Outline of Patient Safety Huddle

1. Reflection

2. Safety Message/Slogan

3. Announcements

4. Boarding in ED. If yes, what support can we provide you to help resolve this?

5. Psychiatric holds in hospital

o If yes, what support can we provide you to help resolve this?

o What location?

o Is there a sitter in place?

6. Patient Safety Issues/Concerns including:

o Obstetrical

o Perinatal

o Medication Errors

o Falls

o Unexpected deaths

o If yes on a-e, what actions need to occur today from our learning to avoid a re-

occurrence of this issue?

7. Physician Safety Issues/Concerns What actions need to occur today from our learning to avoid a

re-occurrence of this issue?

8. Caregiver Safety Issues/Concerns

What actions need to occur today from our learning to avoid a re-occurrence of this issue?

Does the issue need to be escalated to Employee Health?

9. How many patients have a length of Stay > 4 days (See documentation tool)

10. Delays of Service: What actions need to occur today from our learning to avoid a re-occurrence

of this issue?

11. Code Blue/RRT Was the Code Blue/RRT well run? Are there any learning opportunities?

12. Did you experience any EMR related safety issues?

13. Plant Equipment Issues

14. Foleys (See documentation tool)

15. Central Lines (See documentation tool)

16. Skin Ulcers (See documentation tool)

17. Restraints (See documentation tool)

18. Recognition

Add on themes on specific days:

Tuesday: Review recruitment and open positions

Wednesday: Close the loop on safety issues raised over the week

Thursday: Review of Hand Hygiene, MDRO, CAUTI, CLABSI, SSI, HAPU, Falls

Friday: HCAHPS and Patient Experience

Foley Urinary Catheter Documentation Tool

Date

Unit

1. Please complete:

Please enter a number

2. How many patients do I have on the unit with a foley indwelling urinary catheter?

Please enter a number

3. How many patients were admitted with a foley indwelling urinary catheter with a questionable indication?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Bladder outletobstruction

Critical Ins and OutMeasurements

Urological Surgery/PostOp

Open sacral wound orperineal wound

Comfort for end of life

4. Please indicate the clinical reason for the foley indwelling urinary catheter in each of your patients.

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

Not applicable/ Patientis female

5. Was an external cathter (texas or condom catheter) attempted? If not why?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

6. Please indicate for each patient whether there is a nurse drive d/c protocol in place?

Central Line Documentation Tool

Date

Unit

1. Please complete:

Midline catheter

Peripherally InsertedCentral Catheter (PICC)

Subclavian

2. How many patients do I have on the unit with the following:

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Poor peripheral access

Hemodynamicmonitoring

Plamaphaeresis

VasopressorMedications

Nutrition

3. Please indicate the clinical reason for this venous access for each of your patients.

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

4. How many days has the central line (PICC, midline, sublaclvian) been in place?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

5. Please indicate for each patient whether the dressing was checked today?

6. Please come to the Safety Huddle prepared to discuss the plan to remove the central line if there is noclear clinical indication.

Skin Ulcer Documentation Tool

1. How many patients do I have with:

Skin Ulcers

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

2. Among the patients with ulcers on my unit were any present on admission? Were they documentedappropriately?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Stage 1

Stage 2

Stage 3

Stage 4

3. What was the stage of the ulcer?

4. How many patients do I have AT RISK for skin ulcers?

Skin Ulcers

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Device

Disability/Immobility

Diarrhea/Incontinence

Diet/Poor nutrition

5. Among my patients AT RISK for skin ulcer what are the known risk factors?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Conduct a pressureulcer admissionassessment for allpatients with ulcers or atrisk of ulcers

Ensuring that patientsare clean and dry

Consult the dieticianwhen nutritionalelements contribute torisk

Ensure a reliableprocess for redistributingpressure (e.g., use aturn clock as a reminderto staff, implement turnrounds, pressureredistributing beds andmattresses)

Reassess risk for allpatients daily

6. What intervention did I implement to reduce ulcers in this patient?

Restraint Documentation Tool

1. How many patients do I have on my unit with restraints?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

2. Is there a daily physician order for the restraints written?

Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H

Yes

No

3. Have I tried alternatives like: moving a patient closer to nursing station or having family at the bedside?

4. Please come to huddle prepared to discuss why restraints have to be used for your patient rather than asitter.

30 Day Readmission Documentation Tool

1. Demographics: Name/MRN/ Diagnosis on 1st discharge/ Diagnosis on 2nd Admission

Yes No Comments

Mental health diagnsois

Substance abuse

Showing up in ED threetimes in two months

Polypharmacy >6medications

Leaving against medicaladvice

Patient lives alone

2. Readmission Risk Factors:

Yes No Comments

Did thepatient understandthe symptoms ofthe condition gettingworse?

Was thereadequate teaching topatient's family?

Were writtendischarge instructionsprovided to patient?

Did the patient havea follow up with thePCP arranged in 7 days?if no why?

Did the patient go tothe follow upappointment? If no why?

Did the patient filltheir prescriptions? If nowhy?

3. Were the following documented in EMR during the first admission?

4. What actions do we need to take to prevent another readmission? (i.e. education to patient and family)

Length of Stay > 4 days

1. Name of patient/ Medical Record Number/ Room Number

2. What is the diagnosis?

3. What is the cause for the prolonged length of stay?

Yes No Comments

Medical

Social

Administrative

4. What are the plans to transition the patient when the medical/social/administrative reasons are resolved?

Yes No Comments

Home

SNF

LTAC

Nursing Home

Rehab

Other

5. What support do you need either administratively or clinically to discharge the patient?

Safety Issue

DATE WHO AREA WHAT

Week of:_____________

Hospital Quality Institute Vanguard Award 2016

The Patient Safety Huddle:

One Step on Our Journey to Becoming a

High Reliability Organization

Providence Little Company of Mary Medical Center San Pedro

Address: 1300 West 7th Street, San Pedro, CA 90732

1

Table of Contents

1. Number of reported safety events by category per month for 2nd

quarter 2016

2. 2016 Regional metrics: CAUTI, CLABSI, SSI, C Diff, Falls

3. CLABSI

4. 30 Days Readmission Rate

5. Patient Experience Scores: Inpatient and Emergency

Department

6. Hand Hygiene Compliance 2015

7. Hand Hygiene Compliance 2016

2

Number of reported safety events by category per month for 2nd quarter 2016

April 2016

May 2016

June 2016

Legend

Open = Unresolved

Closed = Resolved

Total = Open + Closed

Regional Metrics:CAUTI, CLABSI, SSI, C Diff, Falls

4

Legend

SSI=surgical site infection

Hyst= hysterectomy

CLABSI=central line-associated blood stream infections

C diff= Clostridium difficile

CAUTI=-Catheter-Associated Urinary Tract Infection

Drill Down – CLABSI Rate / ICU CLABSI SIR 2015

CLABSI RATE / ICU CLABSI SIR

STATUS ACTION PLANS

Legend

CLABSI=central line-associated blood stream infections

SIR= standardized infection ratio

Overall Readmissions

6

Overall Readmissions Ratio (O/E) is calculated as the

ratio of predicted readmissions to expected readmissions

Patient Experience Scores

7

Inpatient Goal 72%

Emergency Goal 56%

Hand Hygiene Compliance 2015 HAND HYGIENE 2015

2016 Hand Hygiene Compliance by month and YTD

Behavioral Health Safety Huddle

Date: ___________________

In Attendance:

1. How many patients are currently on Bridges?

2. How many anticipated discharges today on Bridges?

3. How many male/female beds are available on Bridges?

4. How many anticipated transfers or requests do you have on Bridges from Providence or UCLA?

5. How many behavioral health patients are boarding in 2W/3W/3C/ICU?

a. On 5150

b. With Sitter

c. With medications for agitation ordered

6. How many behavioral health patients are boarding in the ED?

a. Are any anticipated to need admission?

1. Looking Back Past 24 hours

a. Do we have any patients in the hospital with a tendency towards violence?

b. Any patients at AWOL or attempt at AWOL?

c. Patient Safety Events: Code Greys, Injuries

d. Caregiver Safety Events: Assaults/Injuries

e. Administrative Updates: Important Updates, Announcements

f. Have we had to contact any regulatory bodies: APS, Police, CDPH, Social Worker

g. Have we confiscated any contraband items?

h. Has security and risk management been consulted?

i. Has environmental rounds been conducted by nursing and security every 4 hours?

2. Looking Ahead:

a. Any census or staffing issues impacting safety: sitters/nursing

b. High Risk Patients

c. Any safety issues that may impact other departments

d. Deficiencies in equipment, supplies that impact safety

e. Conditions inside or outside the hospital that could impact the delivery of safe, quality

care

3. Follow-up

a. Status reports on issues identified today or days before