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Patient Safety Officer2009 Annual Report

Under the direction of the Board of Managers, the Parkland Patient SafetyProgram is designed to identify and manage risks to patient safety with theultimate goal of eliminating preventable deaths and preventable harm that are theresult of medical care.

Though the Department of Patient Safety and Risk facilitates the creation of thisannual evaluation, the responsibility of patient safety belongs with everyemployee and every department. Many of the accomplishments outlined are theresult of clinical and operational leadership from across Parkland Health &Hospital System as well as the daily efforts of the clinicians who directly care forthe patients we serve.

The 2009 Program Evaluation includes both the results of overarching metricsregarding safe outcomes of care along with metrics associated withimplementation of the processes associated with the National Quality Forum(NQF) Safe Practices.

Acknowledgementstothefollowingdepartmentsfortheircontributionsofdatatothisreport:

Clinical Information Services, Data Management and Reporting, Health Information Management,

InfectionPrevention&Control,MedicalStaffServices,OccupationalHealth,Pathology,PatientSafety

&Risk,PerformanceImprovement,Pharmacy

Rev: 02/10/2010

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Table of Contents

Part 1: Safe Outcomes of CareNQF Serious Reportable Events ............................................................... 4Agency for Healthcare Research & Quality (AHRQ)

Patient Safety Indicators .................................................................. 6

Part 2: Selected* NQF Safe PracticesLeadership Systems (SP1) ........................................................................ 8Culture Measurement, Feedback, and Intervention (SP2) ........................ 9Identification and Mitigation of Risks and Hazards (SP4) ........................ 10Disclosure (SP7)...................................................................................... 13Care of the Caregiver (SP8) .................................................................... 14Intensive Care Unit Care (SP11) ............................................................. 14Patient Care Information - Critical Results (SP12) .................................. 15Order Read-Back (SP13) ........................................................................ 16Labeling of Diagnostic Studies (SP14) .................................................... 17Computerized Physician Order Entry (SP16) .......................................... 18Pharmacist Leadership Structure & Systems (SP18) .............................. 19Influenza Prevention (SP20) .................................................................... 20Central Line Associated Bloodstream Infection Prevention (SP21) ........ 21Care of the Ventilated Patient (SP23) .................................................... 23Pressure Ulcer Prevention (SP27) .......................................................... 25Venous Thromboembolism Prevention (SP28) ....................................... 26

Anticoagulation Therapy (SP29) .............................................................. 27Organ Donation (SP31) ........................................................................... 29Glycemic Control (SP32) ......................................................................... 30Falls Prevention (SP33) ........................................................................... 31

Attachments:1. List of Serious Reportable Events (NQF 2009)2. List of Safe Practices for Better Healthcare (NQF 2009)

*There are 34 NQF Safe Practices. 20 Safe Practices are highlighted in the 2009 Patient Safety ProgramEvaluation. Those selected for inclusion are those in which significant improvement activity occurred this pastyear and data exists to evaluate performance.

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Part 1:

Safe Outcomes

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National Quality Forum Serious Reportable Events (NQF SRE)

Why is this important?

The NQF first developed this list in 2003 and subsequently updated it in 2006. The list ofevents is based on the best evidence that they are almost always preventable and shouldnever occur in health care. In the most recent legislative session, Texas joined a growingnumber of states requiring mandatory reporting of never events. The Centers for Medicareand Medicaid Services (CMS) has also adopted many of its Hospital Acquired Conditions(conditions for which they will deny payment) from this list.

How is Parkland doing?

For the past several years, the Patient Safety and Risk department has built an infrastructureto capture internal knowledge of all NQF SRE occurrences at Parkland. Activities included:

Ongoing education for all staff including physicians regarding the need to reportthese types of events

24/7 Availability of both an internet based reporting system and a risk analyst on-call available through the pager system

Surveillance of certain billing codes, patient complaints, and record reviews

Although, the rate of occurrence has remained steady over the past year, it is anticipated thatwith the learnings from these past events and the structural and process improvement effortsoutlined in this report a measurable decline in the occurrence of SRE will be visible over thenext year.

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Analysis of the NQF events that occurred last year indicates that our greatest improvementopportunities are with pressure ulcers, retained foreign objects, and medication errors.(Though healthcare associated infections as noted elsewhere in this report are a significantproportion of our safety events they are not on the NQF SRE list because not all arepreventable.) Each of these events has undergone a formal review process and many of themhave had a root cause analysis in an effort to best learn what happened, why it happened andhow we can prevent it from happening again.

Analysis by patient care process indicates that our opportunity lies within the assessmentphase assessment was the primary root cause of the hospital acquired pressure ulcer cases.

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Agency for Healthcare Research on Quality (AHRQ) Patient Safety Indicators


The AHRQ Patient Safety Indicators (PSIs) utilize readily available administrative claims data

such as coding information to better understand patient safety performance at hospitals. CMShas adopted a number of the PSIs for inclusion in its 2010 Value-Based Purchasing Initiative,with the intent to publicly report performance on these measures. Because the PSIs aredetermined from administrative claims data, performance on these metrics is a reflection of notonly care processes, but also appropriate documentation and coding practices.


Participation in the University HealthSystem Consortium (UHC) Clinical Data Base (CDB) hasallowed Parkland to compare its performance against that of other academic medical centers.UHC currently has 105 members participating in the CDB including 40 members of theNational Association of Public Hospitals. The AHRQ Patient Safety Quality Indicator

Composite is a composite measure using an AHRQ formulation that incorporates performanceon eleven AHRQ PSIs into one metric.

As indicated above, Parklands overall performance on the AHRQ PSI Composite thoughimproving is still higher (higher is worse for this indicator) than the median of the UHCmembership. Internal analysis by a collaborative team with representatives from HealthInformation Management and Clinical Quality Management indicated that hospital acquiredpressure ulcers, prevention of venous thromboembolism, and accidental punctures andlacerations are the top priorities for improvement; the first two indicators a clinical careopportunity and the third is a mixed opportunity (coding, documentation, and clinical care).

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Part 2:

Safe Practices

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Leadership Structure and Systems


Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for thosegaps, adequate investment in performance improvement abilities and activities, and thatactions are taken as necessary to ensure the safe care of every patient.


In 2009 leadership made a number of significant changes that provided necessary supportallowing the continued growth of a comprehensive patient safety program. These changesincluded:

Administrative restructuring to include formation of the Division of Clinical QualityManagement and within it the Department of Patient Safety and Risk.

Alignment of institutional risk management activities with the patient safety program to

eliminate duplication of efforts (event investigations) and to allow for development of aconsistent message to our frontline staff that the purpose of an event investigation isto learn what happened so that we can prevent future patients from experiencing harm.

Creation of the Patient Safety Review Committee, a multidisciplinary leadershipcommittee whose scope includes reviewing significant adverse events and the patientsafety practices designed to ensure safe care.

Formal participation with and reporting to an AHRQ designated Patient SafetyOrganization.

Creation of high level patient safety metrics (number of NQF SRE events and number ofhigh harm events) that are routinely reviewed by institutional medical, nursing, and

operational leadership.

Expansion of the scope of the Patient Care Review Committee, a medical staffperformance body, to include systematic reviews of medical staff performance related toimproving patient safety.

Significant work remains to enhance leadership systems related to patient safety throughout alllevels of both administrative and medical leadership within the organization. Some ofnecessary steps include:

Addressing accountability while preserving the tenets of a just culture that supportssystem learning from events

Effective incorporation of learning from process failures into ongoing care deliverysystem improvement both at an individual nursing unit level as well as at the enterpriselevel

Training of leaders in the principles of clinical process improvement, appropriateinterpretation of data related to process management, and systems theory

Development of role models and mentors regarding effective incorporation of anadverse event response (disclosure, learning, support of the caregiver) into the patientcare process

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Culture Measurement, Feedback, and Intervention


Safe patient care cannot be guaranteed for all patients unless all employees are activelyengaged in ensuring safe care at all times, in other words, unless a culture of safety exists.Just as it is necessary for any other dimension in which one is trying to achieve change,measurement of progress and intentional activities to improve the culture are necessary.


Parkland has administered the AHRQ Culture of Safety Survey every 12 to 18 months for atotal of three surveys. The survey captures questions pertaining to ten dimensions of safetyculture as well as asks staff to give an overall patient safety grade.

As indicated in the graphs above, in comparison to last year (and the year prior, notillustrated), Parklands performance has been unchanged. In comparison to the nationaldatabase, Parkland performs a little worse than average across all dimensions. For the firsttime, formal action plans are being created to try to bring about meaningful change in theseresults.

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Identification and Mitigation of Risks and Hazards


To drive down preventable harm, systematic and reliable approaches to identification andmitigation of risks are required. Identification of risks must come from multiple sources of dataas no one source can provide a comprehensive picture of patient safety in the institution.Identification of risks should be directly linked to prioritization of performance improvementactivities of the organization to ensure true mitigation of clinical risk.


In addition to the NQF SRE and the AHRQ Patient Safety Indicators, the reports in the PatientSafety Net (PSN) are systematically reviewed and analyzed to identify opportunities forimprovement. Work is ongoing with respect to continuing efforts that enhance riskidentification capabilities as well as on the more formal integration of these findings into theannual performance goal setting processes.

At Parkland, reports to the PSN continue to be a rich source of information regarding

improvement opportunities in our patient care processes; reporting rates are consistentlyabove the median for large UHC hospitals. The increases in reporting coincide with GoodCatch games, an initiative designed to encourage reporting of near misses to increase learningregarding opportunities to improve care.

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Reporting of High Harm Events (those safety events that cause harm and either prolongationof hospital stay, need for ICU care, permanent harm, or death) has remained steady over thepast year. Reporting of High Harm Events represents approximately 7% of all reporting to PSN

this means that on a daily basis we harm two patients a day in a significant way.

Some safety events, though a result of medical care, are not preventable by currently knownstandards of care. An example would be the patient that suffers an anaphylactic (a life threatening allergic response) reaction to a medication that he's never previously received.

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Of those High Harm Events thought to be potentially preventable, the largest categories wererelated to procedural complications, coordination of care, and health care associatedinfections. Ongoing improvement efforts (e.g. simulation training for medicine residents,availability of clinical documentation in the electronic medical record, a renewed focus on handhygiene) are directed to decreasing harm to patients.

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Disclosure


Patients expect and deserve timely, transparent, and complete information followingunanticipated serious outcomes including those that are the result of a system failure. Thoughtraditionally disclosure of error has been thought to increase the risk of litigation, multiplestudies have shown the opposite. What most patients want is an apology and the knowledgethat everything is being done to prevent the same error from occurring to someone else.


In December 2008, the Board of Managers approved a policy developed by medical staffleadership supporting a health system stance supporting full disclosure to patients. PatientSafety and Risk staff members are available to support clinicians in this process. Institutionallevel disclosure was performed in one case. Continuing effort is necessary to continue toeducate and support Parkland staff in full disclosure and the resources available. Just inTime educational materials are planned for the Patient Safety intranet site. In addition, efforts

are underway to collaborate with the Ethics Lecture Series for physician training on this topic.

A significant number indicate unknown reflecting that neither the medical record nor therecords of the event review process captured this information. This is significantly increasedfor the NQF Serious Reportable Events because many of these are identified much later afterthe fact through surveillance of coding records.

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Care of the Caregiver


Most adverse events are due to system failures rather than intentional harm or grossnegligence on the part of the caregiver. As a result caregivers directly involved in events

resulting in patient harm often become the second victim. Caregivers can also be traumatizedby the occurrence of an adverse event to someone for whom they were providing care.


By procedure, all reviews of adverse event performed by the Patient Safety and Risk staff areperformed in a systematic fashion to determine what happened without increasing individualcaregiver trauma. Individuals involved in an event are encouraged to participate inimprovement activities to prevent recurrences by sharing their story, sharing suggestions forimprovement, and always being informed of decisions and actions taken to prevent recurrence.In the past year, the procedure was revised to incorporate the participation of a representative

from the Employee Assistance Program (EAP) to be present at debriefings of particularlytraumatic events. Caregivers involved are also educated as to how they personally accessEAP for assistance.

Future efforts will focus on developing frontline manager capacity for support of the individualcaregiver after an adverse event.

Intensive Care Unit (ICU) Care


Patients in the intensive care units are the most critically ill patients in the hospital. Critical

care medicine requires significant expertise given the acuity of the patients and the complexityof the medical treatments and devices now available to save lives.


With the introduction of core privileges for the medical staff this past year, the critical carephysician group adopted privileging standards consistent with this NQF Safe Practice.Specifically, to be privileged to provide care on the Burn ICU service, the Medical ICU service,the Surgical ICU service, and the Neonatal ICU service, the medical staff member must beboard certified in a critical care subspecialty of an appropriate board.

In addition, standard expectations for attending ICU physicians were adopted as outlined in

Medical Staff Procedure: Intensive Care Unit Attending Role and Responsibilities. Theseexpectations address the role of the attending physician regarding:

Communication and coordination of care

Documentation

Supervision of residents

Role in graduate medical education

Schedules

Procedures

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Patient Care Information (Critical Results)


Communication of diagnostic test results critical to a patients care must occur timely so thatclinicians can intervene as appropriate for patients. The Joint Commission has adopted thispractice as a National Patient Safety Goal.


Annually, the Medical Advisory Council approves a list of proposed critical values. Significantchanges were made to the list this past year based upon the work of a physician workgroupthat looked at best practices to clearly define which results are truly critical for patient care.Additional review of the noncompliant charts showed that appropriate interventions were takenin a timely way, suggesting that communication occurred appropriately but was notdocumented.

Ongoing work consists of building flow sheet rows within the electronic medical record tofacilitate documentation of critical results as well as ongoing monitoring of the timeliness ofreporting.

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Read Back


Though verbal orders are necessary to patient care particularly in emergency situations thereis always the risk that they may be misunderstood. To minimize this risk, verbal orders andcritical results are always expected to be written down and read back for confirmation.


Read Back is an expectation in all settings in which either verbal orders or communication ofcritical results occurs. Monitoring of order read back occurs in the laboratory when criticalresults are released to a licensed provider (physician or registered nurse).

As shown, compliance with verbal read back procedures has been consistently high over time.

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Labeling of Diagnostic Studies


Medical treatments for inpatients are often determined by the results of diagnostic tests. Toensure that diagnostic test results are reported on the correct patient, it is critical that allspecimens or studies be correctly labeled. The Joint Commission made correct labeling ofpatient specimens a National Patient Safety Goal.


Correct labeling of specimens continues to be a challenge. To date ongoing efforts haveemphasized the safe practice of labeling at the bedside to minimize the risk for error. Futureefforts will focus in addition on utilization of bar-coding technology to facilitate correct labelingof specimens at all times.

2 to 3 patientsPer day experience

delay in care

Occurrences in 2009 are lower than in past years; however, occurrence rates are still elevated

with significant variation.

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Computerized Physician Order Entry (CPOE)


Given the frequency of medication use and the potential for significant harm if orderedincorrectly, safe ordering of medications is an essential component of a safe healthcaresystem. Correct implementation of computerized physician order entry (a system in which thephysician directly enters orders) eliminates transcription errors due to illegibility, use ofabbreviations, etc. An effective CPOE system is contingent upon proper installation, sufficientphysician training, and ongoing monitoring and improvement.


CPOE was successfully implemented in April 2009 in the inpatient care units. In 2010, theremaining patient care areas including diagnostic areas and documentation of anesthesiaservices will go live. The medical staff has supported CPOE wherever it is available withmandatory training for all physician users. A pharmacy user group as well as multiplephysician user groups monitor its use and makes recommendations for changes as necessary.

The percentage of orders entered by CPOE is very high particularly considering that some

areas of the hospital are still in a hybrid medical record state. (The meaningful userequirement proposed by CMS for the reimbursement incentive program for the adoption ofhealth information technology 80% in ambulatory and 10% in hospital settings of all ordersshould be directly entered.) Since the introduction of CPOE, errors due to misinterpretation ofthe providers request (a previously recurring phenomenon) have been eliminated.

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Pharmacist Leadership Structure & Systems


The medication use process is complex, consisting of multiple phases involving manymembers of the healthcare team. The opportunity for medication errors to occur at any step inthe medication use process is great. According to The Institute of Medicine Report,approximately 7,000 people die each year because of medication errors, many of which arepreventable. The Joint Commission and The National Quality Forum believe pharmacyshould have a leadership role in monitoring and managing the medication use process toassist the organization with reducing the potential for medication errors.


The year 2009 closed with significant improvements being made in pharmacist leadership overthe medication management system throughout the organization. Some of which included:

Establishment of an enterprise wide Medication Use Safety Improvement Committee

chaired by the Pharmacy Director, to review and monitor reports of medication errors.The team identifies and evaluates the effectiveness of medication safety improvementprocesses and communicates trends and improvement opportunities to the medical andoperational leadership and staff.

Initiation of routine reporting by Pharmacy of medication errors in each phase of themedication use process to the Pharmacy and Therapeutics Committee, a Medical StaffCommittee, and to the nursing staff.

Implementation of computerized physician order entry (CPOE) with pharmacist reviewand verification of medication orders prior to medication administration.

Establishment of an Epic Pharmacy workgroup with physician, nursing, pharmacy andIT staff participation to monitor the effectiveness of medication use in Epic andrecommend system improvements.

Pharmacy and Nursing evaluation of the medication administration workflow and riskpoints.

An interdisciplinary approach of evaluating the effectiveness of the medicationmanagement system and changes made throughout the year resulted in theidentification of the top areas for improvements in 2010. Some improvements targeted

include:

o Improve responding and reporting of Adverse Drug Events

o Optimize use of Epic for medication management

o Improve security and storage of medications

o Coordination of care involving medications between inpatient and Jail Health

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Influenza Prevention


Influenza is a seasonal illness that can have serious consequences particularly for the elderlyand the very young. Transmission within the hospital from either patients or employees is asignificant possibility and can be minimized by adherence to Centers for Disease Controlinfluenza prevention practices. One of the most important of these practices is vaccination ofemployees.


Parkland Occupational Health has offered influenza vaccination to employees for many years.New initiatives to improve vaccination rates this year included:

Use of a declination form to document refusal

Publication of employee vaccination/declination rates by division to leadership

Employee Flu Champions

Ongoing efforts to bring the vaccine to employees at place of work

Though influenza vaccination is not mandatory, rates have steadily increased due to activitiessuch as the performance improvement efforts outlined above. Increasing numbers of healthcare institutions are mandating employee influenza vaccination.

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Central Line Associated Bloodstream Infection Prevention


Some patients with catheters placed in their major veins for medical treatments may developinfections with bacteria and fungal organisms central line infections. A large proportion ofthese infections can be prevented by inserting the catheters under sterile conditions,maintaining and accessing the catheters in a clean and safe manner, and removing thecatheters as soon as they are no longer needed. Occasionally central line infections can leadto preventable deaths of patients.


Parkland has implemented a series of evidence based practices known as the central linebundle to prevent these infections. Those practices are:

Appropriate hand hygiene

Use of maximal barrier precautions - sterile draping of the entire patient not just theinsertion site and use of sterile gown and mask by the inserter

Use of chlorhexidine to prepare the site

Avoidance of the femoral site (which predisposes to infections) unless medicallynecessary

Presence of a nurse at every insertion who ensures that all measures noted above arefollowed and intervenes when necessary to protect the patient

The nurse present fills out a checklist documenting compliance with the above measures. Thechart below illustrates the results of those checklists compliance with the bundle though highremains variable.

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As indicated, the overall number of central line infections is significantly lower in 2009. Mostrecent risk adjusted rates by individual type of intensive care unit are lower (lower is better forthis indicator) than the National Healthcare Safety Network (NHSN) mean performance.

Current improvement efforts are focused on daily review of catheter necessity, sterilemaintenance and access of the catheter, and ensuring checklist performance at every insertion

including those insertions performed outside the critical care areas.

NSHN

Participation

Checklist Implementation

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Care of the Ventilated Patient


Patients in the intensive care unit on ventilators are at risk for many complications: ventilatorassociated pneumonia, venous thromboembolism, stress related intestinal hemorrhagicdisease, dentition problems, and pressure ulcers to name a few. To prevent thesecomplications, successful treatment of requires reliable use of evidence based practices.


The adult intensive care units have worked together over the past two years to implement theVentilator Associated Pneumonia (VAP) Bundle: a series of evidence based practices knownto decrease the incidence of complications for patients on ventilators. Current efforts arefocused on strengthening the weaning protocols through the efforts of respiratory therapy careto decrease the time patients spend on a ventilator.

Overall performance of the VAP bundle has been consistent since shortly after initialimplementation. Due to the complexity of their underlying illness (e.g. trauma, hemodynamicinstability) many patients at Parkland are not eligible for the all of the VAP bundle elements the gap in performance noted above is primarily due to medical contraindications.

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VAP Bundle performance on medically eligible patients, though always high has significantlyimproved in recent months. As indicated below, the overall number of patients with ventilatorassociated pneumonia is significantly lower in 2009; recent risk adjusted rates by individualintensive care unit continue to be higher (higher is worse for this measure) than the NHSNmean.

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Pressure Ulcer Prevention


Inpatients are at high risk for development of pressure ulcers because of their medicalcondition and being at bed rest. Once developed, pressure ulcers require specialized nursingcare and significant time to heal. They also run the risk of becoming infected and causingadditional complications for the patient. It is now known that many pressure ulcers can beprevented with the application of specific evidence based practices. Hospital acquired Stage 3and Stage 4 pressure ulcers are a NQF SRE. Hospital acquired pressure ulcers are a hospitalacquired condition for which CMS will deny payment.


During this past year, nursing accepted the challenge of implementing the known evidencebased practices for pressure ulcer prevention: a full skin risk assessment with Braden score atadmission, precautions for all patients, and additional precautions for high risk patients.

2 to 5 patients a monthdevelop pressure ulcer

Results are significantly improved with the process changes implemented this past year.

(Current performance is slightly better than the UHC median.) It is anticipated that furtherimprovement will be noted with integration of nursing care processes with the electronicmedical record.

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Venous Thromboembolism (VTE) Prevention


Inpatients are at significantly increased risk for VTE (blood clots that can form in veins of thepelvis and legs and travel to the lungs) due to underlying medical conditions such as surgeryand bed rest. Though not all hospital acquired VTEs are preventable it is now known thatmany are preventable through appropriate evidence based use of VTE prophylaxis.Postoperative VTE is one of the Patient Safety Indicators selected for public reporting in thiscoming year. CMS has identified VTE post knee and hip orthopedic procedures as a hospitalacquired condition for which payment will be denied.


Data suggests that a high percentage of patients receive VTE prophylaxis but that the risk ofVTE is sometimes underestimated, therefore, some patients may be under-prophylaxed.

20 patients a month

develop VTE

Since the EMR implementation the number of cases of hospital acquired VTE has droppedmost likely due to the inclusion of prophylaxis orders on many admission order sets. (Currentperformance on the postoperative VTE Patient Safety Indicator is slightly worse than the UHCmedian.) Current improvement efforts are focused on building an electronic risk assessmentsystem that integrates with the prophylaxis order set.

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Anticoagulation Therapy


Anticoagulation therapy, most commonly heparin and warfarin, are a frequently used therapyfor the treatment and prevention of various conditions associated with formation of blood clots.Though essential when indicated, these treatments are also very high risk when errors aremade in their usage. The Institute for Safe Medication Practices (ISMP) has designated thiscategory of medication as high alert. The Joint Commission has designated monitoring ofanticoagulation therapy as a National Patient Safety Goal.


Parkland has an extensive ambulatory anticoagulation program including a multidisciplinaryclinic on campus and five pharmacist led clinics at various Community Oriented Primary Carelocations. These clinics utilize a multitude of safe practices allowing for the safe care of a largenumber of patients with minimum complications. These practices include:

Immediate access for discharged patients newly started on warfarin

Comprehensive education for all new patients

Strong pharmacist involvement for appropriate dose adjustment

Point of care INR testing so that changes in therapy can be made at the time of the visit

Written dosage instructions at every visit

Follow up for all patients who miss appointments.

Safety practices for inpatients on anticoagulant therapy include the following:

Heparin protocol as an electronic order set within the EMR which includes

o Default orders for the appropriate monitoring of the drug effect on the patient

o Dose adjustment by nursing within previously established parameters

o Parameters for when the physician must be notified of abnormal clotting results

Development of clinical guidelines for the practitioners regarding safe initiation andmonitoring of warfarin

Pharmacist involvement to ensure that every patient has the appropriate clotting testsat initiation of warfarin

Pharmacist involvement to ensure ongoing ordering of clotting tests as indicated andthat appropriate action is taken as indicated while patients are continued on warfarin

.

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It was not until pharmacists were directly involved in the monitoring of warfarin that a drop inmedication events related to anticoagulation was seen. Future efforts include utilizing clinicaldecision support tools within the EMR to facilitate ongoing improvement

.

Enhanced

Pharmacist

Involvement

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Organ Donation


Hospital policies that are consistent with applicable law and organ donationregulations shouldbe in place and should address patient and family preferences for organ donation, as well asspecify the roles and desired outcomes for every stage of the donation process.


Parkland has a collaborative relationship with Southwest Transplant Alliance, our assignedorgan procurement organization (OPO).

Policies and procedures are consistent with all applicable regulations. The hospital has anOrgan Donation Collaborative team that meets regularly with members from the OPO and theTissue Bank.

Organ donation referral rates are measured to verify that all ventilated patients in the ICU orER with a devastating neurological injury are appropriately referred to the OPO at the time of

death. Family members of medically eligible patients are then approached by the OPO. Theconversion rate is the percentage of eligible patients whose families consent to organdonation. Parkland Hospital has received recognition from Health Resources and ServicesAdministration (HRSA) for outstanding conversion rates in 2006, 2007 and 2008.

.

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Glycemic Control


Nationally, diabetes has reached epidemic proportions with the Centers for Disease Controllabeling it as the seventh cause of death in 2006. Increasing evidence suggests that betterglycemic control during hospitalization results in improved morbidity and mortality outcomes.Hypoglycemia is a frequent adverse event related to insulin usage that is so common that it isoften not perceived as an adverse event. The Institute for Safe Medical Practice has labeledinsulin a high alert drug because of the problems with hypoglycemia if it is administered inerror. Hypoglycemia is associated both with temporary harm and the potential for many longlasting sequelae. CMS has selected conditions associated with poor glycemic control as oneof the hospital acquired conditions for which payment will be denied.


Multiple service lines have devoted efforts this past year to improving glycemic managementfor Parkland patients and reducing the effects of hypoglycemia. Major initiatives have included

the following: An insulin order set incorporated into the electronic medical record build

Coordination of food tray, medication administration, and glucose monitoring on theinpatient units

And implementation of RALS connectivity to facilitate immediate and accuratecommunication of point of care glucose testing results into the EMR.

2 to 5 patients daily

require treatment for

low blood sugar

Rates of severe hypoglycemia have been significantly reduced. Current efforts are focused onoptimization of the insulin order set and house-wide implementation of glucose monitoring,insulin administration, and food tray delivery coordination.

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Falls Prevention


Anytime a patient falls, he/she is at risk of injury, disability, or even death. Many medicaltreatments increase the risk of falling, especially blood pressure and/or cardiac medications,pain medications, and intravenous lines and other devices attached to the body. The JointCommission lists falls as the sixth most common cause of sentinel events. CMS has selectedinjuries due to falls during hospitalization as a hospital acquired condition that will be deniedpayment.


Parkland has a Fall Reduction program which consists of a nursing fall risk assessment onadmission, standardized precautions for all patients and additional precautions for those atincreased risk, and a post fall review process. The most significant interventions continue to beroutine rounding on patients as well as timely response to call lights. Both of these activitiescontinue to be a focus of ongoing improvement efforts on the inpatient nursing units.

1 to 2 patients fall

every day

Despite ongoing efforts the fall rate has not significantly changed over time. In addition to thenursing activity noted above, future efforts will focus on incorporating learnings from every falloccurrence into the fall reduction program.

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Attachment 1

List of Serious Reportable Events (NQF 2009)

Serious Reportable Events

1. The event has resulted in an unanticipated death or major permanent loss of function

unrelated to the natural course of the patients illness or underlying condition.

2. Suicide of any patient receiving care, treatment, and services in a staffed around theclock care setting or within 72 hours of discharge.

3. Unanticipated death of a full term infant

4. Abduction of any patient receiving care, treatment, and services.

5. Discharge of an infant to the wrong family

6. Rape

7. Hemolytic transfusion reaction involving administration of blood or blood products

having major blood group incompatibilities.8. Surgery on the wrong patient or wrong body part

9. Unintended retention of a foreign object in a patient after surgery or other procedure

10. Severe neonatal hyperbilirubinemia (bilirubin greater than 30 mg/deciliter)

11. Prolonged fluoroscopy with cumulative dose greater than 1500 rads to a single field orany delivery of radiotherapy to the wrong body region or greater than 25% above theplanned radiotherapy dose

Surgical Events:

1. Surgery performed on the wrong body part2. Surgery performed on the wrong patient

3. Wrong surgical procedure on a patient

4. Retention of a foreign object after surgery or other procedure

5. Intraoperative or immediately post operative death in a normal healthy patient

Product or Device Events:

1. Patient death or serious disability associated with the use of contaminated drugsdevices, or biologics provided by the healthcare facility

2. Patient death or serious disability associated with the use or function of a device inpatient care in which the device is used or functions other than as intended

3. Patient death or serious disability associated with intravascular air embolism that occurswhile being cared for in a healthcare facility

1

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2

Patient Protection Events:

1. Infant discharged to the wrong person

2. Patient death or serious disability associated with patient disappearance for more thanfour hours

3. Patient suicide or attempted suicide resulting in serious disability, while being cared for

in a healthcare facility.

Care Management Events:

1. Patient death or serious disability associated with a medication error

2. Patient death or serious disability associated with a hemolytic reaction due to theadministration of ABO incompatible blood or blood products (transfusion of the wrongblood type)

3. Maternal death or serious disability associated with labor or delivery on a low riskpregnancy while being cared for in a healthcare facility

4. Patient death or serious disability associated with hypoglycemia, the onset of whichoccurs while the patient is being cared for in a healthcare facility

5. Death or serious disability associated with failure to identify and treat jaundice innewborns

6. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

7. Patient death or serious disability due to spinal manipulative therapy

Environmental Events:

1. Any instance of care ordered by or provided by someone impersonating a physiciannurse, pharmacist, or other licensed healthcare provider

2. Any incident in which a line designated for oxygen or other gas to be delivered to apatient contains the wrong gas or is contaminated by toxic substances

3. Patient death or serious disability associated with a burn incurred from any source whilebeing cared for in a healthcare facility

4. Patient death associated with a fall while being cared for in a healthcare facility

5. Patient death or serious disability associated with the use of restraints or bedrails whilebeing care for in a healthcare facility

Criminal Events:

1. Any instance of care ordered or provided by someone impersonating a physician, nursepharmacist, or other licensed healthcare provider

2. Abduction of a patient of any age

3. Sexual assault on a patient within or on the grounds of a healthcare facility

4. Death or significant injury of a patient or staff member resulting from a physical assaul(i.e. battery) that occurs within or on the grounds of a healthcare facility

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Attachment 2

Safe Practices for Better Healthcare2009 Update

SAFEPRACTICE PRACTICESTATEMENTSafePractice1:

LeadershipStructuresand

Systems

Leadership structures and systems must be established to ensure that there is

organizationwideawarenessofpatientsafetyperformancegaps,directaccountabilityof

leadersforthosegaps,andadequateinvestmentinperformanceimprovementabilities

andthat

actions

are

taken

to

ensure

safe

care

of

every

patient

served.

SafePractice2:

CultureMeasurement,

Feedback,andIntervention

Healthcareorganizationsmustmeasuretheirculture,providefeedbacktotheleadership

andstaff,andundertakeinterventionsthatwillreducepatientsafetyrisk.

SafePractice3:

TeamworkTrainingandSkill

Building

Healthcare organizations must establish a proactive, systematic, organizationwide

approachtodevelopingteambasedcarethroughteamworktraining,skillbuilding,and

teamled performance improvement interventions that reduce preventable harm to

patients.

SafePractice4:

IdentificationandMitigation

ofRisks

and

Hazards

Healthcareorganizationsmust systematically identifyandmitigatepatient safety risks

and hazards with an integrated approach in order to continuously drive down

preventablepatient

harm.

SafePractice5:

InformedConsent

Ask each patient or legal surrogate to teach back, in his or her own words, key

informationabouttheproposedtreatmentsorproceduresforwhichheorshe isbeing

askedtoprovideinformedconsent.

SafePractice6:

LifeSustainingTreatment

Ensure that written documentation of the patients preferences for lifesustaining

treatmentsisprominentlydisplayedinhisorherchart.

SafePractice7:

Disclosure

Following serious unanticipated outcomes, including those that are clearly caused by

systems failures, the patient and, as appropriate, the family should receive timely,

transparent,andclearcommunicationconcerningwhatisknownabouttheevent.

SafePractice8:

Careof

the

Caregiver

Followingseriousunintentionalharmduetosystemsfailuresand/orerrorsthatresulted

fromhuman

performance

failures,

the

involved

caregivers

(clinical

providers,

staff,

and

administrators)should receive timelyandsystematiccare to include: treatment that is

just, respect, compassion, supportive medical care, and the opportunity to fully

participateineventinvestigationandriskidentificationandmitigationactivitiesthatwil

preventfutureevents.

SafePractice9:

NursingWorkforce

Implement critical components of a welldesigned nursing workforce that mutually

reinforcepatientsafeguards,includingthefollowing:

A nurse staffing plan with evidence that it is adequately resourced and actively

managedandthatitseffectivenessisregularlyevaluatedwithrespecttopatientsafety.

Senioradministrativenursing leaders,suchasaChiefNursingOfficer,aspartof the

hospitalseniormanagementteam.

Governanceboards

and

senior

administrative

leaders

that

take

accountability

for

reducing patient safety risks related to nurse staffing decisions and the provision of

financialresourcesfornursingservices.

Provisionofbudgetary resources to supportnursing staff in theongoingacquisition

andmaintenanceofprofessionalknowledgeandskills.

SafePractice10:

DirectCaregivers

Ensure that nonnursing direct care staffing levels are adequate, that the staffs are

competent, and that they have had adequate orientation, training, and education to

performtheirassigneddirectcareduties.

SafePractice11: Allpatientsingeneralintensivecareunits(bothadultandpediatric)shouldbemanaged

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SAFEPRACTICE PRACTICESTATEMENTIntensiveCareUnitCare by physicians who have specific training and certification in critical care medicine

(criticalcarecertified).

SafePractice12:

PatientCareInformation

Ensure thatcare information is transmittedandappropriatelydocumented ina timely

manner and in a clearly understandable form to patients and to all of the patients

healthcareproviders/professionals,withinandbetween care settings,whoneed that

informationtoprovidecontinuedcare.

SafePractice

13:

OrderReadBackand

Abbreviations

Incorporatewithin

your

organization

asafe,

effective

communication

strategy,

structures,andsystemstoincludethefollowing:

Forverbalortelephoneordersorfortelephonicreportingofcriticaltestresults,verify

thecompleteorderortestresultbyhavingthepersonwhoisreceivingtheinformation

recordandreadbackthecompleteorderortestresult.

Standardize a list of Do Not Use abbreviations, acronyms, symbols, and dose

designationsthatcannotbeusedthroughouttheorganization.

SafePractice14:

LabelingofDiagnostic

Studies

Implementstandardizedpolicies,processes,andsystemstoensureaccurate labelingof

radiographs,laboratoryspecimens,orotherdiagnosticstudies,sothattherightstudyis

labeledfortherightpatientattherighttime.

SafePractice

15:

DischargeSystemsA

discharge

plan

must

be

prepared

for

each

patient

at

the

time

of

hospital

discharge,

and a concise discharge summary must be prepared for and relayed to the clinica

caregiver accepting responsibility for post discharge care in a timely manner

Organizations must ensure that there is confirmation of receipt of the discharge

informationbytheindependentlicensedpractitionerwhowillassumetheresponsibility

forcareafterdischarge.

SafePractice16:

SafeAdoptionof

ComputerizedPrescriber

OrderEntry

Implementacomputerizedprescriberorderentry(CPOE)systembuiltupontherequisite

foundation of reengineered evidencebased care, an assurance of healthcare

organizationstaffandindependentpractitionerreadiness,andanintegratedinformation

technologyinfrastructure.

SafePractice17:

MedicationReconciliation

The healthcare organization must develop, reconcile, and communicate an accurate

patientmedicationlistthroughoutthecontinuumofcare.

SafePractice18:

PharmacistLeadership

StructuresandSystems

Pharmacyleadersshouldhaveanactiveroleontheadministrativeleadershipteamthat

reflects their authority and accountability for medication management systems

performanceacrosstheorganization.

SafePractice19:

HandHygiene

Comply with current Centers for Disease Control and Prevention Hand Hygiene

Guidelines.

SafePractice20:

InfluenzaPrevention

Comply with current Centers for Disease Control and Prevention (CDC)

recommendations for influenza vaccinations for healthcare personnel and the annua

recommendations of the CDC Advisory Committee on Immunization Practices for

individualinfluenza

prevention

and

control.

SafePractice21:

CentralLineAssociated

BloodstreamInfection

Prevention

Takeactions topreventcentral lineassociatedbloodstream infectionby implementing

evidencebasedinterventionpractices.

SafePractice22:

SurgicalSiteInfection

Prevention

Take actions to prevent surgicalsite infections by implementing evidencebased

interventionpractices.

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SAFEPRACTICE PRACTICESTATEMENTSafePractice23:

CareoftheVentilated

Patient

Takeactions toprevent complicationsassociatedwithventilatedpatients: specifically

ventilatorassociatedpneumonia,venousthromboembolism,pepticulcerdisease,denta

complications,andpressureulcers.

SafePractice24:

MultidrugResistant

OrganismPrevention

Implementasystematicmultidrugresistantorganism(MDRO)eradicationprogrambuilt

upon the fundamental elements of infection control, an evidencebased approach,

assurance of the hospital staff and independent practitioner readiness, and a re

engineered

identification

and

care

process

for

those

patients

with

or

at

risk

for

MDROinfections. Note: This practice applies to, but is not limited to, epidemiologically

important organisms such asmethicillinresistant Staphylococcus aureus, vancomycinresistantenterococci,andClostridiumdifficile.Multidrugresistantgramnegativebacilli,suchasEnterobacter species,Klebsiellaspecies,Pseudomonas species,andEscherichiacoli,andvancomycinresistantStaphylococcusaureus,shouldbeevaluatedfor inclusiononalocalsystemlevelbasedonorganizationalriskassessments.

SafePractice25:

CatheterAssociatedUrinary

TractInfectionPrevention

Take actions to prevent catheterassociated urinary tract infection by implementing


SafePractice26:

WrongSite,

Wrong

Procedure,WrongPerson

SurgeryPrevention

Implement the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and

WrongPerson

Surgery

TMfor

all

invasive

procedures.

SafePractice27:

PressureUlcerPrevention

Takeactions topreventpressureulcersby implementingevidencebased intervention

practices.

SafePractice28:

VenousThromboembolism

Prevention

Evaluate each patient upon admission, and regularly thereafter, for the risk of

developing venous thromboembolism. Utilize clinically appropriate, evidencebased

methodsofthromboprophylaxis.

SafePractice29:

AnticoagulationTherapy

Organizationsshouldimplementpracticestopreventpatientharmduetoanticoagulant

therapy.

SafePractice

30:

ContrastMediaInduced

RenalFailurePrevention

Utilizevalidated

protocols

to

evaluate

patients

who

are

at

risk

for

contrast

media

induced renal failure and gadoliniumassociated nephrogenic systemic fibrosis, and

utilizeaclinicallyappropriatemethod forreducingtheriskofadverseeventsbasedon

thepatientsriskevaluations.

SafePractice31:

OrganDonation

Hospital policies that are consistentwith applicable law and regulations should be in

placeandshouldaddresspatientandfamilypreferencesfororgandonation,aswellas

specifytherolesanddesiredoutcomesforeverystageofthedonationprocess.

SafePractice32:

GlycemicControl

Takeactionsto improveglycemiccontrolby implementingevidencebased intervention

practices that prevent hypoglycemia and optimize the care of patients with

hyperglycemiaanddiabetes.

SafePractice

33:

FallsPrevention

Takeactions

to

prevent

patient

falls

and

to

reduce

fall

related

injuries

by

implementing


SafePractice34:

PediatricImaging

WhenCT imagingstudiesareundertakenonchildren,childsizetechniquesshouldbe

usedtoreduceunnecessaryexposuretoionizingradiation.

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