses, pharmacists and other staff members gathered at Children’s today to participate in more than 28 patient safety sessions (11 devoted to medication safety) throughout the hospital. In addition to other departments, staff participated from the hospital’s Intensive Care Unit, Acute Care Inpatient Units, Emergency Department, Outpatient Clinics, and Research Institute. The event is being held on a Saturday to minimize the impact on patients and families and to allow staff to focus solely on reviewing and improving patient safety. These activities did not affect care for inpatients or others needing urgent or emergency services.
Patient Safety Day participants gathered together in the morning to remember the two patients who died. The hospital’s CEO, Thomas Hansen, M.D., led the opening remarks “How we emerge from this situation today and over the coming months will be the real test of us as an organization. As I look around this room, I’m confident that we have the best and brightest people to rise to this challenge. You want and I want our hospital to be the leader in patient safety, to be transparent, and to share what we learn with our peers to improve care everywhere. Our work today and in the coming months will not be easy but we must strive for zero errors, this must be our promise.”
The day’s sessions included topics such as decreasing verbal orders and increasing the safety of verbal orders when they are necessary, standardizing medications located on care units, ordering, dispensing and administration of high-risk medications, interruptions, provider-to-provider hand-offs and communication, ambulance transport and patient safety training using simulation.
“Interruptions are a challenge in health care and we want to get rid of them,” said Patient Safety Day participant David Fisher, MD, SVP and medical director at Children’s. “Take for example, a nurse checking the five rights of a patient. Right patient, right delivery method, right dose and so on – if that nurse is going through the five rights and you interrupt them, there’s a chance the five rights won’t be done perfectly and it needs to be done perfectly every time.”
“With medication safety for instance, the first step is ordering. The second step is preparing in the pharmacy. The next step is dispensing from the pharmacy or sometimes from a machine we have on the unit if things are needed more quickly. Each of those steps has multiple processes. Each of these steps has risk. We will work to improve all parts of medication delivery,” Fisher added. “Patient Safety Day is just the beginning of the work we plan to do over the coming months and years to improve our systems and processes.”
Many improvements will be designed as a result of Patient Safety Day. However, implementing many changes simultaneously in a health care setting carries its own set of risks. To ensure these improvements are implemented in the safest way possible, Children’s leadership team will debrief with each session group to understand what is needed to make each change. They will then communicate with staff in the affected areas to obtain input. Then the proposed improvement will be tested to ensure it is the right change.
Today’s event will go into the early evening but a preliminary update includes:
Medications stocked on the patient care units: Session participants began reviewing medications currently stored in patient care units with the aim to decrease the number of high-risk medications on the units. The staff also utilized input from the external group (Institute for Safe Medication Practice) that was invited by Children’s to review and recommend improvements.
Use of simulation training to improve medication safety practices: Session participants used established simulation techniques including simulated training sessions with SimBaby/mannequins to practice new procedures to respond to unexpected events. They are recommending that Children’s routinely use more simulation training to help staff learn a new procedure by seeing it in action in a simulation and then practicing it themselves.
Interruptions: Session participants assessed and categorized the type of interruptions that clinical staff experience daily. One recommendation to reduce interruptions is the use of a visual cue that would serve as a “do not disturb” to indicate that they are in the midst of ordering, preparing, or administering medications and would prevent them from being distracted.
When asked what he’d like families in the community to know about today’s event, Fisher, replied, “We are doing what it takes to overhaul our medication safety systems. We are here to help children and their families, and today is just the start. We remain steadfast in our commitment to provide the best possible care to these vulnerable children. Children’s is a safe place.”
In addition to Patient Safety Day and the work being done over the coming months, Children’s is fully cooperating with state investigations of the recent medication errors and has:
- Changed its policy for calcium chloride administration: only pharmacists and anesthesiologists can prepare doses of calcium chloride in non-emergent situations.
- Initiated a reevaluation of the entire medication delivery system
- Launched a detailed root-cause analysis to determine why usual safety processes failed in each of the medication error cases
- Held forums with more than 2,500 staff members to hear concerns and to review medication safety policies to ensure all staff are re-educated and fully familiar with safe medication behaviors
- Engaged an independent team of patient safety experts from The Institute for Safe Medication Practices to begin a comprehensive review of medication ordering, dispensing, and administration.
About Seattle Children's Hospital
Consistently ranked as one of the best children’s hospitals in the country by U.S. News & World Report, Children’s serves as the pediatric and adolescent academic medical referral center for the largest landmass of any children’s hospital in the country (Washington, Alaska, Montana and Idaho). For more than 100 years, Children’s has been delivering superior patient care and advancing new treatments through pediatric research. Children’s serves as the primary teaching, clinical and research site for the Department of Pediatrics at the University of Washington School of Medicine. The hospital works in partnership with Seattle Children’s Research Institute and Seattle Children’s Hospital Foundation. For more information, visit http://www.seattlechildrens.org.