Quality Tool- 10 Patient Safety Tips for Hospitals

We are all familiar with the term “medical errors.” They can happen at any point, anytime, and are all too common in hospitals. The quality tool I selected this week, 10 Patient Safety Tips for Hospitals, addresses key areas that hospitals can tackle to help prevent or reduce medical errors.

The tool discusses some common tips that we all might think of, for example, access & improve patient safety cultures, build teamwork, limit shifts for hospital staff, and use reliable decision-support tools at the point-of-care. We should be familiar with those tips; however, one of the tips I found to be interesting was to prevent central line-related bloodstream infections by following 5 procedures including washing your hands, using full-barrier precautions, cleaning the skin, avoiding the femoral site, & removing unnecessary catheters. The hospitals that followed these tip and these procedures reduced deadly infections to zero, in a study of 100 hospitals. For me, this was a shock that following what seemed to be basic steps could save that many lives. It is scary to think that hospitals are causing patient deaths because they do not want to “wash their hands” before placing a central line.

Some other suggestions were to make good use of senior ICU nurses. This is a great idea because they have the most experience and they should be able to take the lead on providing proper care. Other tips were to set up a safety reporting system and to minimize unnecessary interruptions. It is important that medical workers keep their concentration when preparing medications or doing other procedures. The smallest distraction could mean the life or death of a patient.

Most of the tips in this tool we probably already know, but a lot of people tend to take caution for granted. Experienced health care providers probably think that they do not need these tips because they have been doing it for years, but I believe you can never be too careful when dealing with people lives.

http://www.ahrq.gov/qual/10tips.pdf

Meeting Minutes: Just the Facts & Classmate Pick of the Week

Meeting Minutes: Just the Facts

We all know that keeping complete and accurate minutes is an important legal obligation to any organization. The article that I selected this week discussed why certain types of information should or should not be included in organizations minutes. I have been in many different clubs and organizations and have seen a variety of styles when it comes to taking notes. I found it interesting that there are four basic types of information that should be included in minutes. For example, time, date, & location of the meeting; document whether proper prior notice of the meeting was given or that the notice was waived by those attending the meeting; who was in attendance (can be the names of people or the number of attendees); and the official actions taken during the meeting including any motions that were approved or defeated. Another thing that was interesting to me was that it is recommended not to include the names of those making or seconding a motion. If the minutes are brought up in a legal proceeding, this could help potential plaintiff’s find “friends” and “foes.” I was unaware of this because most of the meetings I have ever seen list those making or seconding a motion. Most people are not educated on the proper way to take minutes and this could be beneficial or damaging to an organization. Also, it is recommended not to document detailed debates that happen during meetings. The example in the article explains this point clearly.

• “Your group decides to sponsor a fall carnival. You debate in detail the activities to be included at the carnival & their safety. Unfortunately, a child is hurt on the moon bounce. The parents sue, saying the organization knew or should have known of the dangers.”

If the group’s minutes documented their debate over safety, this could work against them. Yes, you might think that they should be responsible, as do I, but in the real world organizations go to any length to cover themselves from liability. There was one other suggestion that I found interesting-- to follow the agenda when taking minutes. For every item on the agenda, there should be a matching item in the minutes. If everyone followed these tips, or the CRAF method that we learned in class, they would have minutes that could serve as a legal document without the worries of damaging information.

http://www.ptotoday.com/pto-today-articles/article/220?tmpl=component&layout=print


Classmate Pick of the Week- Brainstorming Do’s & Don’ts by Tammi

This week I choose to read Tammi’s blog, Brainstorming the Do’s & Don’ts. I can relate to the tips in this article. When I was in Phi Theta Kappa and other organizations, we used brainstorming at weekly meetings and in class discussions. Tammi’s point about, “quantity is more important than quality,” is true. We use to have ideas thrown out that seemed ridiculous, but one of those ideas actually lead to us winning state, national, and international recognition. So when you are in a brainstorming session remember to keep an open mind. Anything is possible if you put your mind to it.

JCAHO Sentinel Alert: MRI Accidents & Injuries and Classmate Pick of the Week

Joint Commission Alert Shines Light on Preventing MRI Accidents, Injuries

The article that I choose this week was published by the Joint Commission on the potential for sentinel events associated with MRIs. This was particularly interesting to me since I received an MRI this summer, and I was clueless of the harms. The article mentioned that there are more than 10 million MRIs performed annually; and of those, the FDA has received over 400 complaints in the last decade. This might seem like a small number, but of those, more than 70% of the accidents were burns and 10% were injuries resulting from metal objects such as ink pins, cleaning equipment and oxygen canisters, which act as missiles when drawn in by the magnetic pull of the MRI machine.

It is the caregivers’ duty to obtain a complete history from the patient prior to the MRI to ensure that they can be safely be scanned. When I went in for my MRI, I was given a lengthy form asking anything from did I have implanted devices to if I had any tattoos. The Joint Commission published a list of recommendations in this Sentinel Event Alert to help reduce the risk of MRI injuries. Some of them include: take precautions to prevent patient burning during screening, never run a cardio-pulmonary arrest code or resuscitate a patient in the MRI room, only use fire extinguishers and oxygen tanks that have been approved for use in a MRI room, and use trained screeners to double check the patients for metal objects, implanted or other devices, drug delivery patches or tattoos. The goal of this alert was to bring attention to the risks associated with MRIs to the nation’s health care organizations. Yes, it is their responsibility to make sure the patient is safe. But, I believe that it is also the patient’s responsibility to be aware of the dangers. You cannot always trust that your caregiver is being completely honest with you, as much as we might like too.
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_02_15_08.htm

Classmate Pick of the Week- The Sorry Work! By Netty

This week I choose to read Netty’s article entitled, The Sorry Works! Coalition: Making the Case for Full Disclosure. I completely agree with Netty in that the issues surrounding medical errors needs and should change. It is sad to know that physicians try to act like the victims, when in reality the patient is the victim. It was interesting to learn that there is actually a method for this, the “deny and defend” method. Patients’ come to healthcare facilities trusting that they will be given the best quality treatment. It is discouraging to a patient knowing that their caregivers could make a fatal mistake causing the patient their lives. I think that some legislation should be undertaken to address these issues.

Quality Tool

The quality tool I selected this week was Nutrition Care Alerts: Warning Signs & Action Steps for Caregivers in Nursing Facilities. Its focus was on the proper nutrition of nursing facility residents, and it provides warning signs and the proper steps the caregivers should take, if needed. This tool was designed to be used every day for every patient suffering from unintended weight loss, dehydration, pressure ulcers, & complications from tube feedings.

This tool is very user-friendly and could easily be applied in different settings besides nursing facilities. It breaks each condition down by warning signs and action steps for the nursing assistant and other members of the care team. The main action step for each condition for the nursing assistant was to report their observations & warning signs to nurses & the dietitian. This is important because if the nurse, who sees the patient daily, does not report the warning signs then the problems cannot be avoided.

Under the section for pressure ulcers, it recommends using the action steps for dehydration, as well as unintended weight loss. To me this is a positive aspect of the tool because if you train the staff on the warning signs & action steps they can be used interchangeably with each condition. It also recommends sharing this guide with coworkers, friends, volunteers, and the resident’s family members. This would allow for everyone to know the signs and what to do if needed to maintain and/or improve the patient’s health.

http://www.ahca.org/quality/care-alert/care-alerts.pdf