Sunday marked the beginning of National Patient Safety Awareness Week, and many hospitals across the state are going above and beyond to call attention, both inside and outside their organizations, to this crucial healthcare concept.
Adverse events resulting from unsafe conditions and faulty processes continue to plague our healthcare system. According to a 2010 study commissioned by the Society of Actuaries, as many as 7 percent of hospital admissions experience some type of medical injury. Moreover, based on the Institute of Medicine’s To Err Is Human report, medical errors are estimated to cause as many as 98,000 deaths per year, earning the rank as the sixth leading cause of death in the United States, according to data from the Centers for Disease Control and Prevention.
In light of this serious issue, Gov. Mike Beebe, at the request of American Data Network Patient Safety Organization, proclaimed March 4 – 10, 2012, Patient Safety Awareness Week in Arkansas and urged all Arkansans to work together to improve patient care. Click here to view the proclamation (PDF).
Room for Growth
White County Medical Center, one of the inaugural members of Arkansas’ first and only patient safety organization, the ADN PSO, will feature a “Patient Safety Room” to promote Patient Safety Awareness Week. “Patient Safety is something our organization is committed to. This is a fun way to educate our staff and promote this important week,” said Debbie Hare, director of quality, risk and regulatory compliance at White County Medical Center.
The room, Hare explained, will be staged with multiple safety violations to help the staff hone their abilities to spot unsafe conditions. The hospital has invited student nurses from an area school to help stage the room and thereby benefit from this learning opportunity as well.
A mannequin will be set up as a patient. The types of safety violations simulated may include: a missing id bracelet, an incorrect armband on the patient, an IV site unlabeled, an empty hand sanitizer bottle, a raised bed with safety rails down, unlabeled medications, a urinal placed on the over-bed table, a syringe with an exposed needle on the bed, a Foley catheter bag on the bed, or a call light out of reach. Through this exercise, WCMC wants to address as many National Patient Safety Goals as possible. Peggy Turner, assistant vice president and director of nursing, engaged the staff by soliciting ideas for which patient safety errors to highlight.
The nurses, clinical support associates, ancillary and financial staff who come to explore the room will be challenged to identify as many errors as they can observe, and the individuals who discover the most errors in the room will be awarded gift certificates to the hospital gift shop.
Fair is Fair
White River Medical Center plans to hold a Patient Safety Awareness Fair for the hospital staff and the community March 9 – 10. Booths at the fair will address an array of patient safety issues, including:
- Standard and transmission-based precautions;
- Catheter-Associated Urinary Tract Infections;
- Catheter-Related Bloodstream Infections;
- Safe Patient Handling, such as “lift” demos using bags of dog food and rice to simulate a patient’s weight;
- Environmental Services, such as how long it takes various wipes to kill germs;
- Orthopedic Complications;
- Surgical Care Improvement Project;
- Stroke Prevention;
- Distracted Driving;
- Risk Management;
- Worker’s Comp; and
- Healthy Eating.
“White River Medical Center feels this is an awesome opportunity to join in on a national effort to raise awareness related to patient safety,” said Michelle Bishop, nursing director at WRMC. “Even though we talk about patient safety every day in our normal day-to-day functions, we can become complacent to the ‘Why’s’ and our interventions can become ‘just a task.’ Our goal with our fair is to re-engage everyone in the organization about patient safety and provide new information as well as review processes already in place. The fair is just one of many interventions used throughout the year to keep the awareness of safety on the horizon of everyone’s minds. Safety equals outcomes!”
Including the Community
Great River Medical Center in Blytheville and South Mississippi County Regional Medical Center in Osceola will kick off Patient Safety Awareness Week with “Kick Off Competency Parties” on Monday and Tuesday. The parties, focusing on the STOP CAUTI program, will include in-services and check-offs on proper Foley insertion and appropriate reasons/diagnoses for inserting a catheter.
Like many Arkansas hospitals, GRMC and SMCRMC are aiming to design activities that involve every party in the care continuum, which is a main goal of this year’s PSAW theme — “Be Aware for Safe Care.” During the latter part of the week, the hospitals will hold lunch-and-learns for the community regarding national patient safety goals. “This will give us a chance to explain the safety issues that we focus on and how we work to prevent them” said Joanne Sullivan, quality coordinator for two facilities.
Patient Safety Officer Phyllis Dorrough said Baptist Health will post the following information in the facility’s internal publication Connection and on the hospital’s intranet. It will also appear on the flat screen monitors positioned near the elevators closest to the cafeteria.
“NATIONAL PATIENT SAFETY AWARENESS WEEK – March 4-10, 2012
In an effort to raise awareness and encourage the engagement of patients, families, health care providers, and the public, Baptist Health is participating in the 2012 Patient Safety Awareness Week campaign, promoted by the National Patient Safety Foundation (NPSF). Additionally, Governor Mike Beebe has proclaimed this week Patient Safety Awareness Week in Arkansas. This year’s theme: ‘Be Aware for Safe Care’ focuses on the need for everyone to understand the importance of patient safety and to recognize the range of efforts being made to improve health safety in the United States and worldwide. By being aware, we can make Baptist Health the leader of safety in Arkansas.”
“I think participation in Patient Safety Awareness Week is a means of elevating the role of patient safety in overall quality of care,” Dorrough said. “The concept of patient safety as a separate component of quality is rather new. Celebrating this week is an opportunity to engage healthcare professionals, organizations and the public in celebration of this very important but newly focused area in healthcare.”
Retreat To Safety
This year, North Arkansas Regional Medical Center hosted leadership retreats prior to Patient Safety Awareness Week in an attempt to help effect top-down cultural change during PSAW and beyond.
Koby Lee, Director of Education at NARMC, said the hospital invited Dr. Brian Wong, CEO of The Bedside Trust, to be guest speaker for the board leadership and strategic planning retreat held at the end of January. Wong discussed his outlook on patient driven leadership. Over the last 10 years, Wong has helped guide numerous hospitals in effecting cultural change by encouraging modifications in the ways their team members interact and work together in the face of challenge. Hospital administrators and medical staff leaders joined board members for this educational retreat.
The following week the hospital hosted a mandatory, day-long managers’ retreat, during which managers focused entirely on patient-centered care and safety. The hospital’s Values Team served as primary presenters for the managers’ retreat. Their primary tool used to spur discussion was the three-part DVD series titled, “First, Do No Harm,” created by Partnership for Patient Safety (P4PS).
The first video depicted a dramatization of a sentinel event that occurred after multiple opportunities for prevention. Lee explained that she was particularly encouraged by the commentary from nonclinical managers, who were quick to recognize the mistakes being made and how the errors might have been prevented. “The biggest challenge that we’re up against, as managers, is how to get our non-direct patient care folks on board,” Lee said. “It’s important that they understand that when we talk about ‘patient-centered care,’ it involves them, too.”
The second video prompted managers to analyze the hospital’s event reporting process. They were tasked to consider how aware staff members really are of the process and whether they’ve been properly trained so that they can fully participate. One area for improvement that resulted from the impromptu gap analysis was that departments like housekeeping not only needed additional training, but also needed easier access to the reporting system. The team’s solution was to create a common generic reporting code that all members of housekeeping could use to log into the system. By implementing simple fixes like this, the hospital is hoping to see an increase in event reporting, which will provide the data necessary to enhance patient safety at NARMC.
Lee said NARMC’s new CEO has communicated that patient safety is the hospital’s “number one priority.” As part of communicating that goal, the hospital has distributed buttons that simply read “First” to all managers and will soon be distributing them hospitalwide. The purpose of the buttons is to serve as visual reminders to staff and patients that NARMC’s first priority is patient safety.
A Most Important Endeavor
Baxter Regional Medical Center also has a series of safety celebrations planned. The hospital will exhibit the governor’s proclamation along with a photo from the signing ceremony on a large video screen by the cafeteria, which receives the most foot traffic. The hospital team also hopes to have a story about the proclamation run in their local paper and has plans to line the main hallways with patient safety banners.
In addition, Baxter is sponsoring a hospitalwide contest, asking for 300 words about patient safety and how it is practiced in each particular department. The winner for the best entry will receive a $50 gift card to a local restaurant.
“I don’t think there can ever be enough information or promotion of patient safety,” said Karla Rainwater, director of quality at Baxter. “Our first responsibility to patients is to do no harm. Excellent care is safe care and all of our patients deserve excellent care. Anything we do to make our care safer, any way we can do it, is our responsibility and our most important endeavor.”
One of the most important effects of Patient Safety Awareness Week is the the widespread reinforcement of the spirit of shared learning. At ADN PSO, we relish new strategies and tactics for promoting and and enhancing patient safety. And that’s why we want to hear from you. Please share in the comments below or via e-mail to firstname.lastname@example.org ways that your organization works to increase patient safety, whether during Patient Safety Awareness Week or anytime.
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