Our Dedication to Improving Patient Safety: Next Steps
October 12, 2010
As our staff and medical staff have come together in forums to discuss the recent patient safety incidents, they have shown their commitment to improve patient safety at Children’s and expressed heartfelt support for their colleagues.
As our staff and medical staff have come together in forums to discuss the recent patient safety incidents, they have shown their commitment to improve patient safety at Children’s and expressed heartfelt support for their colleagues. Forum participants have also given voice to questions that are on all of our minds: How will we prevent the recurrence of these recent incidents? How can we prevent human error in a complex environment? How can we fulfill our promise to families to provide a safe and healing environment?
These are not easy issues for any hospital to solve. However, Children’s is tackling them head on. Teams from throughout the organization are dedicating their time to review and analyze patient safety policies, procedures and practices. They are tasked to implement plans to improve patient safety now and ensure that patient safety remains our highest priority in the future.
“Our leadership team remains committed to supporting all of our clinicians and staff and continuing to shape an environment that enables us all to provide safe care and do our best work,” said Dr. David Fisher, medical director at Children’s.
“We are making progress on the promise we made to our patient families and community to do whatever it takes to overhaul our systems to increase patient safety,” said Fisher.
The following efforts are underway:
Clinical staff forums: More than 2,500 doctors, nurses and other clinical staff have participated in forums to review our medication administration, verbal order policies and to provide input about patient safety. And several hundred non-clinical staff have also contributed ideas through forums.
Family forums: As you know, Children’s embraces the concept of family-centered care and considers families to be members of the care team. Their involvement is critical to our efforts to improve patient safety. Preliminary feedback from the family forums is being used in our ongoing improvement efforts – including choosing a date for our Patient Safety day that is least disruptive to families.
Seeing Things Firsthand: Several teams are currently out visiting various clinical areas to identify themes related to recent safety incidents. Combined with the knowledge gained from the family, clinical and non-clinical staff forums we will develop plans that help us sustain improvements long-term.
Patient Safety day: Children’s is holding a Patient Safety day on Saturday, Oct. 30 where staff and medical staff from all over the hospital will come together to perform a patient safety assessment. Themes identified in recent forums will be used as much as possible to inform this work. We are holding this event on a Saturday to minimize impact to our patients and families. This activity will not affect our ability to provide safe, quality care to our inpatients or others needing urgent or emergency services. Our outpatient clinics and scheduled surgeries will also not be affected.
Institute for Safe Medication Practice: We have hired experts at the Institute for Safe Medication Practice, an independent consulting group, to help us identify areas of opportunity. A team of doctors, nurses and pharmacists from the institute will come to Children’s later this month to begin a two-phased effort. The first phase will involve working with Children’s root cause analysis team to understand the calcium chloride overdose and make recommendations beyond those we have already implemented to prevent the recurrence of this kind of error. The second phase will involve a comprehensive look at medication safety throughout our clinical care areas.
Several themes already identified include:
High risk medications: we want to identify risk in the ordering, preparation and administration of medication and ensure that all required safety practices are followed.
Interruptions: we want to look at the potential impact of interruptions or distractions in our daily work that may affect patient care.
Complexity: hospitals are complex and the patients we see have complex medical conditions. We will work to reduce complex processes and simplify our work whenever and wherever possible.
Policies: there are many policies at hospitals that guide clinical work. We will review elements of our policies including length, terminology, quantity and ease of use. We will also look at the amount and quality of training provided to staff on new policies to see if additional training or simulations should be added.
Communication and hand-offs: in health care settings it is imperative that care teams communicate effectively especially during hand-offs (i.e. sharing information with other providers caring for a patient). We will observe how this is currently being done and implement ways to improve.
Clinical Information Systems: we will review our clinical information systems to determine if there are ways to improve medication safety.
The forums were a great source of ideas for improvement, and the list above is not an exhaustive one of all the themes identified. The analysis, discussion and implementation of process improvements will continue beyond the Patient Safety day in the coming months.
“Our staff show tremendous courage and compassion every day. They provide the best care for our region’s most critically ill patients. Our job is to make sure that we have systems that support our staff by reducing complexity and opportunities for error,” said Pat Hagan, president at Children’s.
A message for members of the media: we understand that members of the media will be interested in the outcome of the Patient Safety day. Our staff need to focus on this important patient safety work and we ask that you respect the privacy of our patients and staff on Oct. 30. We will send an update to media following the Patient Safety Day.
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.