Patient Safety Awareness Week March 8–14, 2020

About the Initiative

Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI), seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognizing the work already being done.

Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient’s physical health, emotional health, financial well-being, or family relationships. Preventing harm in health care settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe health care. IHI promotes addressing patient safety within the public health framework. (Source: IHI.org)

Memorial Hospital would like to take time during Patient Safety Awareness week to share a few internal efforts to promote patient safety throughout the year.

Memorial Hospital Fall Management Program

The Memorial Hospital patient fall management program continues to be successful in reducing patient risk of fall, and mitigating risk of harm from falls or near falls. Memorial patient fall rate reached an all-time low of 1.6/1000 patient days in 2018. In 2019, the rate increased to 3.4. However, the post fall injury rate decreased, with 63% of patient falls resulting in no injury, and no major injuries reported as a result of fall. The continued goal remains zero harm from falls, which the Memorial team demonstrated progress toward in 2019.

Pharmacy Performance Improvement Study of Smart Pump (Guardrail) Utilization Continues to Steadily Improve – Thereby Increasing Medication Infusion Safety

Like many hospitals, Memorial Hospital has invested in "Smart Pumps", which are infusion pumps with Dose Error Reduction Software (DERS). This software gives clinicians the ability to identify the medication to be administered to the patient, use the smart pump software to control concentration and dose rates, and alert the clinician to potential under and over doses of fluids and drugs. Smart Pumps can increase patient safety and reduce costs, but only if clinicians choose to use the Smart Pump software, and if appropriate systems are in place to support safe infusion therapy. Memorial Hospital's pharmacy department conducted a performance improvement study of Smart Pump utilization to evaluate the extent to which this important safety mechanism (Guardrails) is being consistently used. Utilization was determined by review of Guardrails usage reports. The study demonstrated use steadily increased from baseline, improving to over 95% within 6 months of initiating the study.

Nursing Department Performance Improvement Study Shows Barcode Scanning To Maintain a Culture of Medication Administration Safety Remains High

The Nursing Department conducted a performance improvement study to demonstrate consistency in bedside medication verification by barcode scanning the patient bracelet before administration of medications. The study showed the use of this patient identification work flow remains high among users, increasing to over 95% utilization in January. Such results demonstrate the organization's commitment to adopting a culture that emphasizes patient medication administration safety. Likewise it demonstrates continuous efforts to comply with The Joint Commission National Patient Safety Goal (NPSG) 01.01.01 which requires use of at least two ways to identify patients. Barcode scanning medications and the patient armband is one very important work flow to

assure the right medicine is administered to the right patient. In some situations, such as an emergency, time may not allow for barcode scanning prior to administering a medication. However, in such instances, staff are extra vigilant to follow safe medication administration practices and safe patient identification procedures.

Diagnostic Imaging Departments Adds Arms-Up CT Positioner to Improve Patient Safety and Comfort

The new CT Arms-Up positioning device allows patients to be more comfortable and receive less radiation. No more loosely supported buildup of pillows, risk of IV failure, or shoulder pain.

Arms-Up improves patient comfort and outcomes! This one CT positioning device offers multiple benefits to our patients, including: removable ergonomic pillow for patient comfort, pillow keeps chins out of the lung field to eliminate dental artifacts, dual height bar accommodates different patient sizes.

NEW INITIATIVE: No Pass Zone

What is A No Pass Zone?

No Pass Zone is a new initiative Memorial Hospital will be implementing hospital-wide. The initiative supports service excellence and a culture of safety by empowering employees to take action toward improving the patient and visitor healthcare experience. More information will be released to Department Heads for training staff in their specific roles in the organization. In general, the program empowers employees with the knowledge that ALL Memorial Hospital Employees are expected to never pass on opportunities to respond to patient or visitor needs with regard to the following:

• Attend to patient call lights

• Follow 6 foot rule

• Address trash and clutter in the environment

• Follow hand hygiene guidelines

• Maintain quite, healing environment for patients