hhs our in and 2012 - halton healthcare · bennett, professional practice clinician, georgetown;...
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HHS Celebrates Our Success in Quality and Patient
Safety 2012
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PATIENT SAFETY EXPO 2012 Celebrating Achievements and Excellence in Care!
The Patient Safety Expo is a celebration of all the great work everyone does at Halton Healthcare Services (HHS)
year round to make our organization a centre of excellence. Along with colleagues across the country, we
recognize Canadian Patient Safety Week (October 28 – November 1, 2012) by showcasing inspiring
improvement work from the entire organization.
As we move through considerable self‐reflection this fall, using national
standards for quality and safety in readiness for our on‐site
Accreditation survey in May 2013, the timing of the Patient Safety
Expo provided an excellent opportunity to recognize the many
quality‐safety improvements here at HHS.
The quality improvement work undertaken by our colleagues
epitomizes in many ways, particularly at this time through their
Expo displays – excellent teamwork and communication. This has
been a key theme for Canadian Patient Safety Week this year.
“Effective teamwork and communication are critical for ensuring
high reliability and the safe delivery of care. Teamwork and
communication techniques can improve
quality and safety, decrease patient harm, promote cross‐professional
collaboration and the development of common goals, decrease workload issues,
and improve staff and patient satisfaction” (Canadian Patient Safety Institute website).
A very special thanks to the members of the 2012 Safety Expo Planning Committee who worked tirelessly over the past few months to shape the activities and many details that made Expo 2012 more successful than ever: Anita
Arnold, Senior Technologist, Haematology, Laboratory; Angela Barrett, Senior Administrative Assistant; Karen
Bennett, Professional Practice Clinician, Georgetown; Stephanie Black and Natalie Neal, Physio and Occupational
Therapist Assistants, Rehabilitation; Sheryl Brown, Supervisor, Housekeeping/PAL Program; Lynn Budgell, Safety
Coordinator; Andrea D’sa, Director, Medical Affairs, Carole Dalton, Patient Care Manager, Emergency Department,
Oakville; Jason Ford, Physiotherapy Assistant, Georgetown; Deborah Hill, Program Director, Emergency/ Ambulatory
Care and Cardio‐Respiratory; Kim Kohlberger, Program Director, Rehab and Geriatrics; Jennifer Luckanuck, Minimal
Lift Coordinator, Physiotherapist; Cathleen MacIsaac, Administrative Assistant; Cindy Outerson, Senior
Administrative Assistant; Rosemary McNeely, Director of Volunteers, Oakville Hospital Volunteer Association; Angie
Molezzi, Business Development, Marketing Specialist; Lesley Patel, Communications Specialist, Public Relations;
Karen Vokner, Professional Practice Clinician, Milton
Many others worked behind the scenes to make the Patient Safety Expo possible. Six volunteers assisted us this year
– Michele Giesen, Georgetown; Gail Trenholm, Oakville; Ali Hmood, Judy Bayer, Janet Liu and Donna Stover at
Milton. Kailo also lent a helping hand. Thanks to all of you for your support!
Enjoy this booklet ‐ it celebrates teamwork, hard work, and excellence in practice at HHS. From the Expo 2012 Planning Committee, a big thank you to everyone for participating in the 2012 Patient Safety Expo.
Lynn Budgell, Committee Chair
Patient Safety Expo 2012
* 60 teams
* 600 visitors
* Three full days of exhibits (October 25, 29 & November 1)
* Awards/Celebrations Evening (November 14)
*Awesome Initiatives
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Patient Safety Awards Reception Wednesday, November 14, 2012
Piper’s Health Golf Club
A warm and gracious thank you to our Keynote Speaker:
Amir Ginzburg, MD, FRCPC
Quality Improvement & Patient Safety: When Rubber Hits the Road
Amir Ginzburg is a general internist at the Credit Valley Hospital and Trillium Health
Centre. As the Medical Director of Patient Safety and Quality, Amir has led efforts to
improve critical incident management, reduce catheter associated urinary tract
infections, enhance detection of adverse events through the Institute for Healthcare
Improvement's Global Trigger Tool, and institute read‐backs for verbal and telephone
orders. He is passionate about supporting a culture of safety and about aligning physician
governance of quality and patient safety with corporate strategic aims. He is currently
championing several organization‐wide improvement efforts centered on avoidable
hospitalization, patient safety education, and the spread of order sets into the Long Term
Care arena. Amir is a national Master Facilitator for the Patient Safety Education Program
Canada and is a member of the Canadian Society of Hospital Medicine's Quality and
Patient Safety Committee. Along with others, Amir is currently working with the Royal
College of Physicians and Surgeons of Canada to develop a curriculum and educational
delivery vehicle to Advance the Safety of Patients in Residency Education (ASPIRE).
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Awards
Outstanding Quality & Safety Award
The quality and safety champion award is awarded this year to 11 exceptional people who have been
nominated because they show leadership and commitment to the development of the quality and
safety program in their respective areas and sometimes across the organization. They are respected by
their colleagues, are keen and positive, visible, innovative, and approachable opinion leaders and
change agents. In recognition of this award, these 2012 Quality and Safety Champion Award winners
will be supported to attend a quality‐safety related conference of their choice in the coming months
and share what they learned on their return.
Congratulations!
▪Edyta Buda▪
RN, Mental Health
▪Genny Cho▪
Patient Care Manager, CCC,
Rehabilitation and Geriatrics Program
▪Wendy Denovan▪
Team Leader, Nuclear Medicine
▪Nelson Ferriera▪
Child & Youth Worker, CAPIS
▪Jacqueline Minezes▪
Manager, Rehab Services
▪Angela Roode▪
Clinician‐Diabetes/Safe Medication
Practices, Nursing Lead‐Medication
Management Implementation Team
▪Leslie Ross▪
RN, Paediatrics
▪Ashley Tolsma▪
Medical Radiation Technologist,
Oakville
▪Dr. Don Trant▪
Associate Chief of Staff for Georgetown
Hospital, Medical Director for the
Georgetown Family Practice Program
▪Claire Trojan▪
RN, ICU and CCOT, Oakville
▪Ingrid Vajda▪
Occupational and Physiotherapy
Assistant, Cardiac Rehab Program
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Expo Safety Displays 2 East Medicine ‐ We are "Kidney Clever".... Keeping Our Peritoneal Dialysis Patients Safe Judith Forward, RPN and Ana Matias, RN Improvement Project; Chris Linskey, Renal Educator, in collaboration with the nurses from 2 East Medicine
50 SHADES OF RED...Otherwise Known as Transfusion Reactions to Blood Products Cathy Goacher, Professional Practice Coordinator/Manager Nursing Resource Team
5 Safety Checks at the Bedside and the Transition to Bedside Reporting The Inpatient Paediatric Team at OTMH
Antimicrobial Stewardship – How are we Doing? Dr. Tom Warren, Infectious Disease Physician; Jill White, Antimicrobial Stewardship Pharmacist, Pharmacy Dept; Helena Trabulsi, Director of Pharmacy, Pharmacy Dept; Grace White, Pharmacy Clinical Manager, Pharmacy Department
Best Dressed Tube – Get it Straight Reduce the Wait Judy Maxwell, Laboratory Quality Coordinator
BMV Bedside Medication Verification– The Super Hero of Medication Safety Elaine Hooper, RN PMP
The Bug Stops Here…Pump It Up! Improving Hand Hygiene Compliance Rates by Making it Everyone’s Responsibility Faye Matthews, Hand Hygiene Coordinator; Shirley Lanza, Manager Infection Prevention and Control Service
CADD Solis PCA and the CADD Legacy PCA Pump Karen Bennett, Professional Practice Clinician, Georgetown
Chronic Obstructive Pulmonary Disease Services Across the Continuum of Care Jacqueline Minezes, Manager Rehabilitation Services
Clot Beware – No VTE! Grace White, Pharmacy Clinical Manager; Karen Vokner, PPC MDH; Lynn Budgell, Patient Safety
Code Amber Christi Robert, RN, Professional Practice Clinician, Maternal Child Program and Code Amber Working Group
Cuffed Care – Caring for the In‐mate Population on a Medical/Surgical Unit Karen Vokner, PPC – Milton Family Practice; Monica Friesen, Patient Care Manager – Med‐Surg/OBS
The Danger of Overrides with Automated Dispensing Units – Risky Business Angela Roode ‐ Diabetes Clinician and PPC ‐ Safe Medication Practice; Linda Chou, Pharmacist; Micky Brankovic, RN ‐ADU Project Trainer
Demystifying Oral Anticoagulants Anticoagulation Team
D.I. Biopsy Safety Checklist April Sabatini, Team Lead Ultrasound; Cheryl Coles, Sonographer
Discharge Teaching Tool for the Newborn Jacqueline Goodban RN, PNC(C) ‐ Clinical Resource Nurse – MDH, Obstetrics
Epidural Infusion Safety – Monitoring the Patient, not the Pump! Carmen Caloian, APS Champion, 2C Pain Committee Member, RN; Danielle Dunwoody CNS, APS
Examining our Safety Culture Lynn Budgell, Patient Safety Coordinator
Excellent Foot Health Contributes to a Safe Workplace The Oakville Hospital Footcare & Orthotic Centre
Flu Campaign 2012 Karina Prokopchuk, OH&S Manager; Suzanne Hughes, OH&S Nurse; Jennifer Lightowler, OH&S Coordinator; Jacqueline Cassavoy, OH&S Assistant
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Expo Safety Displays Georgetown ED Redevelopment – Integrated Planning Jennifer Cousins RN ED, Kim Liley RN ED and Shirley Andrechek, Patient Care Manager, Emergency Department
Getting the Whole Picture – Videofluoroscopic Swallowing Study Alyssa Weinmaster, Speech‐language pathologist, OTMH and MDH; Melanie Ribeiro, Speech‐language pathologist, OTMH; Adrienne Curran, Speech‐Language Pathologist, OTMH; Nela Wilson, Speech‐Language Pathologist, GH; Michelle Zuzarte, Speech‐Language Pathologist, OTMH
The Go to for 02 Jennifer Grierson and Laureen Taylor on behalf of the Respiratory Therapy Department
Identifying Knowledge Deficits Related to Hydromorphone Kasia Siek, RN and Danielle Dunwoody, CNS, APS
Implementation of Primary Care Nursing in the Emergency Department Carole Dalton, PCM Emergency and Annie Duong PPC Emergency
Implementing ICE‐PACs in the EDs Annie Duong, PPC – Emergency Services; Karen Vokner, PPC – Milton Family Practice
Improving the Patient Experience with Routine Rounding Desa Hobbs, Program Director, Medicine and Critical Care; Jennifer Kustra, Director, Total Rewards and Organizational Development
Insulin Administration Safety Angela Roode RN, BScN,CDE and Claire Latto‐Hall RN, BScN
Introducing AIDET to the Milton ED Karen Vokner, PPC – Milton Family Practice; Colleen Schmidt, Interim Patient Care Manager – ICU/ED/Ambulatory Clinics
Keeping Hospitalized Hemodialysis Patients Safe Maintaining Open Communication with our Inpatient Partners Chris Lynskey, PPC Nephrology
Keeping Individuals Safe & Independent in Their Own Homes ConnectCARE Emergency Response Service Team
Managing an Incident – It Takes a Team! Lynn Budgell, Patient Safety Coordinator
Medication Management Project Status Update Diane Olmstead, Project Manager ‐ Medication Management
The Mental Health Act: Myths and Misconceptions Anthony Wright, PPC Mental Health; Erica Howard, OTA Mental Health
Milton Gives New Life with Trillium Gift of Life Karen Vokner, PPC – Milton Family Practice; Mallorie Crawford, RN – ICU, Colleen Schmidt, Interim Manager ER/ICU/Ambulatory Clinics
Minimal Lift and Safe Handling ‐ Know Your Protective Equipment Jennifer Luckanuck, Minimal Lift Coordinator
Neonatal Resuscitation Program (NRP) Tanya Bell, RN; Kathryn Doren, RN; Monica Friesen, RN; Eileen Gagne, RRT; Leann Harper, RN; Deciah Lebel, RN; Anna‐Marie Merchant, RN; Christi Robert, RN; Jonathan Sam, MD
Open the Door to Safety – Awareness is Key The Work‐Fit Total Therapy Centre Team
Optimizing RPN Scope of Practice: Care of the APS Patient Elena Bloise RN, BScN, MN; Christian Ocampo, RPN; Danielle Dunwoody, RN, BScN, CNCC(C), MS; Erin Greene, RPN; Sabrina Mascarin, CRN, RN; Christina Moldovan, RN, BScN, MN; Kelly Roy, PCM, RN, MS; Colleen Silver, ANP – Geriatrics & Neurology
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Patient Chart Labels Deanna Mol, IT Analyst and Grace White, Pharmacy Clinical Manager
Patient Flow is Everyone’s Business Desa Hobbs, Program Director Medicine and Critical Care; Deborah Hill, Program Director Emergency/Ambulatory Care and Cardiorespiratory Services
Procedure Able? Check the Coag Table! Ashley Patrick, DI Patient Safety Champion; Colleen Nicholson, DI Nurse; Melanie Maddock, DI Team Leader
Promoting Safety Tool (MORSE, CAM, & Wandering) Use and Documentation Lynn Budgell, Coordinator, Safety, Quality & Risk; Nancy Greaves PT, Clinical Analyst; Judi Montgomery, PPC Rehabilitation and Geriatric Program
Quick Tips For Falls Prevention – The MORSE Judi Montgomery, PPC Rehabilitation and Geriatric Program, Falls Committee Member
Red Flags for Visitors of Elderly or Friends or Relatives: Signs of Abuse/Neglect or Lack of Coping Sian Surridge and Jamie Curran, Occupational Therapists, CCC at Oakville
Revitalizing Medication Reconciliation at HHS – Med Rec To Go Elaine Hooper, RN PMP; Cathy Goacher, PPC/Manager NRT; Laura Lachowiez, Nursing Clinical Analyst and Boris Curcic, Pharmacy Analyst
Safer Elder Care – An Innovative Approach to Improving Care of the Hospitalized Older Adults Dr. Kirsten Lindner; Jennifer Luckanuck, OT, PT, MHA; Delayne Haasz, RN, BA, BSN, MSc‐NP (student)
Safety Huddles Advance the Game! Judi Montgomery, PPC, Rehabilitation and Geriatrics Program
Service Animals: An Important Job To Do Kelly Ingram, Patient Relations Advisor
Shades of Grey In Mental Health Group Inclusion Jennifer Opper, Angela Everest, Jane Mondano and Corrine Dube, Case Managers, Mental Health Day Program, OTMH
Specialized Geriatric Services at HHS Jacqueline Minezes, Manager Rehab Services
Think About It…Before You Alter an Order Grace White, Pharmacy Clinical Manager, and Janice Mack, Pharmacist
“U” Can Make a Difference! Dangerous Abbreviations and Dose Designations Helena Trabulsi, Director of Pharmacy and Grace White, Pharmacy Clinical Manager
War & Peace – The Saga of a Community Hospital’s Multidisciplinary Approach to C. difficile Melanie Koshman, Infection Control Clinician; Shirley Lanza, Manager, Infection Prevention and Control Service; Sean Shu, Consultant, Decision Support; Dr. Neil Rau, Medical Director, Infection Prevention and Control Service
What Is Accessibility? Lynn Singh, Director, Quality & Patient Relations; Kelly Ingram, Patient Relations Advisor
Where’s Waldo? Cindy Svenkenson, Manager, Parking and Security; Jo‐Ann O’Hagan, Supervisor, Parking; Sheryl Brown, Supervisor, Housekeeping/PAL Program; Sonya Martin, Call Centre Operator
Workplace Violence & Harassment Prevention Karina Prokopchuk, OH&S Manager; Jennifer Lightowler, OH&S Coordinator; Jacqueline Cassavoy, OH&S Assistant
Expo Safety Displays
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Safety Display Awards
Most Creative Design Board (Display) Where’s Waldo
Cindy Svenkenson, Manager, Parking and Security; Jo‐Ann O’Hagan, Supervisor, Parking; Sheryl Brown, Supervisor, Housekeeping/PAL Program; Sonya Martin, Call Centre Operator
Biggest Impact Open the Door to Safety – Awareness is Key
The Work‐Fit Total Therapy Centre Team
Most Original Initiative Service Animals: An Important Job To Do
Kelly Ingram, Patient Relations Advisor
Team Collaboration Neonatal Resuscitation Program (NRP)
Tanya Bell, RN; Kathryn Doren, RN; Monica Friesen, RN; Eileen Gagne, RRT; Leann Harper, RN; Deciah Lebel, RN; Anna‐Marie Merchant, RN; Christi Robert, RN; Jonathan Sam, MD
Best Initiative that Involved Patients and Families Discharge Teaching Tool for the Newborn
Jacqueline Goodban RN, PNC(C) ‐ Clinical Resource Nurse – MDH, Obstetrics
Honourable Mentions
Best Dressed Tube – Get it Straight Reduce the Wait Judy Maxwell, Laboratory Quality Coordinator
The Go to for 02 Jennifer Grierson, RRT and Laureen Taylor, RRT on behalf of the Respiratory Therapy Department
50 SHADES OF RED …. Otherwise Known as Transfusion Reactions to Blood Products Cathy Goacher, Professional Practice Coordinator/Manager Nursing Resource Team
Revitalizing Medication Reconciliation at HHS – Med Rec To Go Elaine Hooper, RN PMP; Cathy Goacher, PPC/Manager NRT; Laura Lachowiez, Nursing Clinical Analyst
and Boris Curcic, Pharmacy Analyst
5 Safety Checks at the Bedside and the Transition to Bedside Reporting The Inpatient Paediatric Team at OTMH
The following awards were established to recognize the outstanding work done by our Expo participants. Hundreds cast their vote in the following categories:
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Quality Improvement/Safety Initiatives
This section of the booklet provides a brief summary of the more than 50 quality improvement/safety initiatives showcased by our staff. In keeping with a corporate initiative to use a standardized approach to how we communicate across the organization, all of the storyboards descriptions have been structured using the S.B.A.R. format. Use of this
structured approach can have a positive impact on our conversations, written or verbal. SBAR stands for:
S: Situation: What happened? What was the opportunity?
B: Background: What were the circumstances relevant to this situation?
A: Assessment: What was the specific problem or opportunity/measurement/metrics?
R: Recommendation: What was done to correct the quality‐safety issue? Next steps?
Each SBAR summary includes who to contact should you wish to connect – Safer together!
Gearing Up for Accreditation! f
As we are doing final preparations for our on‐site Accreditation Survey in May 2013, many of the poster boards were branded with an ROP (Required Organizational Practice) designation post‐it to serve as a reminder. ROPs are just one component of the
comprehensive suite of Accreditation standards. However, all the featured initiatives in this booklet reflect our continuing efforts to enhance quality and safety throughout
our organization.
2 East Medicine ‐ We are "Kidney Clever"... Keeping Our Peritoneal Dialysis Patients Safe S: Peritoneal dialysis patients run the risk of infection (peritonitis) requiring hospitalization for treatment. Prolonged peritonitis can lead to a possible loss of peritoneal membrane resulting in the patient transferring to hemodialysis. Eighteen percent related mortality in P.D. patients is the result of peritonitis. B: Peritoneal dialysis is home based dialysis. 2 East Medicine is a renal unit, and is unique to OTMH in that we recognize the need to keep the P.D. patient safe to decrease the need for hospitalization and increase the success of home dialysis. A: It is difficult to ensure sterility in the home environment with P.D. exchanges. However, through patient education, staff education and support and maintaining aseptic technique we can keep the P.D. patient safe. R: The staff on 2 East receive ongoing in‐services on peritonitis and infection. That education is carried into our daily practice and reinforced with our patients who then return to the community for continued home dialysis. Submitted by: Judith Forward, RPN and Ana Matias, RN Improvement Project; Chris Linskey, Renal Educator, in collaboration with the nurses from 2 East Medicine
50 SHADES OF RED…Otherwise Known as Transfusion Reactions to Blood Products
S: Transfusion reactions can occur any time during, or even after the transfusion is completed. Increased knowledge and awareness regarding transfusion reactions on the part of healthcare providers, patients and families results in improved patient outcomes. B: There is always a risk of under‐recognizing transfusion reactions which, in turn results in a lack of appropriate patient treatment and under‐reporting. HHS has a detailed Policy and Procedure for the Administration of Blood and Blood
Accreditat
ion Alert
This is an
ROP
(Required
Organizat
ional
Practice)
An essent
ial safety
practice
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Products that addresses transfusion reactions and a Blood Product Transfusion Record/Intervention for documenting transfusions and transfusion reactions. A: In addition to the tools mentioned, there is a significant role for the patient and family during a transfusion. With adequate education, they’re able to partner with the healthcare team in recognizing the signs and symptoms of a potential reaction. R: Ensuring as the treatment provider that you have the necessary knowledge regarding signs and symptoms of transfusion reactions will allow you to equip your patients and families with the information they need to partner with us in the early recognition of a transfusion reaction.
Submitted by: Cathy Goacher, Professional Practice Coordinator/Manager Nursing Resource Team
5 Safety Checks at the Bedside and the Transition to Bedside Reporting
S: The function of a safety handoff is to communicate patient information to provide safe and continuous care for the patient. The time of hand over specifically increases the risk for vulnerable hospitalized patients, such as our paediatric population. Handoffs occur at busy times with multiple distractions and time constraints, therefore the team wanted to reduce the risk of adverse events to our patients during shift change and handover. B: Patient safety is our number one concern. Research shows that bedside reporting improves accuracy of patient identification, improves communication and encourages family to have active involvement. A: The bedside safety check was created to ensure a systematic review of quality assurance measures during handover. Over time, the team transitioned from safety checks at the bedside to completing a full bedside report. R: The team has received positive verbal feedback from the families that we care for and the paediatric nurses have identified that there has been a reduction in nurse call bells at the beginning of each shift.
Submitted by: The Inpatient Paediatric Team at OTMH
This is an
ROP
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Antimicrobial Stewardship – How Are We doing?
S: The goal of an Antimicrobial Stewardship Program (ASP) is to promote optimal use of anti‐infective agents. Monitoring of activities and outcomes is essential in order to define and attain the goals of the program. B: HHS has operated an enhanced ASP since 2009. A: During the past year, the ASP has focused on the following strategies:
Prospective Audit and Feedback Review of antibiotic prescriptions is performed by an Antimicrobial Stewardship Team of Infectious Diseases (ID) Pharmacist and ID Physician. Direct feedback is provided to the prescriber. The purpose of this process is to optimize antibiotic therapy delivered to patients. During the past year, this program has been expanded to cover ICU at OTMH and all patient care areas at Milton District Hospital.
Timely reassessment of anti‐infective therapy Review of expiring antibiotics is performed by pharmacists. Automatic stop order dates are adjusted by pharmacists where appropriate. Pharmacists support nursing in communicating with prescribers to ensure timely reassessment of antibiotic therapy.
Measurement of antimicrobial use A database has been developed that allows us to report quantities of anti‐infective agents dispensed by month. This allows for monitoring of trends in the consumption of these agents in our hospitals.
R: Antimicrobial Stewardship is a team effort! Submitted by: Dr. Tom Warren, Infectious Disease Physician; Jill White, Antimicrobial Stewardship Pharmacist, Pharmacy Dept; Helena Trabulsi, Director of Pharmacy, Pharmacy Dept; Grace White, Pharmacy Clinical Manager, Pharmacy Department
Best Dressed Tube – Get it Straight Reduce the Wait S: Blood specimens are being received in the laboratory with wrinkled barcodes, crooked barcodes and the label obscuring visual assessment of blood volume. B: In recent months, the number of instances where less than optimal labeling has occurred has dramatically increased. In order for the automated analyzers to read the barcode on the specimen label the barcode must be straight and flat. In order to achieve this, the Lab staff must re‐print and re‐label the tubes – this is a Patient Safety risk! Visual assessment of appropriate blood volume is also part of the Lab testing protocol. If the volume of blood cannot be viewed and the tube is not filled with an adequate amount of blood, erroneous test results may occur. This re‐work impacts the time it takes for results to be available to healthcare providers. A: Initially, incident reports were entered into the IRS system, but there quickly became too many. The issue was brought to the PPC group, and educational posters were provided for frontline staff. Further, the PPC’s of each unit are being provided documentation of incidents specific to their units for further follow‐up. The Best Dressed Tube display was created to provide an entertaining way of relaying information on optimal specimen labeling practices for nursing staff at several educational venues ‐ Interprofessional Fall Fair, ICU Professional Development Days and Patient Safety Expos. An updated Specimen Labeling procedure will also be made available on HOPP. R: We anticipate after providing a simple and amusing reminder of how “to” and “not to” label specimens, we will see an improvement! Submitted by: Judy Maxwell, Laboratory Quality Coordinator
This is an
ROP
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BMV Bedside Medication Verification– The Super Hero of Medication Safety S: Patient safety can be enhanced through the use of strategies and technology for the management of medications. Drug related events are the second most common type of event to which all adverse events are related. All components of the HHS Medication Management Plan focus on reducing risks and promoting safety as the introduction of automation (technology) into the pharmacy and nursing medication processes replace manual practices. Unit dose packaging is a Medication Standard from Accreditation Canada. The ultimate goal is to have unit dose medications prepackaged, labeled and bar‐coded ready for administration at the patient bedside. B: Technology is a key enabler of safe medication distribution and delivery. Pharmacy and Nursing are collaborating on a number of initiatives that will reduce risk of medication errors. One of the final phases of the Medication Management plan is the use of Bedside Medication Verification (BMV). A: BMV allows caregivers to utilize bar code scanning technology prior to administering medications. During the medication administration process, BMV is used to confirm patient identity and medication information against data readily available via MEDITECH's on‐line Medication Administration Record. Immediate access to a patient’s current results and medication administration information greatly reduces preventable medication errors. The use of bar code scanning increases accuracy and efficiency of caregivers administering medications, providing physicians faster and easier access to critical information to manage patient care. Caregivers scan bar codes on patient wristbands and medications to correctly identify the patient and the appropriate medication. Medications are identified by the manufacturer’s assigned number or the appropriate identification number generated by the Pharmacy. BMV software processes the data which contributes to safe administration by ensuring the “Eight Rights” of safe medication administration: Right Patient, Right Medication, Right Dosage, Right Route & Site, Right Time, Right Documentation, Right Reason, and Right Response. R: The latest test results, allergies, and medication orders are immediately available through the patient profile to alert the caregiver to any potential problems prior to medication administration. Since medication information is scanned and matched to the Hospital’s formulary dictionary ‐ checking for drug interactions, allergies, and duplications and appropriate dose ranges can be performed prior to administering medications to the patient. This technology will contribute to the culture of safety at HHS and protect patients and staff during the medication administration process. Submitted by: Elaine Hooper, RN PMP
The Bug Stops Here…Pump It Up! Improving Hand Hygiene Compliance Rates by Making it Everyone’s Responsibility S: In 2008, Ontario’s Just Clean Your Hands program was implemented followed by mandatory public reporting of hand hygiene compliance rates. At HHS, compliance and engagement was low despite already having an established hand hygiene program. B: A hand hygiene task group comprised of Senior Management, Program/Department Directors, Public Relations and Infection Prevention and Control, was formed to improve hand hygiene compliance and promote engagement at all levels; staff, physicians, volunteers and patients. With the CEO’s support, hand hygiene was branded the organization’s number one patient safety initiative. A: Weekly task group meetings kick‐started an improvement plan with the following key action items identified:
Development of a communication and marketing plan
Revision and update of hand hygiene mandatory education
This is an
ROP
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Improvements to the auditing process
Implementation of reward and recognition incentive program
Facilities’ assessment
Patient/visitor engagement plan
R: Corporate hand hygiene compliance rates increased to 69.1% (2011/2012) from 57.4% (2010/2011) for Moment #1 (before initial patient /patient environment contact). Submitted by: Faye Matthews, Hand Hygiene Coordinator; Shirley Lanza, Manager Infection Prevention and Control Service
CADD Solis PCA and the CADD Legacy PCA PUMP
S: HHS recently introduced a new IV Solis PCA pump. This is an ambulatory infusion pump system for acute pain whether being used in the birthing suite or for post‐op patients. B: HHS already had in existence the CADD Legacy PCA pump which is mainly used via the subcutaneous route for those patients with chronic or palliative pain. There were great concerns that staff would be confused with the name ‘PCA’ in both pumps. A: A safety campaign was launched to raise awareness that there are the two different pumps in the Hospital and used for very different purposes. It was also enforced that both are programmed in mG not mL to avoid drug errors. Both pumps involve narcotic infusions but usually via different routes. Both pumps require an independent double check on initiation and with any changes to the pumps as per our High Risk Drug Policy. R: Staff are reminded to check carefully to ensure the correct pump is being used on initiation and for the correct purpose.
Submitted by: Karen Bennett, Professional Practice Clinician, Georgetown
Chronic Obstructive Pulmonary Disease Services Across the Continuum of Care S: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of death and disability. Acute exacerbations are the most frequent cause of medical visits, Emergency Department visits, hospital admissions and re‐admissions and an increased length of stay in the Hospital. B: In 2007, the Ministry of Health and Long‐Term Care announced an Aging at Home Strategy. The goal was to invest in community services to enable older adults to stay healthy and live more independently in their homes as well as reduce pressures on the health system. As part of the strategy, HHS received funding for a COPD Program Coordinator and an enhancement to the Outpatient Pulmonary Rehabilitation Programs. A: The COPD Program Coordinator serves as a resource to patients who are admitted to the Hospital. Education on symptom management, progression through a care path and linkages with other hospitals, outpatient programs as well as community supports and services are a focus of the role. R: The impact of the services includes facilitation of discharge from hospital, reduction in acute care bed pressures, reduction in unnecessary admissions as well as visits to the Emergency Department and a reduction in length of stay. A poster highlighting this new HHS program was presented at the International Nurses Improving Care for Health System
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Elders (NICHE) Conference in March 2012.
Submitted by: Jacqueline Minezes, Manager Rehab Services
Clot Beware – No VTE!
S: A new Accreditation Canada ROP (Required Organizational Practice) requires all healthcare organizations across the country to ‘identify medical and surgical clients at risk of venous thromboembolism (DVT and PE) and provide appropriate thromboprophylaxis’. There are several specifications outlined in the ROP that are required to support best practice. This has provided HHS with the opportunity to carefully review our practices and implement changes where needed.
B: There is significant international evidence that hospitals can do better ‐ VTE continues to be one of the most common complications of hospitalization; certainly the most common preventable cause of death in hospitals. More than 450 randomized studies have proven that VTE can be prevented safely and affordably.
A: An interdisciplinary tri‐site HHS committee is working to evaluate our practices and tools with the goal to ensure that our VTE prevention program and compliance is second to none. Components of the project include: chart audits to determine our compliance with appropriate prophylaxis; development of new guidelines for care providers, inclusion of a risk scoring tool and revision of our physician order set, to name a few.
R: Education strategies, implementation of revised/new tools and ongoing monitoring will be the focus of early 2013.
Submitted by: Grace White, Pharmacy Clinical Manager, Karen Vokner, PPC MDH; Lynn Budgell, Patient Safety Coordinator
Code Amber
S: The safety and security of the infants and children we care for at HHS is of utmost importance. All employees at HHS have a responsibility to protect infants and children from being abducted from the Hospital.
B: It is critical in the event of a suspected abduction that staff be able to recognize an abductor and know the actions to be taken, therefore a Code Amber Policy and Procedure was developed and implemented at HHS.
A: In July 2012 ‐ security services, hospital staff and the Halton Regional Police participated in a mock Code Amber in the Maternal Child Unit at OTMH. In preparation, all staff in the organization completed a Code Amber e‐Learning Module.
R: In the event of a real Code Amber, staff now have the knowledge and tools to quickly, safely and efficiently deal with the situation. Submitted by: Christi Robert, RN, Professional Practice Clinician, Maternal Child Program and Code Amber Working Group
This is an
ROP
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Cuffed Care – Caring for the In‐mate Population on a Medical/Surgical Unit
S: Milton District Hospital (MDH) admitted over 110 patients from the Maplehurst Correctional Complex in 2011/12 onto the Medical/Surgical Unit. From the guards to the care, this patient population has some very unique requirements which need to be met to ensure that quality‐safe care is delivered on the unit while maintaining confidentiality and the dignity of the patient.
B: Maplehurst Correctional Complex is a 1,550 bed maximum security facility situated in Milton off of Highway 401. Immediately adjacent to it is the Vanier Centre for Women, a 124 bed Correctional Facility for women. Patients coming to MDH from these facilities are admitted with a variety of medical and surgical diagnoses including need for palliative care. A: Each patient admitted to the unit is accompanied by two correctional officers who assist with patient monitoring and promoting safety and security of staff and other patients and their families. The staff on Med‐Surg need to work collaboratively with the officers to maintain the standard of care for all patients while ensuring a safe environment. R: Nurses and other healthcare providers provide excellent care to this unique population and continue to do so despite increasing patient acuity. Integral to the provision of quality care to patients is the commitment to partnership and effective communication between Maplehurst staff, nurses, and on‐site correctional officers. Submitted by: Karen Vokner, PPC – Milton Family Practice; Monica Friesen, PCM – Med‐Surg/OBS
The Danger of Overrides with Automated Dispensing Units – Risky Business
S: An override occurs on the Omnicell Automated Dispensing Unit (ADU) when a nurse removes a medication that has not been reviewed and released for administration by a pharmacist. B: Profiled ADUs are one of the most important safety enhancements that contribute to the reduction in medication errors with the use of this technology. This safety feature provides a direct interface between the pharmacy and the ADU on the patient care unit so that pharmacists can profile medications on the patient list before meds are removed from the ADU for administration. A: Nursing staff can help to improve medication safety by waiting for pharmacy to profile medications prior to administering medications to their patients. When an override is required, double‐checking of targeted high alert medications by another nurse is critical to prevent errors. R: Overrides on the ADUs should only be used when the patient’s condition may be adversely affected if there is a delay in the administration of the medication. Overrides should be avoided when pharmacy is open. Submitted by: Angela Roode ‐ Diabetes Clinician and PPC ‐ Safe Medication Practice; Linda Chou, Pharmacist; Micky Brankovic, RN ‐ADU Project Trainer
Demystifying Oral Anticoagulants S: Two new oral anticoagulants (dabigatran and rivaroxaban) are now available for stroke prevention in patients with atrial fibrillation. They do not require INR monitoring, however, they have some unique properties that may put patients at risk of bleeding. B: We have had some near misses and actual incidents at HHS where healthcare providers (nurses, pharmacists and physicians) have not recognized some of the new features/unique risks of these drugs.
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A: Declining renal function may require a change in dosing (drug may accumulate and increase bleeding risk). Dabigatran should not be crushed, chewed, or opened. There is no specific antidote for reversing dabigatran and rivaroxaban. A cross program/site Anticoagulation Team developed the tools and resources to assist clinicians to safely monitor these new anticoagulants – this initiative was launched across all three sites in September 2012. R: We need to recognize these anticoagulants and understand what makes them different from the oral anticoagulants we already know (warfarin). Strategies such as safety huddles, posters, quizzes, etc., are underway. Submitted by: Anticoagulation Team
D.I. Biopsy Safety Checklist S: Numerous biopsies are performed on a daily basis in the Diagnostic Imaging (DI) Department. It was necessary to create a department wide system which would ensure consistency and accuracy when sending specimens to the lab. B: With the number of biopsies increasing, and variability in the technologist involved in the biopsy process, it became necessary to standardize a system that would ensure all necessary information sent with specimens to the lab was accurate. A: The D.I. Biopsy Safety Checklist was created. This checklist accompanies every patient undergoing a biopsy. It contains a number of check boxes which must be completed by the technologist, ensuring that all necessary information is included on the lab requisition form and specimen container labels. The patient directly confirms that the name and source of the specimen is correct. This form also includes any patient allergies and necessary RN/Technologist comments. Upon biopsy completion the form is scanned into the patients PACS account. R: The Biopsy Safety Checklist directly impacts biopsy information accuracy and patient safety. It ensures all DI departments and technologists are maintaining information integrity and accuracy when preparing specimens being sent to the lab. It is a “final check” in the biopsy process, necessary within a busy department performing multiple biopsies daily. Submitted by: April Sabatini, Team Lead Ultrasound, Cheryl Coles, Sonographer
Discharge Teaching Tool for the Newborn S: Specific information pertaining to discharge of the newborn speaks squarely to the safety of the newborn after leaving the Hospital environment. It is imperative that parents and guardians of the newborn understand fully the follow‐up care required for the newborn. Reviewing and updating procedures will improve communication between parents of the newborn and nursing staff. B: No specific circumstances leading up to this change were identified, per se, as safety of the newborn on discharge has always been of top concern. Concerns were brought forward more as a way to hone current practices and to improve upon and review practices already in place. A: Current research and practices were reviewed and discussed. An updated Newborn Discharge template/checklist was designed for possible implementation. R: We anticipate the results to be significant improvement in the safety of all facets pertaining to discharge of the newborn. Not only will this improve parents‐of‐the‐newborn to nursing staff communication, it will also provide the
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parents of the newborn a resource to refer to with all instructions clearly communicated. Submitted by: Jacqueline Goodban RN, PNC(C) ‐ Clinical Resource Nurse OBS ‐ MDH
Epidural Infusion Safety – Monitoring the Patient, Not the Pump! S: At HHS the 2C Inpatient Surgery Pain Committee functions to ensure proper pain management and collaboration on methods to enhance patient care with respect to acute pain. Due to early dislodgement of epidurals and concerns from nursing regarding catheter patency, an initiative was started with the 2C Pain Committee to target patient assessment skills verses pump assessment. B: Epidural infusions are an anesthetic technique utilized by Anesthesia for patients with expected acute pain. HHS utilizes epidural infusions for post‐operative pain management for a variety of inpatient surgeries. Although the prevalence of epidural use throughout the three HHS sites is small, the impact of this modality is significant to the patients who require epidurals. A: The Acute Pain Service (APS) worked collaboratively with the Pain Committee to provide education and training around epidural catheters and infusions. The Pain Committee worked at engaging the staff in increasing their overall assessment skills with respect to epidurals, targeting patient specific assessments of skin integrity, dressing intactness, sensory assessment and motor testing to ensure adequate analgesic effect. R: Overall, staff reported an increased satisfaction and level of knowledge regarding epidural catheters. In addition to the increased staff satisfaction on 2C Inpatient Surgery, the patients anecdotally reported that they receive more information and education from their nurses with regards to managing their pain. Submitted by: Carmen Caloian, RN and APS Champion, 2C Pain Committee Member, & Danielle Dunwoody CNS, APS
Examining Our Safety Culture
S: Accreditation Canada requires all healthcare organizations across the country to conduct a ‘patient safety culture’ survey every three years. The survey seeks the opinions and perceptions of clinical staff, those who support patient care and physicians, about patient safety issues at work. HHS launched the survey on October 25th to coincide with the Patient Safety Expos. The four week campaign is underway to engage wide‐spread participation by our staff and physicians.
B: The purpose of the survey is to measure the presence and degree of safety culture. ‘Culture’ is widely recognized as a significant driver in changing behaviour and expectations in order to increase safety in a workplace. Culture can be defined as the pattern of beliefs, values, attitudes, norms, unspoken assumptions and entrenched processes that shape how people behave and work together (NPSA, 2004).
A: All physicians and clinical staff – those in direct clinical / care roles, departments servicing and supporting patient care and their managers and directors and senior team are being asked to participate during the month of November. The survey is quick to do and can be done either on paper or on‐line.
R: The survey results will provide us with valuable insights into our staff and physicians’ perceptions of patient safety, as well as areas of strength and where improvements are needed. Results will be shared across HHS and will help guide the work we need to do together in the coming year!
Submitted by: Lynn Budgell, Patient Safety Coordinator
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Excellent Foot Health Contributes to a Safe Workplace
S: The Oakville Hospital Footcare & Orthotic Centre provides relief to clients suffering from various foot problems. Whether it is custom orthotics, compression stockings, routine nailcare, or more advanced services like diabetic and arthritic footcare, plantar fasciitis, and corns/calluses, the staff provide outstanding personalized care and education to help you maintain your healthy feet.
B: The Oakville Hospital Footcare & Orthotic Centre is owned and operated by HHS, and has been providing a full spectrum of exceptional footcare services for over 20 years.
A: Our team consists of Registered Chiropodists, Registered Practical Nurses, Professional Shoe Fitter, and a Reflexologist. They work with children, adults and seniors, treating a wide variety of foot conditions.
R: To learn more about The Oakville Hospital Footcare & Orthotic Centre or to book a biomechanical assessment with one of our highly trained professionals, please call 905.338.4669 or visit www.OakvilleHospitalFootcare.ca today.
Submitted by: The Oakville Hospital Footcare & Orthotic Centre Team
Flu Campaign 2012 S: Our goal this year is to increase physician, staff and volunteer influenza immunization rates to attain the 70% goal as set by the Ministry of Health and Long‐Term Care. B: Historically, immunization rates fall well below the recommended rate across the province. Last flu season, HHS finished at 43%. A: Occupational Health and Safety (OH&S) is required to identify the barriers or personal reasons individuals will not participate in the flu shot program in 2012.
R: OH&S has created educational material about Influenza facts in Canada that will be distributed by email and is available on the OH&S Connections site. The vaccine launch date was October 15, 2012. We have created a decision form to help us understand the reasons staff are not being immunized. All staff will be treated with respect when they share their reasons to OH&S. We will attend meetings, safety huddles and have a flu cart travel to departments to make it as convenient as possible for everyone at HHS to be immunized.
Submitted by: Karina Prokopchuk, OH&S Manager; Suzanne Hughes, OH&S Nurse; Jennifer Lightowler, OH&S Coordinator; Jacqueline Cassavoy, OH&S Assistant
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Georgetown ED Redevelopment – Integrated Planning S: The Redevelopment Project at Georgetown Hospital includes a new Emergency Department, a renovated Diagnostic Imaging Department and the addition of a CT Scanner. Site work is underway and construction has begun. There will be many changes affecting access and processes during redevelopment and upon occupancy of the new space. Construction for the Emergency Department and CT space will be ongoing for the next year. B: The new physical space will require changes to service and care delivery ‐ patient flow processes, work flow, etc. Changes to access are being experienced beginning with the site preparation phase. A: Operational Readiness Planning will be key to ensuring processes are in place and changes communicated, to ensure safe patient care during construction, on opening day, and beyond. R: The Emergency Department has established an Integrated Planning Group that is engaged in “Operational Readiness” planning. Weekly meetings involve key stakeholders. Various communication techniques are employed to share information with the team and gather feedback. The team is supported by and working closely with The Corporate Operational Readiness project leads. Submitted by: Jennifer Cousins, RN ED; Kim Liley, RN ED; Shirley Andrechek, Patient Care Manager, Emergency Department
Getting the Whole Picture – Videofluoroscopic Swallowing Study S: Speech‐Language Pathologists primarily rely on bedside assessment when abnormalities of swallowing arise, however VFSS (Videofluoroscopic Swallowing Study) can be used in certain cases to provide radiographic insight on what is occurring at the level of the oropharynx.
B: As an increasing number of patients with complex swallowing needs are seen for assessment, VFSS is conducted in a select number of those cases, allowing Speech‐Language Pathologists to better implement swallowing recommendations with confidence, particularly when bedside assessment results are limited. A: Using different food and liquid trials coated in barium, oropharyngeal swallowing can be analyzed through VFSS and therapeutic strategies can be introduced and their effectiveness evaluated. Working with the radiologist and medical radiation technologists, Speech‐Language Pathologists use VFSS in several different ways: to verify aspiration and airway protection, to evaluate efficiency of the swallowing physiology, and to apply positional and/or compensatory strategies to increase swallowing safety. R: VFSS helps to provide recommendations for safe and effective feeding and swallowing, subsequently reducing potentially life‐threatening health outcomes such as aspiration pneumonia, dehydration, and/or malnutrition. VFSS results can also indicate the need for referral to other specialists if swallowing difficulties do not appear oropharyngeal in nature. Submitted by: Alyssa Weinmaster, Speech‐Language Pathologist, OTMH and MDH; Melanie Ribeiro, Speech‐Language Pathologist, OTMH; Adrienne Curran, Speech‐Language Pathologist, OTMH; Nela Wilson, Speech‐Language Pathologist, GH; Michelle Zuzarte, Speech‐Language Pathologist, OTMH
The Go to for 02 S: Oxygen is a medication frequently used in the healthcare setting. It is often taken for granted, and the dangers associated with both oxygen use and storage are commonly forgotten.
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B: As Respiratory Therapists, we frequently find incorrectly stored oxygen cylinders posing a danger to staff, patients and structures. Oxygen is a colourless, odourless, combustable gas that is necessary to maintain human life. Incorrect use of oxygen therapy equipment may result in inaccurate oxygen concentrations being delivered to the patient and has the potential to result in carbon dioxide retention. A: With the assistance of a poster board reviewing the use of oxygen equipment, flow rates, correct storage, hazards, properties, indications for use and oxygen toxicity we hope to prevent hazardous situations and potential harm to patients and staff. R: Increased staff awareness about oxygen safety can prevent incorrect storage and use of equipment, and optimize oxygen therapy. Submitted by: Jennifer Grierson, RRT and Laureen Taylor, RRT on behalf of the Respiratory Therapy Department
Identifying Knowledge Deficits Related to Hydromorphone S: Hydromorphone is one of three top medications found to be associated with harm by the Institute for Safe Medication Practices (ISMP) Canada. The number of Canada‐wide incidents related to harm or death, as of June 30, 2011 was reported to be 160. During 2012, ISMP Canada developed a survey to identify potential knowledge gaps or deficits in various healthcare providers. B: Hydromorphone (Dilaudid ®) is a potent, centrally acting opioid analgesic that is used for moderate to severe pain. Its adverse effects are similar to those of the other opioids used for moderate to severe pain, more specifically, morphine and fentanyl. The primary concern with all three opioids is the risk of respiratory depression. A: Due to the incidents related to HYDROmorphone and its use, ISMP developed a survey to examine the extent of healthcare professionals’ knowledge deficits or gaps that may contribute to incidents. One suggestion from ISMP Canada analysts was that the difference in potency between morphine and HYDROmorphone is not well understood by all health professionals. R: Information about the national survey findings and interesting points about HYDROmorphone and its safety as well as the difference in potency between morphine and HYDROmorphone are being shared across the organization – starting with Safety Expo 2012. Submitted by: Kasia Siek, RN and Danielle Dunwoody, CNS, Acute Pain Service (APS)
Implementation of Primary Care Nursing in the Emergency Department S: When caring for patients in the Emergency Department (ED) it is crucial to identify who is responsible and accountable for the duration and care of that patient in the emergency department.
B: Presently in the ED, there are a couple of nursing models that are practiced depending on the area that the nurse is assigned to. In the treatment area, primary nursing is already established. In the acute/resus area, the nurses are practicing team nursing.
A: There are benefits to a team nursing approach. However, given the nature of the ED it is best practice to have more of a primary approach to nursing care. A primary nursing approach will improve patient care, ensure continuity of care, accountability, and responsibility for patients.
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R: The implementation and change in practice from team nursing to primary care nursing is a slow and evolving process. The ED is in the early phase of implementation. The goal to conduct a pilot in Winter 2013 and achieve full implementation prior to the opening of the New Oakville Hospital.
Submitted by: Carole Dalton, PCM Emergency and Annie Duong PPC Emergency
Implementing ICE‐PACs in the EDs
S: In July 2012, Halton EMS became part of the ICE‐PACs trial involving several regions across Peel, Halton and Toronto. The study involves the randomization of post‐cardiac arrest patients into “cool” or “standard of care” groups. The study is estimated to last two years. Patients randomized to cool will now have their core body temperature lowered in the field with the goal to improve neurological outcomes.
B: Induced Hypothermia in post cardiac arrest patients has increased survival rates and improved patient outcomes. This once critical care process is now being done in the back of an ambulance and crosses over into the Emergency Department (ED). This familiar process for the Critical Care Unit, is a new and exciting process in management of post cardiac arrest patients in pre‐hospital and emergency care.
A: This new change in process has resulted in an urgent need for emergency staff and physician education and guidance. Currently, HHS has seen cooling patients at all three sites.
R: As a response to this demand, a new ED Hypothermia order set is under development. Looking forward, opportunities exist for ongoing education, chart reviews of individual patient outcomes. We will await study results in approximately three years to validate if sooner is better. Submitted by: Annie Duong, PPC, Emergency Services; Karen Vokner, PPC, Milton Family Practice
Improving the Patient Experience with Routine Rounding S: The patient experience has long been challenging to monitor, measure, and improve; particularly for general medicine departments where patient dissatisfaction is not uncommon. Disappointing patient satisfaction scores reflected a need for the Medicine Program at Oakville‐Trafalgar Memorial Hospital to take action. The teams developed, implemented and evaluated an interdisciplinary, standardized and routine rounding practice where patients and families could be integrated into their care plan/processes. B: After reviewing their clinical data, the literature, consultation with other organizations experienced in rounding practices and identifying key desired outcomes, the team decided to focus on five key areas of patient care to be addressed during rounding: pain, positioning, personal care, patient safety, and plan of care. With support of the entire interdisciplinary team, the rounding project was implemented in 2011. A: 5‐P rounding allows staff to address all areas of patient concerns with each encounter. Patients and families are encouraged to fully participate and prepare for each ‘round’ with any questions or information for discussion with staff. This approach helps to guide communication so that patients feel their needs are being completely addressed. R: Implementation of structured and routine rounding is effective in the Medicine Program. It pre‐emptively addresses the common concerns patients have and addresses high priority areas of care. Addressing all of the 5Ps ensures that the basic needs of our patients are met.
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Submitted by: Desa Hobbs, Program Director, Medicine and Critical Care; Jennifer Kustra, Director, Total Rewards and Organizational
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Insulin Administration Safety S: Insulin continues to be reported as a top offender on the list of high alert medication that can result in harmful and serious adverse events for hospitalized patients. B: Approximately 30% of patients in hospital have diabetes. In many cases they will require insulin during their stay to manage blood glucose. Preventable patient harm associated with errors involving insulin use continues to be a problem in hospitals and are often related to use of abbreviations, legibility with physician orders, failure to follow the “leading zero always/no trailing zero” rule and calculation errors. A: Suggested practices to reduce the risk of associated errors with insulin use include the use of pre‐printed orders, order sets, elimination of insulin sliding scales, elimination of commonly used drug abbreviations and implementation of independent double‐check for all insulin administration. R: Consistent use of physician order sets and ongoing use of medication‐safety principles will contribute to the standardization of practices. Careful monitoring of trends by the Diabetes Medication Safety Working group is providing the foundation for improving Insulin Administration Safety at HHS. Submitted by: Angela Roode RN, BScN,CDE and Claire Latto‐Hall RN, BScN
Introducing AIDET to the Milton ED S: The AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You), framework was introduced to improve quality and patient satisfaction through standardizing communication to patients and their families about wait times in the Emergency Department (ED) on arrival at Triage. Education provided by scripting the triage nurse response to information about wait times is an initiative utilized to prevent patient dissatisfaction with perceived wait times.
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B: NRC Picker results were showing that patients wanted improved communication about wait times and processes when they arrived to the ED. The AIDET framework was designed for use in a healthcare setting with a similar patient population where individuals are often anxious and uncertain about their situation. The AIDET tool was then adapted to meet the needs of patients and the department. A: After daily huddles with the ED staff, AIDET was trialed at the Milton District Hospital ED in Spring 2012. Posters and lanyard information were printed and disseminated to staff as an outline of the information to be given. Staff was encouraged to integrate the information into their personal communication using similar language. R: After a great kick‐off, and some slight revisions of the tool, staff felt confident with AIDET. Reminders to staff at huddles and staff meetings continue to keep momentum alive continue, and audits (staff and patient) are being planned. Submitted by: Karen Vokner, PPC – Milton Family Practice; Colleen Schmidt, Interim Patient Care Manager – ICU/ED/Ambulatory Clinics
Keeping Hospitalized Hemodialysis Patients Safe Maintaining Open Communication with our Inpatient Partners S: A review of several incidents regarding the transfer of hospitalized hemodialysis patients between inpatient areas and the dialysis unit has prompted us to review the process of communication and transfer reports. There has been an inpatient communication sheet in place for several years. This has not been consistently used and sometimes the sheet is not complete. B: Renal patients often have more than one co‐morbid condition which may or may not be related to their kidney disease. This can lead to increased hospitalization. As a result, multiple care‐givers are involved including inpatient staff, dialysis staff, hospitalists, nephrologists and other specialists. There is an increased potential for incomplete communication about patient care as the patient is sent to dialysis. A: The current “Hemodialysis Inpatient Communication Record” as well as the transfer process were reviewed as were similar forms from other dialysis programs. We developed a new form (draft) with input from the dialysis and inpatient CRNs. R: Transfer of Accountability at transfer points is an Accreditation ROP. Our plan is to pilot the new form/process on 2East and 3Centre/West for one month before rolling out to the rest of HHS. Anticipated outcomes include: improved reporting system; decrease in medication errors, inappropriate/duplicate blood work; and improved patient safety. Submitted by: Chris Lynskey, PPC Nephrology
Keeping Individuals Safe & Independent in Their Own Homes S: ConnectCARE Emergency Response Service allows seniors to live safely and independently in their own home for as long as possible with a simple press of a waterproof button, 24 hours a day, seven days a week.
ConnectCARE offers a range of sensors including: Fall Detector, CookStop Sensor, Wandering Client Sensor, Flood Detector, Bed Occupancy Sensor and so many more…
B: ConnectCARE Emergency Response Service is owned and operated by HHS, and has been providing Emergency Response Service to Halton and surrounding areas for over 20 years
A: Our state‐of‐the‐art technology allows a two‐way speaker to have live communication between the client and our monitoring centre to ensure appropriate action is taken to get the client the help they need as soon as possible.
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R: To learn more about ConnectCARE Emergency Response Services, please call 1.800.665.7853 or visit www.ConnectCAREHalton.ca today. Submitted by: ConnectCARE Emergency Response Service Team
Managing an Incident – It Takes a Team! S: An important component of any patient safety program is the effective prevention and management of risks in our environment and processes that impact each other and our patients. Our Incident Reporting System (IRS) is a voluntary, on‐line system that lets our employees and physicians report any unintended or unplanned safety incident. Reporting is a key first step to making sure we take action and prevent it from happening again! B: Every time a safety incident is reported it triggers an e‐mail notification to the manager in the area and contributes to being able to track and trend across the organization. Together, the involved team members (who immediately respond and mitigate the problem) and the manager ‐ ensure that the situation is reviewed, solutions identified and actions taken where appropriate. Communication and learning is shared across the team and if relevant, to other areas, programs and sites. A: Each year more than 2200 safety incidents, including ‘near misses’ are reported by the staff at HHS. Our approach is to recognize that most errors represent an opportunity to improve our complex ‘systems’ that often contribute to unintended/unplanned incidents. It is important to ‘thank’ our staff who take the time to complete a report! R: The benefits of a well‐used Incident Reporting System are clear – it allows a window into understanding when and why things go wrong and provides teams with the opportunity to make improvements. Creating a culture of safety takes individuals and teams that work and learn together and communicate effectively across teams and the organization. It is a journey we are on together. Submitted by: Lynn Budgell, Patient Safety Coordinator
Medication Management Project Status Update
S: HHS has embarked on an ambitious plan to modernize our drug distribution system. Automated Dispensing Units (ADUs) have been implemented now at Georgetown Hospital and on most Oakville‐Trafalgar Memorial Hospital (OTMH) nursing units. New robotic technology, known as the BoxPicker – an automated, high speed storage and drug retrieval carousel, as well as a high speed, automated tablet packager, are now live in the main Pharmacy at Oakville.
B: Technology is a key enabler of safe medication distribution and delivery. The ultimate goal is to have unit dose medications prepackaged, labeled and barcoded, ready for administration at the patient bedside. To create a timely and accurate patient record of medication administration for caregivers, nurses issuing the medications will update the patient’s computerized record. The use of barcode scanning will facilitate the eight ‘rights’ of medication administration.
A: While implementation of the new ADUs began at Georgetown Hospital, preparations began for the installation of the BoxPicker and high speed tablet packager (ATP) at the OTMH Pharmacy. Over the fall of 2011 and winter of 2012, nine ADUs were installed at Georgetown Hospital on all nursing units.
This past spring saw the implementation of the ADUs begin on the nursing units at OTMH. To date 4C, 4E, 4W, 3C, 3W, 3E, 2E, 1E, Renal Dialysis 1 & 2, Burlington Satellite Dialysis and 2C have the ADUs operational. Staff were trained by super users on the units and via e‐learning. LEAN exercises were held to guide in workflow redesign. Process revisions are underway on the nursing units.
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R: The ADUs have been well received. Although it is too soon to compare medication administration incidents to the time prior to the use of ADUs, the safety and accuracy inherent in the technology has immediately been experienced. There are multiple checks built into the system to ensure accuracy of meds administered.
The project continues with the installation of 14 additional ADUs at OTMH into the winter of 2013. Next, Milton District Hospital will see 10 ADUs implemented there. Submitted by: Diane Olmstead, Project Manager ‐ Medication Management
The Mental Health Act: Myths and Misconceptions S: Frequently, individuals with mental health needs are admitted to non‐psychiatric units. Often, mental health concerns and the Mental Health Act are ignored or misunderstood. This puts both the patient and the organization at risk. B: The Mental Health Act is an Ontario law that governs how individuals with mental illness are cared for. The Mental Health Act provides clear guidelines and direction that must be adhered to ensure that patient rights are protected. Regardless of the disposition of the patient in the Hospital, the Mental Health Act remains in effect. The organization must ensure that patient rights are respected and care is provided in accordance to the Mental Health Act. A: Members of the HHS team need ongoing support and education to assist in understanding the complexities of the Mental Health Act to properly support and protect individual rights and the unique needs of patients experiencing mental health concerns. R: The Mental Health program supplied a poster board for display at the Patient Safety Expo to highlight key areas of discussion related to the Mental Health Act. This will help to both educate and create awareness among all members of the HHS community. Submitted by: Anthony Wright, PPC Mental Health; Erica Howard, OTA Mental Health
Milton Gives New Life with Trillium Gift of Life S: Milton District Hospital (MDH) ICU had no standardized process for Trillium Gift of Life (TGLN) Notification of Death resulting in the unit not meeting the target of 100% for mandatory reporting of death. A process was required to ensure that all patients meeting criteria were reported to TGLN. B: In January 2012, HHS, MDH, became a designated facility under the Trillium Gift of Life Network Act. This legislation requires the Emergency Department and ICU to call TGLN in all cases where patients meet the indicators of high risk of imminent death or have died. A: While a question in the admission history for ICU related to Organ and Tissue donation has been there for quite some time, it isn’t a mandatory field and is never revisited after the documentation is filed. Therefore, strategies were needed to remind staff on a daily basis which made daily patient rounds an option. In addition, a reminder was added to the death package checklist. Currently, we are working toward adding it to the death note intervention on PCS. R: It is anticipated that there will be earlier discussion and better planning related to end of life and organ/tissue donation, ultimately resulting in achieving the desired 100% reporting of patients. Submitted by: Karen Vokner, PPC – Milton Family Practice; Mallorie Crawford, RN – ICU, Colleen Schmidt, Interim Manager ER/ICU/Ambulatory Clinics
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Minimal Lift and Safe Handling ‐ Know Your Protective Equipment S: In community and healthcare sectors, more than 50% of lost‐time injuries are related to Musculoskeletal Disorders (MSDs). About half of these healthcare‐related MSDs result from client handling. Under the Occupational Health and Safety Liability Act employers must provide a safe workplace, which includes educating staff on MSDs, their prevention and their link to patient handling techniques. Maintaining a safe work place includes utilizing the protective equipment provided in all areas (lifts, slings, sliders, rollaboards etc.). B: MSDs impact a person physically and psychologically. They are the number one type of lost‐time claims reported to the WSIB, resulting in major direct and indirect costs for Ontario employers. Because of the work performed in the healthcare setting, this population is at risk for client handling injuries. Knowing the protective equipment and how to access and use it is key to preventing critical incidents for our staff and patients. A: Staff may not be aware of what protective equipment is available to assist with patient transfers. A comprehensive handout with all types of protective equipment was developed to distribute to all HHS areas. In addition, a multipronged approach for Minimal Lift & Safe Patient handling training and education has been implemented. This approach includes a comprehensive Minimal Lift & Safe Patient handling e‐learning, online transfer equipment videos, monthly practical corporate education sessions for new staff, yearly unit specific Minimal Lift practical educational sessions as well as practical sessions in annual staff skills fairs/department education days. R: It is anticipated that with a continued multipronged approach and clear access to protective equipment to utilize for minimal lift and safe patient handling, HHS will see a decrease in patient related handling injuries. Submitted by: Jennifer Luckanuck, Minimal Lift Coordinator
Neonatal Resuscitation Program (NRP)
S: In 2011, the Canadian Pediatric Society released new guidelines related to neonatal resuscitation.
B: These new guidelines had significant changes to both the clinical and educational components of the program. The team was faced with the challenge of creating an interactive learning environment to deliver the new guidelines.
A: The NRP Instructor Team created a four hour interactive course consisting of four hands on skills stations, an interactive skill station for each participant to consolidate skills, and a simulated resuscitation requiring the entire group of participants to take a team approach in the management of a resuscitation. The courses were planned to be
multidisciplinary in nature and have included RNs, RRTs, Family Physicians, Obstetricians, Pediatricians, Anesthetists, and Emergency Physicians working in Obstetrics, the Special Care Nursery and Emergency Rooms across all three hospitals.
R: To date, we have put approximately 150 interdisciplinary healthcare professionals through the program. Creating a multidisciplinary learning environment with interactive skills stations has better prepared our staff to manage a neonatal resuscitation.
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Submitted by: Tanya Bell, RN; Kathryn Doren, RN; Monica Friesen, RN; Eileen Gagne, RRT; Leann Harper, RN; Deciah Lebel, RN; Anna‐Marie Merchant, RN; Christi Robert, RN; Jonathan Sam, MD
Open the Door to Safety – Awareness is Key S: Work‐Fit Total Therapy Centre offers comprehensive rehabilitation services focusing on improving the safety and well being of our local Halton community clients. We offer speciality programs including Hip and Knee Saver Programs, Vestibular Rehab for Vertigo, Core Stability Training, Pre/Post Natal Physiotherapy, Chiropractic Services, Corporate Wellness & Return to Work Programs, Educational Sessions and Consultations. As a not‐for‐profit service, all net proceeds support hospital HHS programs.
B: Work‐Fit Total Therapy is affiliated with HHS, and has been providing a full spectrum of exceptional rehabilitation services for over 20 years.
A: The Work‐Fit Total Therapy Team works together in developing new and evidence based assessment and treatment programs that are customized to promote well being to our clients.
R: To learn more about Work‐Fit or to book an assessment with one of our highly trained team members ‐ Physiotherapists, Registered Massage Therapists, and or Chiropractors, please call (905) 845‐9540 or visit www.WorkfitPhysiotherapy.ca today.
Submitted by: The Work‐Fit Total Therapy Centre Team
Optimizing RPN Scope of Practice: Care of the Acute Pain Service Patient S: 2Center Inpatient Surgery at Halton Healthcare Services recently changed from an all RN to RN/RPN skill‐mix nursing model. B: After implementation of the new model, the 2Center nursing team identified that for the model to be sustainable long‐term, the RPN scope of practice needed to expand to include the geriatric hip patient population under the care of the Acute Pain Service (APS). A: A collaborative plan was developed by the APS Clinical Nurse Specialist, Geriatric Nurse Practitioner, 2C Patient Care Manager and 2C Clinical Resource Nurse, to create a comprehensive education program for geriatric fractured hip patients for the RPN group. The methodology entailed developing objectives, core curriculum, and a timeline for outcome evaluation. Four RNs from the 2C staff acted as RPN mentors throughout this initiative, attended the education session, and were acknowledged as leaders in pain management and as resources to staff during the roll out process. On July 17th, the expanded scope of RPN practice went live. An audit was completed in August to ensure RPNs were being given the opportunity to utilize the education received. Anecdotal feedback and discussion were encouraged on an individual level and addressed at all subsequent staff meetings. R: Currently, RPNs continue to care for geriatric hip fracture patients and the 2C staff has embraced this change in practice. Inpatient surgery is in the process of hiring additional RPNs who will also be oriented to inpatient surgery using this educational strategy. The collaborative team continues to explore opportunities to provide RPNs with the knowledge, skills, and judgment to optimize their scope of practice. It is advised that, upon implementing a mixed skill set on an inpatient surgical unit, a needs assessment of both RNs and RPNs be performed in order to ensure clinical competence and collaborative efforts of the nursing staff and optimal patient safety with regards to the care provided.
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Submitted by: Elena Bloise RN, BScN, MN; Christian Ocampo, RPN; Danielle Dunwoody, RN, BScN, CNCC(C), MS; Erin Greene, RPN; Sabrina Mascarin, CRN, RN; Christina Moldovan, RN, BScN, M; Kelly Roy, PCM, RN, MS; Colleen Silver, ANP – Geriatrics & Neurology
Patient Chart Labels S: For many years, patient information on Physician order sheets has been achieved using standard ‘addressograph’ cards/machines. When these order sheets are scanned to the Pharmacy Department, the patient information is often blurry or missing key information needed by pharmacy to enter medication orders in Meditech. The same is true for other forms such as Diagnostic Imaging (DI) requisitions. B: During a LEAN rapid improvement event, it was recognized that clear patient information was key to streamlining and improving safety for medication entry. The concept of using ‘labels’ was trialed by a medical unit at Oakville‐Trafalgar Memorial Hospital and resolved many of the issues. Stakeholders in Pharmacy /Lab/DI were consulted re the usage and design—resulting in a label with key patient information similar to patient cards used in the addressographs. A: The solution is actually quite simple ‐ using a print patient chart label routine in Meditech, a sheet of 30 chart labels can be produced for a patient, used on physician order sheets and paper requisitions (does not replace lab specimen labels). Label Stock can be ordered from Staples. R: This new initiative was launched on Monday, Oct. 29, 2012 and staff will be asked to: order the labels for their own area in advance of the live date; place extra labels at the front of the patient’s chart for later use; when placing a label on physician’s orders/requisitions, check carefully to ensure the correct patient; and a reminder that these labels should not be used on two or three part forms such as pathology. It is anticipated that this new process will have a significant impact on improving safety. Submitted by: Deanna Mol, IT Analyst and Grace White, Pharmacy Clinical Manager
Patient Flow is Everyone’s Business S: Increasing Emergency Department (ED) volumes have contributed to patient flow challenges leading to the opening of additional beds during surge at short notice. B: Patient care and patient safety is compromised in this circumstance. Funding linked to patient flow was threatened. A sustainable strategy was required to ensure consistent and smooth patient flow. A: It was determined that the key challenges were: building teams, leadership development, enhanced communications and improved outcomes. R: A culture shift at the front line medicine and ED started with leadership. The poster displays the initiatives/strategies implemented to achieve consistent and smooth patient flow. Submitted by: Desa Hobbs, Program Director Medicine and Critical Care; Deborah Hill, Program Director Emergency/Ambulatory Care and Cardiorespiratory Services
Procedure Able? Check the Coag Table! S: Patient Interventional exams were being cancelled, rebooked or delayed due to patients not being prepared correctly
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for interventional exams in diagnostic imaging.
B: Previously there was a generic protocol for all procedures to withhold anticoagulants for a set timeframe. For specific procedures, this time frame may have been longer or shorter than required which compromised the patient’s safety. There also was no standard method of communication to the patient care units for instructions to withhold anticoagulants. This resulted in patients coming to the Interventional Suite not prepped for the procedure, and additionally wasted time, resources and most importantly, for the patient, there was delay, discomfort and inconvenience.
A: Best practice guidelines were gathered to create the Interventional Radiology Procedure Anticoagulation Management Guideline, an easy to follow resource for staff. The chart has been sent to the units and physicians to follow for patient preparation. It is more specific to patient’s procedure and medications.
R: It has resulted in a reduction in patient rebookings and delays. There has been increased communication with the units and better patient preparation. Ultimately, this has created a safer patient experience.
Submitted by: Ashley Patrick, DI Patient Safety Champion; Colleen Nicholson, DI Nurse; Melanie Maddock, DI Team Leader
Promoting Safety Tool (MORSE, CAM, & Wandering) Use and Documentation
S: HHS is now required to document and assess the “wandering /elopement risk” for all inpatients. This requirement will add another assessment/documentation tool to the healthcare provider’s intervention list.
B: A strategic vision at HHS is to improve patient safety by developing the culture, processes and measurements/tools that are demonstrated to enhance patient safety and reduce adverse events or incidents. HHS currently uses the MORSE Fall risk assessment and the CAM (Confusion Assessment Method) to assess risk for the inpatient population. The introduction of the Wandering/Elopement Risk assessment will aid the clinician in both their clinical reasoning and decision making process as they determine the wandering risk for their patients.
A: The Least Restraint Committee and Falls Prevention Committee were cognizant of the need for this safety/risk documentation, as well as the increased documentation requirements on the clinician. With the launch of the new Wandering/Elopement Risk assessment tool across HHS during the late fall of 2012, the three assessments will then be assembled together under a group assessment heading to facilitate the ease of completion of all three tools.
R: It is anticipated that that grouping of all three of the risk assessment tools will aid the clinician in their clinical reasoning and promotion of patient safety as well as improve compliancy in completion of these required tools.
Submitted by:
Lynn Budgell, RN Coordinator, Quality & Patient Relations; Nancy Greaves PT, Clinical Analyst; Judi Montgomery, PPC Rehabilitation and Geriatric Program
Quick Tips For Falls Prevention – The MORSE S: The ‘MORSE’ is a falls risk assessment tool that is used world‐wide to assist in helping inpatient teams determine who might fall during their hospital stay. The literature tells us that up to 50% of hospital patients are at risk for falls and those who fall have a longer hospital stay. The ‘MORSE’ tool includes six simple questions that are proven to be effective in capturing many who are at ‘high risk’. We recognized an opportunity to improve how we were using this important tool.
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B: The MORSE tool was implemented across most of the inpatient units in 2010 as just one, key component of a new Falls Prevention Program. In 2011, we evaluated how well we were doing. This included conducting audits to determine how often the MORSE risk assessment tool was completed as part of the admission assessment. Our findings – the tool was often incomplete and staff reported that they needed further clarification in a number of areas: gait, mental status, history of falls, and secondary diagnoses. A: With excellent feedback and suggestions in hand, the Falls Committee carefully reviewed the tool with a goal to improve its utility and ease of use, i.e. improving instructions on the tool to assist the user to make the right choice; streamlining the layout and ‘interventions’ section of the tool. This incorporates helpful software functionality that quickly guides the user to the appropriate area on the tool. R: The refreshed MORSE falls risk tool was re‐launched in September 2012 with other components/strategies of the falls program to follow in late fall 2012. Submitted by: Judi Montgomery, PPC Rehabilitation and Geriatric Program, Falls Committee Member
Red Flags for Visitors of Elderly or Friends or Relatives: Signs of Abuse/Neglect or Lack of Coping S: With fewer community resources and higher numbers of seniors, it is easy for elderly people to, “slip through the cracks,” and have their home or health situation deteriorate into a crisis. It is even more likely if family members are out of town and only visit occasionally. B: It is disheartening to have elderly patients found in terrible situations, living in an unsafe or filthy environment or worse yet having been taken advantage of or abused. Usually there may have been some “Red Flags” that could have been identified by a visitor a month or two previously and some action could have taken place. A: These “Red Flags” are directed at families who may only be able to visit occasionally – they highlight what to look for in terms of signs of lack of coping, abuse, or neglect. Then action can be taken before the situation gets out of control. Suggestions are also made as to whom to call for assistance. R: Hopefully the identification of these “Red Flags” will make identification of problem situations easier and quicker and prevent a crisis situation. We will make a pamphlet version for families and also take advantage of opportunities to display the board for educational purposes. Submitted by: Sian Surridge and Jamie Curran, Occupational Therapists, CCC at Oakville
Revitalizing Medication Reconciliation at HHS – Med Rec To Go
S: The “Med Rec To Go” team was assembled to revitalize Medication Reconciliation (Med Rec) and improve the quality of the Best Possible Medication History (BPMH) for patients. Improvement can be achieved by providing re‐education as well as additional tools for creating a BPMH.
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B: Since 2009, HHS has had software in place (Iatrics – PDI) that can be used by all staff to record a patient’s BPMH and use this information for Med Rec. Med Rec is a proven tool to increase patient safety and decrease medication errors; however it is an under‐utilitized tool. The Med Rec To Go team has been put in place to encourage and engage staff to make Med Rec a part of their workflow. Revitalization of Med Rec would better meet the needs of patients as they move across the continuum of care while at HHS.
A: By promoting awareness of access to and use of the HHS “Patient/Family Home Medication List” we are improving the quality and completeness of the medication summary available upon admission to the Hospital. By engaging staff in required Med Rec re‐education and promoting its benefits it is hoped that the rates of Med Rec use will increase across HHS.
R: Support and education for staff, emphasize the importance of performing a BPMH for every admitted patient and further use of that information for Med Rec throughout the patients hospital stay. Informing staff at HHS that there are many resources available to them that can both enhance the quality of, and reduce the time required to obtain a BPMH. Also, encouraging patients to bring an up‐to‐date list of medications to every hospital visit is key.
Submitted by: Elaine Hooper, RN PMP; Cathy Goacher, PPC/Manager NRT; Laura Lachowiez, Nursing Clinical Analyst and Boris Curcic, Pharmacy Analyst
Safer Elder Care – An Innovative Approach to Improving Care of the Hospitalized Older Adults S: Older adults are the fastest growing sector of the population in Canada, with those age 85+ suffering most from chronic illness and frailty. This segment of the population has become the largest consumer of HHS based services and is most at risk for adverse health outcomes as a consequence of hospitalization. The key purpose of the “Safer Elder Care” (SEC) initiative at HHS is to decrease risk and improve the quality of care provided to geriatric patients. B: Utilizing Nurses Improving Care for Healthsytem Elders (NICHE) as an established framework and driven by an interdisciplinary Elder Care Mentor/Champion model, Safer Elder Care (SEC) hardwires ‘best practice’ concepts into core clinical processes targeting common geriatric issues (such as delirium, falls, mobility, continence/catheter use, pain, dementia, skin and wound care) through staff/patient education, policy and practice change. A: Core components include:
Interdisciplinary Steering committee (total = 24) Interdisciplinary Champion Model – Mentors and Champions (total = 101) Clinical management tools:
delirium screening tool (CAM), order set, nursing protocol falls: risk screening, identification and prevention (MORSE, armbands, falling star posters, mats, low beds, exit alarms)
NICHE resources: webinars, e‐learning modules, self‐evaluation Education: CME lunch n’ learns, workshops, patient brochures Performance measurement: SEC process audit tool; Geriatric Institute Assessment Porfile (GIAP) survey; internal and external data sources
R: SEC has achieved many successes, ranging from recognition as an innovative program in the 2008 OHA Patient Safety Handbook to identification as a ‘Leading Practice’ in the 2010 HHS Accreditation. Submitted by: Dr. Kirsten Lindner; Jennifer Luckanuck, OT, PT, MHA; Delayne Haasz, RN, BA, BSN, MSc‐NP (student)
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Safety Huddles Advance the Game! S: Inpatient Rehabilitation is a leader in sustaining weekly ‘Safety Huddles’ for over three years. It has evolved into a valuable process demonstrated by our weekly commitment and the improvement strides made as a result. B: The Safety Huddle was implemented at HHS in 2008. It is a brief (5‐10 minutes) action‐focused meeting of the inter‐disciplinary team that promotes discussion and problem‐solving of patient/staff related safety issues. More than three years ago, Inpatient Rehabilitation seized the opportunity to implement Safety Huddles in order to help advance their safety culture. A: The team now relies on regular weekly huddles as an effective way to communicate safety‐related issues ‐ they are conducted weekly; at the same time and place; with a designated point‐person who rallies the team; documents the issues brought forward and coordinates the action plan. Our ongoing issues and action list remains posted and visible for all to see and has proven to be an effective way to update both the staff and families about our current safety issues and how they are to be resolved. R: We recommend that all areas introduce Safety Huddles. Based on our experience, the benefits to staff and patients are undeniable. With the teams’ involvement we have been able to identify and resolve together more than 250 safety issues. Submitted by: Judi Montgomery, PPC, Rehabilitation and Geriatrics Program
Service Animals: An Important Job To Do S: It is sometimes possible for a person with a disability to be assisted by a service dog. By definition, a service dog is a dog that is individually trained to perform tasks that mitigate the disability of the dog's owner. Think of a service animal as an animal with a job to do for a person with a disability. Since each person experiences a disability differently and therefore has different needs for assistance, each dog is to some extent custom‐trained for the individual it will be helping. B: The customer service standard of the Accessibility for Ontarians with Disabilities Act (AODA) requires Ontario businesses, including hospitals, to let people with disabilities use their service animals on the parts of their premises open to the public or to third parties unless the animal is otherwise excluded by law from the premises. A: This information needs to be disseminated widely across all areas of the organization so that we are in compliance with this legislation, and so that we provide the best possible patient experience to all of our patients. Methods of communication include: on‐line learning, Quality & Safety Savvy, Abbreviations, HHS website and the Patient Safety Expo. R: All hospital staff will recognize service animals and the role they play in assisting patients and visitors who have a disability. Submitted by: Kelly Ingram, Patient Relations Advisor
Shades of Grey In Mental Health Group Inclusion S: A Mental Health Day Program client was physically assaulted outside of the program hours by a co‐client’s friend. His injuries resulted in hospitalization. B: Many of our clients are vulnerable and do not necessarily have the skills to protect themselves, emotionally or physically from dangerous situations. This program receives referrals for people who have or have had involvement with
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the legal system. To facilitate a safe environment we are challenged to decide who is appropriate for a group treatment setting and wonder if we can ethically refuse people on the basis of prior behaviour. A: We chose to turn to the College of Nurses of Ontario’s seven Ethical Values. Using these values in combination with a problem solving format, we developed a model for Ethical Decision Making that could facilitate a safer group treatment environment. R: We are now working toward increased client safety by consistently using the Ethical Decision Making Model. Decisions can be explained and justified by referring to this process. We are hoping to increase education and awareness by creating a Grand Rounds presentation to clear some of the “grey” that is often encountered when differing values and diverging courses of action exist. Submitted by: Jennifer Opper, Angela Everest, Jane Mondano and Corrine Dube, Case Managers, Mental Health Day Program, OTMH
Specialized Geriatric Services at HHS
S: Specialized Geriatric Services (SGS) are defined as interdisciplinary services which diagnose, treat and rehabilitate frail elders with complex and multiple medical, functional and psychosocial problems. The purpose is to reduce the burden of disability by detecting and treating reversible conditions and recommending optimal management of chronic conditions. B: In 2007, the Ministry of Health and Long‐Term Care announced an Aging at Home Strategy. The goal was to provide older adults and their families with an integrated continuum of community‐based services to enable seniors to stay healthy and live more independently in their homes, as well as to reduce pressures on health care system. As a result, the Mississauga Halton Local Health Integration Network (MH LHIN) received funding to support the implementation of this strategy in the Mississauga Halton Region. This led to the implementation of SGS across three hospitals in the MHLHIN. A: Some of the services offered at HHS include a Falls Clinic/Strong and Steady Falls Prevention Program, Urgent Geriatric Assessment Clinics and Geriatric Medical Outreach Program. Performance targets were set by the MH LHIN and include wait times, referrals and number of visits. R: A poster highlighting our services, performance and lessons learned was presented at the International Nurses Improving Care for Health System Elders Conference in March 2012 and showcased at the HHS 2012 Patient Safety Expo. Submitted by: Jacqueline Minezes, Manager Rehab Services
Think About It…Before You Alter an Order S: Physician Orders are often altered by well‐meaning clinicians after the orders have been scanned to pharmacy. Pharmacists often detect and report near misses and occasionally discover actual medication incidents that have occurred because of a bad habit that is hard to break. B: It is tempting to take a short‐cut when correcting information on the patient’s chart. It may seem efficient to alter Physician Orders, but this practice may result in harm to patients and it is considered falsifying a legal record. A: Medication incident reporting data at HHS demonstrates that many clinicians do not properly handle documentation changes that are necessary to ensure that patients are receiving the best care. R: Think about it…before you alter an order. Your patient’s safety is at risk.
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Submitted by: Grace White, Pharmacy Clinical Manager; Janice Mack, Pharmacist
“U” Can Make a Difference! Dangerous Abbreviations and Dose Designations S: The elimination of known dangerous abbreviations, symbols, and dose designations is an example of a medication safety initiative that can immediately improve comprehension of medication orders and reduce the likelihood of misinterpretation leading to error. B: A list has been developed of abbreviations and dose designations that are not to be used at HHS. It is available on HOPP and the requirements have been communicated to staff and physicians over the past several years by different means including memos, newsletters, and poster displays and direct feedback through concurrent review by pharmacists. A: The items on the list have been reported to the Institute for Safe Medication Practices (ISMP) Canada as being frequently misinterpreted and involved in harmful medication errors. HHS clinicians should never use these on any medication‐related documentation when hand‐written or entered as free text into a computer. R: Since the list was published, recommendations have been made to revise some of the items. A survey of participants at the 2012 Patient Safety Expo will be used to review the official HHS list and generate ideas to help us minimize this safety risk to our patients. Submitted by: Helena Trabulsi, Director of Pharmacy and Grace White, Pharmacy Clinical Manager
War & Peace – The Saga of a Community Hospital’s Multidisciplinary Approach to C. difficile S: In 2007, OTMH experienced a significant increase in the incidence of Hospital acquired C. difficile. B: In recent years, the devastating outcomes related to the NAP1 strain along with mandatory public reporting and media attention focused on outbreaks have made C. difficile a top priority for acute care centres and public health units across the province. A: Formed in 2007, the Multidisciplinary C. difficile Management Committee continues to meet regularly to review
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surveillance data and identify prevention and control initiatives. The meetings are scheduled monthly and increased to biweekly or weekly as needed to prospectively respond to increased incidence. R: The multidisciplinary nature and sustained function of the committee ensures that C. difficile remains a clear priority and promotes continuous quality improvement even when the incidence rates are maintained below the facility’s targets. In addition, participation by the Public Health department provides transparency and has allowed HHS to cultivate a collaborative relationship between the organizations. Submitted by: Melanie Koshman, Infection Control Clinician; Shirley Lanza, Manager, Infection Prevention and Control Service; Sean Shu, Consultant, Decision Support; Dr. Neil Rau, Medical Director, Infection Prevention and Control Service
What Is Accessibility? S: HHS is committed to providing accessible service to all persons with disabilities. We must be in compliance with the Accessibility for Ontarians with Disabilities Act (AODA). B: One in seven people in Ontario has a disability. Over the next 20 years, that number will rise as the population ages. AODA was passed in 2005. Its goal is to make Ontario accessible for people with disabilities by 2025. The first standard, the Customer Service Standard, came into effect in 2008. A: We will improve service and the experience of all patients and visitors who have a disability by making small changes in the way we provide care. R: A mandatory eLearning module is available for all staff, physicians and volunteers. The HHS Accessibility & Diversity Committee will provide continued support. Submitted by: Lynn Singh, Director, Quality & Patient Relations; Kelly Ingram, Patient Relations Advisor
Where’s Waldo? S: HHS is committed to fostering a culture that promotes safety and dignity of our patients. Prevention starts with the identification of patients who may be at risk for wandering or elopement. Early identification of patients who may be at risk and development of care plans will minimize Code Yellow events. Response and participation by all staff during a Code Yellow is one of the ways that HHS ensures the safe return of missing patients who may be at risk. B: Every year HHS experiences patients who are away from their Department/Unit and are identified as missing patient(s) and/or have eloped for an unexpected period of time. A: HHS has a multi‐pronged approach to identifying patients at risk, preventing and minimizing Code Yellow incidents. Action required is to raise the awareness of our vulnerable population and our role as staff is to assist in indentifying, preventing and responding to Code Yellow incidents. R: Increasing education and awareness about Prevention and Response is essential to reduce the number of missing patient incidents and to ensure a positive outcome in the case of a Code Yellow. Submitted by: Cindy Svenkenson, Manager, Parking and Security; Jo‐Ann O’Hagan, Supervisor, Parking; Sheryl Brown, Supervisor, Housekeeping/PAL Program; Sonya Martin, Call Centre Operator
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Workplace Violence & Harassment Prevention S: A new Required Organizational Practice (ROP) for Accreditation 2013 requires HHS to implement a comprehensive strategy to prevent Workplace Violence. B: Bill 168 – Violence and Harassment in the Workplace – was created as a result of a tragic occurrence at Hotel‐Dieu Grace Hospital November 12, 2005. Lori Dupont, 37, had been in an unstable relationship for two years with her killer, anesthesiologist Marc Daniel, 50. She had told others at her workplace about her relationship, none of whom reported the incident to anyone else. She died of blood loss after he stabbed her in the chest multiple times with a dagger in the hospital’s recovery room before injecting himself with a lethal dose of an anesthetic. A: HHS recognizes the potential for violence in the workplace and therefore will make every reasonable effort to identify possible sources of violence. R: Through the application of our Workplace Violence and Harassment Prevention Policy and Procedure, we strive to eliminate or minimize these risks. This policy is reviewed annually. Mandatory Workplace Violence e‐learning was launched in 2010 to all staff and is also a requirement for new hires. In early January 2013, we anticipate the launch of our new Occupational Health and Safety Refresher annual mandatory training. Reporting all incidents is important and encouraged! Without reporting, incidents of violence and harassment can quickly escalate or be repeated. Submitted by: Karina Prokopchuk, OH&S Manager; Jennifer Lightowler, OH&S Coordinator; Jacqueline Cassavoy, OH&S Assistant
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Notes
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