| A.C. Camargo Cancer Center |
São Paulo |
Brazil |
Implementation of Rapid Response Teams at Surgical Ward- Massive Bleeding View Commitment
Commitment
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A.C. Camargo Cancer Center
Implementation of Rapid Response Teams at Surgical Ward- Massive Bleeding
Contact Info
Name Aline Chibana
Phone: (011) 218-9511
Email: alineychibana@gmail.com
Position: MD, Quality and Risk Manager - Department of Anesthesiology
Organization Name: A.C. Camargo Cancer Center
Organization Address:
R. Pires da Mota, 1167
Liberdade, 08810-170 Brazil
Participants:
-
Dr. Eduardo Giroud Joaquim - MD, Medical Director
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Implementation of Rapid Response Teams at Surgical Ward- Massive Bleeding How Many Hospitals Will This Commitment Represent? 1 Action Plan
Establish the members of each RRT and the criteria for activating them;
Perform literature review and elaborate protocols
Perform structural changes (difficult airway cart, define priority elevators, pagers etc)
Start a 3-month pilot test - review the results and improve Commitment Timeline
Establish the members of each RRT - November 13th, 2014
Literature review / Protocols - January 15th, 2015
Structural changes - March 20, 2015
Staff training - March 31, 2015
Start 3-month pilot test - April 1st, 2015
Review of results and improvements - July 1st, 2015
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Implementation of a Difficult Airway Team at an Oncologic Center View Commitment
Commitment
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A.C. Camargo Cancer Center
Implementation of a Difficult Airway Team at an Oncologic Center
Contact Info
Name Daniel Gilio
Phone: (119) 114-0220
Email: danielgilio@yahoo.com.br
Position: MD, Quality and Risk Manager - Department of Anesthesiology
Organization Name: A.C. Camargo Cancer Center
Organization Address:
R. Pires da Mota, 1167
Liberdade, 08810-170 Brazil
Participants:
-
Dr. Eduardo Giroud Joaqui,, MS, Medical Director
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Dra. Aline Yuri Chibana, MD, Anesthesiologist
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management Commitment Name:
Implementation of a Difficult Airway Team at an Oncologic Center How Many Hospitals Will This Commitment Represent? 1 Action Plan
Establishment of the members of the team;
Perform literature review and elaborate protocol;
Perform structural changes;
Investment in training and education;
Review of results and improvements.
Commitment Timeline
Establishment of the members of the team - January 2014
Perform literature review and elaborate protocol - March 2014
Perform structural changes - July 2014
Investment in training and education - The whole period
Review of results and improvements - December 2015
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Implementation of Rapid Response Teams at Surgical Ward – Difficult Airway View Commitment
Commitment
×
A.C. Camargo Cancer Center
Implementation of Rapid Response Teams at Surgical Ward – Difficult Airway
Contact Info
Name Aline Chibana
Phone: (011) 218-9511
Email: alineychibana@gmail.com
Position: MD, Quality and Risk Manager - Department of Anesthesiology
Organization Name: A.C. Camargo Cancer Center
Organization Address:
R. Pires da Mota, 1167
Liberdade, 08810-170 Brazil
Participants:
-
Dr. Eduardo Giroud Joaquim - MD, Medical Director
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management Commitment Name:
Implementation of Rapid Response Teams at Surgical Ward – Difficult Airway Commitment Start Date 09/30/2014 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Establish the members of each RRT and the criteria for activating them;
Perform literature review and elaborate protocols
Perform structural changes (difficult airway cart, define priority elevators, pagers etc)
Start a 3-month pilot test - review the results and improve Commitment Timeline
Establish the members of each RRT - November 13th, 2014
Literature review / Protocols - January 15th, 2015
Structural changes - March 20, 2015
Staff training - March 31, 2015
Start 3-month pilot test - April 1st, 2015
Review of results and improvements - July 1st, 2015
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Implementation of Rapid Response Teams at Surgical Ward – Cardiac Arrest View Commitment
Commitment
×
A.C. Camargo Cancer Center
Implementation of Rapid Response Teams at Surgical Ward – Cardiac Arrest
Contact Info
Name Aline Chibana
Phone: (011) 218-9511
Email: alineychibana@gmail.com
Position: MD, Quality and Risk Manager - Department of Anesthesiology
Organization Name: A.C. Camargo Cancer Center
Organization Address:
R. Pires da Mota, 1167
Liberdade, 08810-170 Brazil
Participants:
-
Dr. Eduardo Giroud Joaquim - MD, Medical Director
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Implementation of Rapid Response Teams at Surgical Ward – Cardiac Arrest Commitment Start Date 09/30/2014 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Establish the members of each RRT and the criteria for activating them;
Perform literature review and elaborate protocols
Perform structural changes (difficult airway cart, define priority elevators, pagers etc)
Start a 3-month pilot test - review the results and improve Commitment Timeline
Establish the members of each RRT - November 13th, 2014
Literature review / Protocols - January 15th, 2015
Structural changes - March 20, 2015
Staff training - March 31, 2015
Start 3-month pilot test - April 1st, 2015
Review of results and improvements - July 1st, 2015
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| AACD- Associação de Assistência à Criança Deficiente |
Pernambuco |
Brazil |
Criar uma Cultura de Segurança View Commitment
Commitment
×
AACD- Associação de Assistência à Criança Deficiente
Criar uma Cultura de Segurança
Contact Info
Name Alessandra Fatima de Sousa
Phone: +55(11)5576-0434
Email: afsousa@aacd.org.br
Position: Gerente da qualidade
Organization Name: AACD- Associação de Assistência à Criança Deficiente
Organization Address:
155 Avenida Advogado José Paulo Cavalcanti , Ilha Joana Bezerra, Recife
, 50080-810 Brazil
Participants:
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Leonardo Hiroki Kawasaki , Diretoria Medica Hospitalar
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-
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety
Commitment Name:
Criar uma Cultura de Segurança
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Nosso compromisso visa melhorar o resultado na pesquisa de Cultura de Segurança até o próximo ciclo de 2019. As oportunidades de melhoria relacionam-se as seguintes dimensões:
Percepções gerais da segurança do paciente ( nota de segurança)
Resposta não punitiva ao erro
Commitment Description & Detail:
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade
Action Plan:
Nosso compromisso visa melhorar o resultado na pesquisa de Cultura de Segurança até o próximo ciclo de 2019. As oportunidades de melhoria relacionam-se as seguintes dimensões:
Percepções gerais da segurança do paciente ( nota de segurança)
Resposta não punitiva ao erro
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade Commitment Timeline:
Dimensão 1:
Percepções gerais da segurança do paciente (nota de segurança)
Ação de melhoria 1:
• Reforçar as práticas do disclosure
• Ampliar o uso de gatilhos para identificação de eventos
• Ampliar o sistema de notificação espontânea eletrônica para o CR
• Ampliar as horas de trabalho do profissional dedicado ao gerenciamento de riscos
• Criar um Comitê de Seguranca do Paciente multidisciplinar
Dimensão 2:
Resposta não punitiva ao erro
Ação de melhoria 2:
• Segurança do Paciente e Cultura Justa
• Como construir uma melhoria
• Árvore de decisão para a segurança nas decisões de culpabilidade
Impact DetailsLives SavedPredicted Lives Spared Harm:
0.08 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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| AL JALILA CHILDREN’S SPECIALTY HOSPITAL |
Dubai |
United Arab Emirates |
Patient Safety Challenge: Establishing a Culture of Safety View Commitment
Commitment
×
AL JALILA CHILDREN’S SPECIALTY HOSPITAL
Patient Safety Challenge: Establishing a Culture of Safety
Contact Info
Name Dr. Mohamed Al Awadhi
Phone: 00971-50-4111411 / / 00971-4-2811024
Email: MAAlAwadhi@ajch.ae
Position: Chief Operating Officer
Organization Name: AL JALILA CHILDREN’S SPECIALTY HOSPITAL
Organization Address:
P.O. Box 7662 , Oud Metha , Bur Dubai
Dubai, 7662 United Arab Emirates
Participants:
-
Deborah Norton-Westwood, Director of Quality and Patient Safety Department
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Patient Safety Challenge: Establishing a Culture of Safety Commitment Start Date 02/01/2018 How Many Hospitals Will This Commitment Represent? 1 Action Plan
As a new organization and the first Pediatric stand-alone hospital in the UAE and the gulf region, Al Jalila Specialty Children’s hospital’s commitment to safe, quality care and positive outcomes for our children and their families is foremost. Fundamental in achieving that effort is building a foundation that embodies a ‘Culture of Safety’. The promotion of a culture that at all levels of the organization continuously measures progress in patient safety, identifies and mitigates risks, and encourages shared accountability; a culture that demonstrates a commitment to the provision of safe, effective, timely and equitable care for children, and an exceptional child and family experience.
In establishing a ‘Culture of Safety’ implementation of the following initiatives is necessitated:
1. Review, revise and update the existing Quality Plan - focusing on robust, efficient and effective processes in which to achieve the goal of a high reliability organization.
2. Seek approval of the Quality Plan from the AJCH Leadership Executive and the AJCH Board of Directors
3. Confirm approval for the Quality and Patient Safety Department budget and Organization chart
4. Develop and seek approval for job descriptions for approved Quality and Patient Safety Officers
5. Develop a Project Plan (Gantt chart) with clear goals, action plans inclusive of timelines for implementation of the comprehensive Quality Plan.
6. AJCH to support and implement education and ‘walk the talk’ on the organizational commitment to a ‘Just Culture’ (No blame).
7. Establish a ‘Good Catch’ program to recognize and reward the reporting of near miss adverse events or significant system issues.
8. Develop a comprehensive reporting structure for external/internal reporting inclusive of a bi-directional feedback to clinical and non-clinical staff.
9. Establish an Executive Quality Safety Committee with interdisciplinary representation accountable to the AJCH board to oversee individual department established action plans for patient and families, staff and visitors safety activities throughout the organization (monthly)
10. Establish an interdisciplinary Quality working group (weekly) for bi-directional feedback communication, review of events and issues of concern at unit, departmental and organizational level.
11. Weekly organizational safety rounds that include members of the executive leadership
12. Daily Safety Huddles to promote transparency, teamwork and real-time review of safety events
13. Establish a comprehensive Unit Based Safety Program (CUSP)
14. Provide ongoing patient safety education to clinical and non-clinical staff
o Procure membership with Institute of Health Improvement (IHI)
o Institute of Health Improvement (IHI) Open School of Learning (self-learning modules)
15. Procure an electronic software Adverse Event Reporting System:
o A Request for Information (RFI) will commence within the next one month
o Development of ‘Requirements’ for the software is required for comprehensive evaluation of vendors
o Establish an interdisciplinary evaluation team (end users)
o Through the use of Webinars and a ‘weighted’ evaluation scoring system evaluation of a minimum three (3) vendors will commence.
o Once an Adverse Event software program (e.g. Datix, RL Systems etc.) is chosen, the procurement process (RFI) will commence.
o Once procured, the Quality Department will provide education in the form of in-services to all relevant end users.
o Superusers will also be sought to champion and support any ongoing issues for end user staff.
16. Provide awareness / education on Change Management:
17. Approval will be sought for implementation of a standardized hospital wide communication tool e.g. ‘Team STEPPS’
18. Secure Human Resource policies to promote and protect staff from retaliation e.g. Code of Conduct, Whistle blower, Dignity at Work, Grievance, and Confidentiality
19. Ensure all Framework of Care documents e.g. Policies, Clinical Practice Guidelines, Care Pathways and Procedures are developed in accordance with evidence based or best practice and aligned to Joint Commission International Standards.
Commitment Timeline
As AJCH is a relatively new organization (opened November 2016) and as yet is not fully operational to its’ intended maximum capacity of 200 acute care beds, recruitment and onboarding of a full complement of healthcare team members is an ongoing and top priority. It is our intention that by the end of 2018 that a ‘Culture of Safety’ is commenced in earnest, adopted by all members of the AJCH healthcare team and integrated into the values and everyday culture of the organization.
Impact DetailsLives Lost in Last Calendar Year:8 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
See Action plan described above
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Patient Safety Challenge: Establishing a Culture of Safety – Update – 01.02.19 View Update
Commitment Update
×
AL JALILA CHILDREN’S SPECIALTY HOSPITAL
Patient Safety Challenge: Establishing a Culture of Safety – Update – 01.02.19
Contact Info
Name Dr. Mohamed Al Awadhi
Phone: 00971-50-4111411 / / 00971-4-2811024
Email: MAAlAwadhi@ajch.ae
Position: Chief Operating Officer
Organization Name: AL JALILA CHILDREN’S SPECIALTY HOSPITAL
Commitment DetailsCommitment Start Date: 02/01/2018 How many hospitals are represented in this commitment?
Action Plan:
As a new organization and the first Pediatric stand-alone hospital in the UAE and the gulf region, Al Jalila Specialty Children’s hospital’s commitment to safe, quality care and positive outcomes for our children and their families is foremost. Fundamental in achieving that effort is building a foundation that embodies a ‘Culture of Safety’. The promotion of a culture that at all levels of the organization continuously measures progress in patient safety, identifies and mitigates risks, and encourages shared accountability; a culture that demonstrates a commitment to the provision of safe, effective, timely and equitable care for children, and an exceptional child and family experience.
In establishing a ‘Culture of Safety’ implementation of the following initiatives is necessitated:
1. Review, revise and update the existing Quality Plan - focusing on robust, efficient and effective processes in which to achieve the goal of a high reliability organization.
2. Seek approval of the Quality Plan from the AJCH Leadership Executive and the AJCH Board of Directors
3. Confirm approval for the Quality and Patient Safety Department budget and Organization chart
4. Develop and seek approval for job descriptions for approved Quality and Patient Safety Officers
5. Develop a Project Plan (Gantt chart) with clear goals, action plans inclusive of timelines for implementation of the comprehensive Quality Plan.
6. AJCH to support and implement education and ‘walk the talk’ on the organizational commitment to a ‘Just Culture’ (No blame).
7. Establish a ‘Good Catch’ program to recognize and reward the reporting of near miss adverse events or significant system issues.
8. Develop a comprehensive reporting structure for external/internal reporting inclusive of a bi-directional feedback to clinical and non-clinical staff.
9. Establish an Executive Quality Safety Committee with interdisciplinary representation accountable to the AJCH board to oversee individual department established action plans for patient and families, staff and visitors safety activities throughout the organization (monthly)
10. Establish an interdisciplinary Quality working group (weekly) for bi-directional feedback communication, review of events and issues of concern at unit, departmental and organizational level.
11. Weekly organizational safety rounds that include members of the executive leadership
12. Daily Safety Huddles to promote transparency, teamwork and real-time review of safety events
13. Establish a comprehensive Unit Based Safety Program (CUSP)
14. Provide ongoing patient safety education to clinical and non-clinical staff
o Procure membership with Institute of Health Improvement (IHI)
o Institute of Health Improvement (IHI) Open School of Learning (self-learning modules)
15. Procure an electronic software Adverse Event Reporting System:
o A Request for Information (RFI) will commence within the next one month
o Development of ‘Requirements’ for the software is required for comprehensive evaluation of vendors
o Establish an interdisciplinary evaluation team (end users)
o Through the use of Webinars and a ‘weighted’ evaluation scoring system evaluation of a minimum three (3) vendors will commence.
o Once an Adverse Event software program (e.g. Datix, RL Systems etc.) is chosen, the procurement process (RFI) will commence.
o Once procured, the Quality Department will provide education in the form of in-services to all relevant end users.
o Superusers will also be sought to champion and support any ongoing issues for end user staff.
16. Provide awareness / education on Change Management:
17. Approval will be sought for implementation of a standardized hospital wide communication tool e.g. ‘Team STEPPS’
18. Secure Human Resource policies to promote and protect staff from retaliation e.g. Code of Conduct, Whistle blower, Dignity at Work, Grievance, and Confidentiality
19. Ensure all Framework of Care documents e.g. Policies, Clinical Practice Guidelines, Care Pathways and Procedures are developed in accordance with evidence based or best practice and aligned to Joint Commission International Standards.
Commitment Update:
Year End Progress Report:
In establishing a ‘Culture of Safety’ implementation of the following initiatives is necessitated:
20. Review, revise and update the existing Quality Plan - focusing on robust, efficient and effective processes in which to achieve the goal of a high reliability organization.
A year-end report for the Quality Department is underway much of which will mirror the initiatives implemented below and based on accomplishments and working underway, the Quality Plan will be revised for 2019.
21. Seek approval of the Quality Plan from the AJCH Leadership Executive and the AJCH Board of Directors
As 2018’s report was already approved, this will be done for the 2019 Quality Plan Report.
22. Confirm approval for the Quality and Patient Safety Department budget and Organization chart
Completed inclusive of Job descriptions
23. Develop and seek approval for job descriptions for approved Quality and Patient Safety Officers- Completed
24. Develop a Project Plan (Gantt chart) with clear goals, action plans inclusive of timelines for implementation of the comprehensive Quality Plan. Completed
25. AJCH to support and implement education and ‘walk the talk’ on the organizational commitment to a ‘Just Culture’ (No blame).
26. Establish a ‘Good Catch’ program to recognize and reward the reporting of near miss adverse events or significant system issues. To be implemented in 2019 as it will be incorporated with the electronic Event Reporting System.
27. Develop a comprehensive reporting structure for external/internal reporting inclusive of a bi-directional feedback to clinical and non-clinical staff. External reporting is conducted with our regulatory body monthly and quarterly dependent on information requirements. Internal data KPI’s is publicly displayed and communicated via monthly reports, and though unit based Quality champions.
28. Establish an Executive Quality Safety Committee with interdisciplinary representation accountable to the AJCH board to oversee individual department established action plans for patient and families, staff and visitors safety activities throughout the organization (monthly) Delayed until 2019.
29. Establish an interdisciplinary Quality working group (monthly) for bi-directional feedback communication, review of events and issues of concern at unit, departmental and organizational level. The focus this year has been to initiate and or solidify the foundational structure. Quality Champions for each clinical area and those for non-clinical areas are being reviewed and commencing 2019 regular meetings will be underway with a communication strategy set into place. Key to this will be the implementation of the electronic event reporting system as having a manual system is cumbersome, difficult to maintain and obtaining reliable data is a challenge particularly when resources are slim..
30. Weekly organizational safety rounds that include members of the executive leadership. Environmental Safety Rounds have and continue to be been conducted on all clinical areas with one unit being done per month. A report with items identified, action plans is sent to the department head and displayed for all staff to view.
31. Daily Safety Huddles to promote transparency, teamwork and real-time review of safety events.
These are being conducted twice daily early am and late afternoon to identify any staffing or other issues of concerns. The huddles are well attended and have proven to be an effective mode of communication.
32. Establish a Comprehensive Unit Based Safety Program (CUSP). Postponed until 2019 but the Pediatric Surgical floor will be a trail of CUSP with the Nursing Manager having experience in conducting a CUSP.
33. Provide ongoing patient safety education to clinical and non-clinical staff
o Procure membership with Institute of Health Improvement (IHI)
o Institute of Health Improvement (IHI) Open School of Learning (self-learning modules) Procured but due to the high priority of other projects the Open School or Learning initiative will take effect in the first or 2nd Quarter of 2019.
34. Procure an electronic software Adverse Event Reporting System:
o A Request for Information (RFI) will commence within the next one month
o Development of ‘Requirements’ for the software is required for comprehensive evaluation of vendors
o Establish an interdisciplinary evaluation team (end users)
o Through the use of Webinars and a ‘weighted’ evaluation scoring system evaluation of a minimum three (3) vendors will commence.
o Once an Adverse Event software program (e.g. Datix, RL Systems etc.) is chosen, the procurement process (RFI) will commence.
o Once procured, the Quality Department will provide education in the form of in-services to all relevant end users.
o Superusers will also be sought to champion and support any ongoing issues for end user staff.
o Electronic Event Reporting software has been procured for Risk Event and Patient, Family and Visitor Feedback. Currently we are working with the company localizing the product nomenclature etc to our healthcare environment. Full implementation is anticipated to take approximately 6-8 months.
35. Provide awareness / education on Change Management: Postponed 2019
36. Approval will be sought for implementation of a standardized hospital wide communication tool e.g. ‘Team STEPPS’ Currently we have two TeamSTEPPS Master trainers and are actively seeking to onboard more. If not possible the plan will be to educate current staff to Master Trainers thus enabling provision of the program in the 2nd QTR 2019.
37. Secure Human Resource policies to promote and protect staff from retaliation e.g. Code of Conduct, Whistle blower, Dignity at Work, Grievance, and Confidentiality. A total of 20 HR policies have been completed and are in process of being socialized to all staff.
38. Ensure all Framework of Care documents e.g. Policies, Clinical Practice Guidelines, Care Pathways and Procedures are developed in accordance with evidence based or best practice and aligned to Joint Commission International Standards.
o A new and separate Policy and Procedure template has been introduced for as by definition policies and procedures serve different purposes thus enabling succinct information to the end user. The template includes Compliance references e.g. JCIA, CAP etc., Reference List, Measures of Compliance (where indicated).
o Standards of Care for each Nursing Service for example: Critical Care, Outpatient Department, and the Emergency Department have also been developed. SOC streamline common standards across all services based on clinical condition rather than location and delineating standards unique to each service e.g. Perioperative.
*Additional Accomplishments:
1. College of American Pathologist (CAP) accreditation attained April 2018
2. Scheduled for March 3-7th JCIA Pre-Assessment Survey
3. With the continued work on implementation of our electronic medical record, documentation and issues for the ordering and sending of Lab specimens has been a challenge necessitating for the former education sessions and for the latter, a Performance Improvement Project.
4. A standardized Medication Calculation software program to assess staff’s ability to calculate drugs has been procured and will be introduced in early 2019.
5. A Staff Competency Framework program is being developed across the Nursing and Allied Health Service.
6. General and Nursing Orientation has been revamped moving it from one of passive learning to active learning/participation.
7. Identification of members (parents) for a Patient Advisory Council. Planning and incorporation of Patient Advisory Council membership to be discussed Jan/Feb 2019.
8. Implementation of Executive Leadership Workarounds held monthly. Minutes of the meeting and action items are reviewed and feedback provided to the attendees and unit.
9. Clinical (Key Performance) Indicators have been reviewed and where necessary revised with representatives from each clinical and Non-clinical area. Re-formatting of the KPI’s have been done and rather than using static Quality boards as we have in the past we are endeavoring to upload the information and display digitally for unit chosen and key hospital wide KPI’s.
10. To enhance communication, a hospital wide Intranet is underdevelopment via SharePoint. This will also enable the internal review and publishing of Policies and Procedures as well as maintain version history
11. Key Committees initiated:
o Pharmacy and Therapeutics Committee
o Medical Executive Committee
o Bereavement and Palliative Care Committee
o Child Protection Committee
Your commitment aligns with APSS
Challenge 1 - Culture of safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
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Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
8 |
Lives Lost
13 |
Lives Lost:
13 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
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Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
13 |
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| Advanced Resuscitation Training |
California |
United States |
The Advanced Resuscitation Training (ART) program has been featured at the Patient Safety Movement conference in the past and is the foundation for APSS 11. View Commitment
Commitment
×
Advanced Resuscitation Training
The Advanced Resuscitation Training (ART) program has been featured at the Patient Safety Movement conference in the past and is the foundation for APSS 11.
Contact Info
Name Daniel Davis
Phone: (951) 355-4539
Email: danieldavismd@gmail.com
Position: MD
Organization Name: Advanced Resuscitation Training
Organization Address:
200 West Arbor Drive Hillcrest , San Diego County
San Diego, 92103 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic prevention and resuscitation of in-hospital cardiac arrest Commitment Name:
The Advanced Resuscitation Training (ART) program has been featured at the Patient Safety Movement conference in the past and is the foundation for APSS 11. How Many Hospitals Will This Commitment Represent? 6 Action Plan
This will be an ongoing tally as more hospitals adopt the ART program. Central to the ART program is a data collection effort, including documentation of preventable death reduction. Commitment Timeline
This first estimate of 695 lives includes the UC campuses only. We will update the numbers as we enroll additional institutions in the ART program.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
See APSS 11.
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| Aga Khan University Medical Center |
Sindh |
Pakistan |
Reduction in Anesthetic Medication Errors View Commitment
Commitment
×
Aga Khan University Medical Center
Reduction in Anesthetic Medication Errors
Contact Info
Name Shemila Abbasi
Phone: +922134930051
Email: shemila.abbasi@aku.edu
Position: Assistant Professor
Organization Name: Aga Khan University Medical Center
Organization Address:
Stadium Road, P.O. Box 3500 , Aga Khan University Hospital, Karachi City, Karachi East
Karachi, 74800 Pakistan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication errors Commitment Name:
Reduction in Anesthetic Medication Errors How Many Hospitals Will This Commitment Represent? 1 Action Plan
Action Plan: Standardization of prescription, specific labels, medication audits, e-mail alert, sharing of information at meetings of consultants and trainees, anaesthesia and surgical technicians.
Commitment Timeline
July 2017 to July 2020.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| Alameda Health System |
California |
United States |
Reduce the Rate of Hospital-Acquired Pressure Ulcers View Commitment
Commitment
×
Alameda Health System
Reduce the Rate of Hospital-Acquired Pressure Ulcers
Contact Info
Name Kerin Bashaw
Phone: (510) 535-7576
Email: kbashaw@alamedahealthsystem.org
Position: Vice President, Quality
Organization Name: Alameda Health System
Organization Address:
1411 East 31st Street
Oakland, 94602 United States
Participants:
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Fefe Tequame, Senior Director Patient Care Services. HAPU Harm Reduction Team leader.
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Satira Dalton, Director of Quality and Performance Improvement.
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Claudia Landau, HAPU HRT Physician Sponsor.
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Annette Johnson, Data Analyst
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Kathie Shea, Quality Coordinator
Commitment DetailsCommitment Name:
Reduce the Rate of Hospital-Acquired Pressure Ulcers Action Plan
With support from executive sponsors and direction from a multi-disciplinary Harm Reduction Team, the health system is implementing a comprehensive HAPU reduction plan. Before January 2014, waffle mattresses will be available for use on all nursing floors. We hope to have trained and staffed new Skin Champions before April 2014. By June 2014, prevention and treatment guidelines including standardized electronic documentation will be rolled out to the hospital units. Accompanying audits and standardized processes for ensuring accountability related to wound care will be carried out by nurse managers. By August 2014, reporting of key data elements related to ulcers and wound care will be automated in the EHR, and regularly monitored by nurse managers and the Quality Improvement department. As the overall commitment completion date of December 2014 approaches, we plan on embedding all of these interventions into the culture and standard work at AHS.
Commitment Timeline
By December 31st 2014, our goal is to reduce the rate of stage 1-4 hospital acquired pressure ulcers to 0.63 per 1,000 discharges.
Impact Details
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Reduce the Rate of Hospital-Acquired Pressure Ulcers – Update View Update
Commitment Update
×
Alameda Health System
Reduce the Rate of Hospital-Acquired Pressure Ulcers – Update
Contact Info
Name Kerin Bashaw
Phone: (510) 535-7576
Email: kbashaw@alamedahealthsystem.org
Position: Vice President, Quality
Organization Name: Alameda Health System
Commitment DetailsCommitment Start Date: 12/20/2013 How many hospitals are represented in this commitment?
Action Plan:
Commitment Update:
AHS has continued to develop their Skin Champion program, adding more nurses and increasing their presence. These specially educated nurses provide a resource on the hospital floors to consult with regarding HAPU prevention and treatment. Furthermore, they extend education to the bedside for other nurses. To increase the visibility of HAPU risk for patients, visual cues have been used in nursing common areas as well as patient rooms to indicate patients that require prevention measures. A guideline detailing expectations regarding wound care for each unit has been developed and monitored for compliance. New products such as skin barriers and waffle mattresses are being utilized on the hospital floors. All of these efforts are coordinated and monitored by the HAPU Harm Reduction Team, which is a multidisciplinary group of nurses, physicians, and quality improvement staff.
Your commitment aligns with APSS
Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Impact Details
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| Apollo Hospitals |
Delhi |
India |
To Improve Hand Hygiene Compliance View Commitment
Commitment
×
Apollo Hospitals
To Improve Hand Hygiene Compliance
Contact Info
Name Ms Pritindira Sachdeva
Phone: +91-011-29873037
Email: pritindira_s@apollohospitalsdelhi.com
Position: Lead- Apollo Quality Program and Special Initiatives
Organization Name: Apollo Hospitals
Organization Address:
Mathura Road , Jasola, South Delhi
New Delhi, 110020 India
Participants:
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Mr Gaurav Loria, Head-Quality, Apollo Hospitals Group
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Dr R. S Uberoi, Chief Quality Officer, Indraprastha Apollo Hospitals, Delhi
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Mr Balaji, Head-Quality, Apollo Hospitals, Chennai
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Dr Yatheesh, Head-Quality, Apollo Hospitals, Bangalore
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Dr Maitrayee, Senior Manager-Quality, Apollo Hospitals, Kolkatta
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
To Improve Hand Hygiene Compliance Commitment Start Date 05/15/2017 How Many Hospitals Will This Commitment Represent? 40 Action Plan
The action plan includes a uniform policy for implementation of Hand Hygiene and plans for monitoring and sustenance. Periodic Gap Assessment to check resources for hand hygiene across the facility, regular and ongoing training for various staff categories, posters to motivate and remind staff comprise the action plan. Further included are the audit and observation schedules, compliance results reporting and action taken by department heads. Hand Hygiene campaigns help to invigorate the staff. Commitment Timeline
2 Years
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
As per APSS #2A
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To Improve Hand Hygiene Compliance – Update – 10.08.2019 View Update
Commitment Update
×
Apollo Hospitals
To Improve Hand Hygiene Compliance – Update – 10.08.2019
Contact Info
Name Ms Pritindira Sachdeva
Phone: +91-011-29873037
Email: pritindira_s@apollohospitalsdelhi.com
Position: Lead- Apollo Quality Program and Special Initiatives
Organization Name: Apollo Hospitals
APSSWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene How many hospitals are represented in this commitment?
Did you download and use the APSS in tandem with your action plan?
Yes Commitment Name:
To Improve Hand Hygiene Compliance – Update – 10.08.2019 Commitment DetailsCommitment Update:
Based on the APSS #2A Hand Hygiene given by the Patient Safety Movement Foundation, we improvised and developed the Hand Hygiene(HH) Toolkit. The
components of this toolkit included:
1. Policy on Hand Hygiene
2. Plan for Implementation, Monitoring, Reporting and Sustenance for Hand Hygiene Compliance
3. Workflow for Hand Hygiene Compliance
4. Gap Assessment- Hand Hygiene Facilities Measurement Audit Tools
5. Hand Hygiene Compliance Observation Form
6. Hand Hygiene Training Module for Staff
7. Hand Hygiene Training Module for Observers and Champions
8. Presentation Template- for reporting Hand Hygiene compliance results
9. Posters on Hand Hygiene
10. Motivational Films for Hand Hygiene
The Hand Hygiene Toolkit (comprising of the listed essential 10 components) was circulated to the Quality Teams the 40 units of Apollo Hospitals for immediate
implementation in May 2017.
Compliance to Hand Hygiene improved through the month on month(MOM) monitoring of the HH Toolkit implementation.
Compliance of the HH Toolkit was linked to the monthly report card of each of the Apollo Hospitals units and the unit wise Medical Directors.
The role of the Infection Control Teams was critical to the improvement of Hand Hygiene Compliance
The Medical Heads, Quality Teams, Nursing Teams, Infection Control Teams and all other Support Departments at each Apollo Hospitals, work in unison to promote the compliance of Hand Hygiene. This is achieved through-
Ongoing Trainings
- Audits
- Leadership rounds
- Campaigns and events Best Practices:
Status- Hand Hygiene Compliance
We're happy to report our current status as it relates to hand hygiene compliance.
I. 21 of our most improved locations have increased their compliance levels from 86.5%
(baseline) to 92.72% (2019)
II. The current Average Hand Hygiene Compliance Levels- across our 40 hospitals is –
90.63(baseline) to 92.39% (2019) Impact Details Lives Saved
Methodology for Determining Lives Saved:
N/A
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Mejorar el cumplimiento de higiene de las manos View Commitment
Commitment
×
Apollo Hospitals
Mejorar el cumplimiento de higiene de las manos
Contact Info
Name Ms Pritindira Sachdeva
Phone: +91-011-29873037
Email: pritindira_s@apollohospitalsdelhi.com
Position: Lead- Apollo Quality Program and Special Initiatives
Organization Name: Apollo Hospitals
Organization Address:
Mathura Road , Jasola, South Delhi
New Delhi, 110020 India
Participants:
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Mr Gaurav Loria , Head- Quality
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Dr. R. S Uberoi, Apollo Hospitals Group
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Mr Balaji, Chief Quality Officer
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Dr Yatheesh, Indraprastha Apollo Hospitals
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Dr Maitrayee, Delhi
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, Head-Quality
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, Apollo Hospitals
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, Chennai
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, Head-Quality
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, Apollo Hospitals
Commitment DetailsCommitment Name:
Mejorar el cumplimiento de higiene de las manos Commitment Start Date 05/15/2017 Action Plan
Impact DetailsHow many lives do you expect to spare from harm in the next calendar year 1
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Mejorar el cumplimiento de higiene de las manos View Commitment
Commitment
×
Apollo Hospitals
Mejorar el cumplimiento de higiene de las manos
Contact Info
Name Ms Pritindira Sachdeva
Phone: +91-011-29873037
Email: pritindira_s@apollohospitalsdelhi.com
Position: Lead- Apollo Quality Program and Special Initiatives
Organization Name: Apollo Hospitals
Organization Address:
Mathura Road , Jasola, South Delhi
New Delhi, 110020 India
Participants:
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Mr Gaurav Loria , Head- Quality, Apollo Hospitals Group
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Dr. R. S Uberoi, Chief Quality Officer, Indraprastha Apollo Hospitals, Delhi
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Mr Balaji, Head-Quality, Apollo Hospitals, Chennai
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Dr Yatheesh, Head-Quality, Apollo Hospitals, Bangalore
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Dr Maitrayee, Senior Manager-Quality, Apollo Hospitals, Kolkatta
Commitment DetailsCommitment Name:
Mejorar el cumplimiento de higiene de las manos Commitment Start Date 05/15/2017 Action Plan
El plan de acción incluye una política uniforme para la implementación de Higiene de las Manos y planes para el monitoreo y sustento. Evaluación periódica de la brecha para verificar los recursos para la higiene de las manos a través de la instalación, la formación regular y continua para diversas categorías de personal, carteles para motivar y recordar al personal comprenden el plan de acción. Se incluyen además los planes de auditoría y observación, los informes de resultados de cumplimiento y las medidas adoptadas por los jefes de departamento. Las campañas de Higiene de las Manos ayudan a revitalizar al personal. Commitment Timeline
2 años
Impact DetailsMethodology for Determining Lives Saved:
Según APSS, # 2A
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| Banner Health University Medical Center Tucson |
Arizona |
United States |
Commitment to Airway Safety View Commitment
Commitment
×
Banner Health University Medical Center Tucson
Commitment to Airway Safety
Contact Info
Name Kurt Denninghoff
Phone: 520-626-1551
Email: kdenninghoff@aemrc.arizona.edu
Position: Distinguished Professor of Emergency Medicine, Associate Head of Research
Organization Name: Banner Health University Medical Center Tucson
Organization Address:
1501 North Campbell Avenue Campus Farm , Pima County
Tucson, 85724 United States
Participants:
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James R. Miner, MD, Chief, Emergency Medicine
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David W. Wright, MD, Professor and Vice Chair, Innovation and Discovery
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned extubation Commitment Name:
Commitment to Airway Safety How Many Hospitals Will This Commitment Represent? 1 Action Plan
The Unplanned Extubation Clinical Trial Group consists of Banner University Medical Center Tucson, Hennepin County Medical Center Minneapolis, and Emory University/Grady Memorial Hospital Atlanta. This group of hospitals are committed to improving patient safety and eliminating preventable deaths related to unintentional (unplanned) removal of patients' life sustaining breathing tubes, known as unplanned extubation. Although none of our three participating facilities currently track unplanned extubation, a very clear safety signal in the medical literature suggests that approximately 7.3% of mechanically ventilated ICU patients experience an unplanned extubation. In our three facilities, we care for approximately 4,500 mechanically ventilated ICU patients years, which would predict 330 patients will experience an unplanned extubation each year. These 330 incidences of unplanned extubation will lead to:
1. 93 cases of Ventilator Associated Pneumonia (VAP)
a. The rate of VAP in mechanially ventilated ICU patients experiencing Unplanned Extubation is 28% compared to the rate 14% rate of VAP seen in uncomplicated
mechanically ventilated patients.
2. 63 Deaths
3. $13.5 Million in wasted healthcare costs.
Therefore, we are committed to clearly defining the problem in our facility and developing processes to eliminate related preventable deaths. Therefore, we will work to develop the following:
1. First, we will develop a system to track extubation data on every intubated, mechanically ventilated patient, including intentional (planned) extubation and unintentional (unplanned).
2. Using the PSMF Core UE Dataset, we will track all incidences of unplanned extubation and develop a quality management system to decrease the rate of UE and eliminate preventable deaths from UE.
a. We will perform a root cause analysis of every unplanned extubation
3. We will work to institute the Patient Safety Movement Foundation Actionable Patient Safety Solutions (APSS) 8B for Airway Safety- Unplanned Extubation
4. One of the Actionable Patient Safety Solutions for preventing unplanned extubation is to standardize tracheal tube restraint devices, utilizing the most proven methods/devices. However, the current literature does not clearly identify any device or technique currently on the market that is superior at preventing unplanned extubation. The PSMF Unplanned Extubation APSS 8B Technology PLan describes a restraint device that was found to restrain against significantly greater forces compared to other systems such as adhesive tape, Laerdal Thomas Tube Holder and the Hollister AnchorFast. Because bench data suggests superiority of the SolidAIRity device in restraining against force, it is also likely to significantly decrease the incidence of unplanned extubation. However, this must be proven. The device, the SolidAIRity Airway Stabilization System is expected to receive FDA 510K market clearance mid-2018. To answer the question, "Is the SolidAIRity Airway Stabilization System superior at preventing unplanned extubation?", The Unplanned Extubation Clinical Trial Group will participate in a multi-center study that will compare the unplanned extubation rate in patients whose endotracheal tubes are restrained by the SolidAIRity Airway Stabilization System versus HCMC's curennt standard of care tube restraint device, the Hollister AnchorFast. Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year 330 How many lives do you expect to save in the next calendar year 69 Methodology for Determining Lives Saved:
The three facilities that make up the UE Clinical Trial Group combined cares for the approximately 4,500 mechanically ventilated ICU patients yearly. Based upon the 7.3% unplanned extubation rate described in an extensive literature review published in Anesthesia and Analgesia in 2012, it is expected that 330 patients will experience an unplanned extubation. Of those 330 patients, 93 patients (28%) will develop a ventilator associated pneumonia and 63 patients (19%) will die.
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| Baylor Scott & White Health Care System |
Texas |
United States |
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk. View Commitment
Commitment
×
Baylor Scott & White Health Care System
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk.
Contact Info
Name Don Kennerly MD, PhD
Phone: (214) 265-3621
Email: donaldk@baylorhealth.edu
Position: Chief Patient Safety Officer
Organization Name: Baylor Scott & White Health Care System
Organization Address:
3500 Gaston Avenue
Dallas, 75246 United States
Participants:
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Joel Allison, President and CEO Baylor Scott & White Health Care System
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Don Kennerly, MD, PhD, Chief Patient Safety Officer. Baylor Scott & White Health Care System
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David Ballard, MD, PhD, Chief Quality Officer, Baylor Scott & White Health Care System
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Jan Compton, RN, BSN, Chief Patient Safety Officer, Baylor Scott & White Health Care System North
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Michael Ramsay, MD, FRCA Chairman Department of Anesthesiology, Baylor University Medical Center
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The Breathe Team, Baylor University Medical Center
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk. How Many Hospitals Will This Commitment Represent? 46 Action Plan
The plan is already in place but is being updated regularly and enhanced. Milestones Completed:
39.5% reduction in Hospital Standardized Mortality Rate in 5 years (year on year = 9.6% / yr). 360 fewer
deaths in last 2.5 years
45% reduction in preventable hospital acquired adverse events in last 4 years Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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High Risk Surgery Initiative View Commitment
Commitment
×
Baylor Scott & White Health Care System
High Risk Surgery Initiative
Contact Info
Name Jan Compton
Phone: 214-265-3622
Email: jan.compton@bswhealth.org
Position: Chief Patient Safety Officer
Organization Name: Baylor Scott & White Health Care System
Organization Address:
3500 Gaston Avenue
Dallas, 75246 United States
Participants:
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Robert A. Probe MD,FAAOS, Chief Medical Officer Baylor Scott and White Health
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David J. Ballard, MD, MSPH, PhD, FACP, Chief Quality Officer Baylor Scott and White Health and President STEEEP Global Institute
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
High Risk Surgery Initiative How Many Hospitals Will This Commitment Represent? 23 Action Plan
All final recommendations are approved through the The Baylor Scott and White Health STEEEP Governance Council. After approval of each procedure, a notification letter is sent to senior leaders and physician providers with recommended hospital volumes and required program elements.
For surgeons wishing to continue to provide these services within the Baylor Scott & White System, we are encouraging application for privileges at one of the hospitals meeting minimum volume requirements. Commitment Timeline
This high risk surgery work began in fall of 2015. The expected implementation date is June 30, 2017 which includes the initial 11 procedures. BSWH plans to evaluate other procedures that may benefit from this process. For this reason, we entered a completion date for the initial 11 procedures, but not for the ongoing evaluation of additional procedures.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
The estimated number of lives saved for High Risk Surgeries for calendar year 2017 is 12, and 20 for calendar year 2018. This was calculated using mortality estimates reported in literature along with procedure volumes in identified low volume BSWH facilities.
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| Beneficencia Española de Tampico |
Tamaulipas |
Mexico |
Calidad y Seguridad del Paciente View Commitment
Commitment
×
Beneficencia Española de Tampico
Calidad y Seguridad del Paciente
Contact Info
Name JUAN ARMANDO MONROY
Phone: 8332412363
Email: AMONROY@BENE.COM.MX
Position: Quality Manager
Organization Name: Beneficencia Española de Tampico
Organization Address:
3909 Avenida Miguel Hidalgo , Guadalupe
Tampico, 89120 Mexico
Participants:
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Juan Armando Monroy, Ing. Arq.
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
No What Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Calidad y Seguridad del Paciente Commitment Details/h6>Commitment Summary:
Fortalecer el proceso de prevención de caídas a través de su re diseño, incorporando tecnologías y buenas prácticas aplicables a todo tipo de pacientes. Mejorar la participación y comunicación con el paciente y sus familiares. Action Plan:
Mapear el proceso actual, rediseñar el proceso incorporando escalas de evaluación aplicables a los diferentes grupos de pacientes, así como tecnologías para recolección de datos e información, evaluación del paciente, para la detección de caídas, para la educación del paciente y la familia, así como para el desarrollo de herramientas de calidad calidad y metodologías que apoyen a la investigación, acción y atención cuando estas ocurran. Impact Details Lives Saved
Lives Spared Total:
0.03300000000000001 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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| Brigham and Women’s Hospital |
Massachusetts |
United States |
Improve the overall quality and safety of the preparation and testing of compounded sterile products in the pharmacy department. View Commitment
Commitment
×
Brigham and Women’s Hospital
Improve the overall quality and safety of the preparation and testing of compounded sterile products in the pharmacy department.
Contact Info
Name William Churchill
Phone: (617) 732-7164
Email: wchurchill@partners.org
Position: Chief of Pharmacy Services
Organization Name: Brigham and Women’s Hospital
Organization Address:
75 Francis Street
Boston, 02115 United States
Participants:
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Chief of Pharmacy Services
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Pharmacy Managers
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Pharmacy Technicians
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Pharmacists
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Pharmacy Quality Assurance Coordinator
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3 - Medication safety Commitment Name:
Improve the overall quality and safety of the preparation and testing of compounded sterile products in the pharmacy department. How Many Hospitals Will This Commitment Represent? 1 Action Plan
BWH is a 793 licensed bed tertiary care academic medical center. BWH dispensed over 8.5 million doses of medications to our inpatients of which approximately 1.2 million are IV admixtures.
Initial use of IV robotics began in 2008 with a Cytocare robot. We now have 4 IV Station robots on site, 4 IV soft workflow assist devices, and an IV station ONCO (Chemo robot) due on site early spring. Q/A coordinator (microbiologist) Hired June 2013.
Interface of robot software with BWH pharmacy system complete.
Implementation of Simplify documentation system November 2013.
Currently 60% of IV admixtures are being made with gravimetic assessment.
Target is 85% by end of Fiscal year 2014 Commitment Timeline
Timeline is for total implementation to be at end of FY 2015
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL |
Estado de México |
Mexico |
Conservar la Seguridad del Paciente por Riesgo de Caídas Dentro de Su Proceso Quirurgico por la Limitación Visual del Paciente. View Commitment
Commitment
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Conservar la Seguridad del Paciente por Riesgo de Caídas Dentro de Su Proceso Quirurgico por la Limitación Visual del Paciente.
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DIRECTOR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
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ISABEL ELVIRA MUCHARRAZ GARCIA, JEFA DE ENSEÑANZA, INVESTIGACION Y CALIDAD
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults Commitment Name:
Conservar la Seguridad del Paciente por Riesgo de Caídas Dentro de Su Proceso Quirurgico por la Limitación Visual del Paciente. Commitment Start Date 08/01/2018 How Many Hospitals Will This Commitment Represent? 3 Action Plan
El riesgo de caídas por la limitación visual del paciente Commitment Timeline
Capacitación a los pacientes y familiares con material de apoyo
01/agosto/2018
Capacitación al personal
01/agosto/2018 (2 veces por mes )
Aplicación de la cedula de evaluación
Mensual
Evaluación de resultados
Cuatrimestral de acuerdo con los resultados del sistema INDICAS
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
no aplica
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Conservar la Seguridad del Paciente por Riesgo de Caídas Dentro de Su Proceso Quirurgico por la Limitación Visual del Paciente. – Update – 04.24.19 View Update
Commitment Update
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Conservar la Seguridad del Paciente por Riesgo de Caídas Dentro de Su Proceso Quirurgico por la Limitación Visual del Paciente. – Update – 04.24.19
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DIRECTOR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Commitment DetailsCommitment Start Date: 08/01/2018 How many hospitals are represented in this commitment?
Action Plan:
De acuerdo con la OMS, se calcula que actualmente más de mil millones de personas, o sea, un 15% de la población mundial, padece alguna forma de discapacidad y se estima también, que el 82% de todas las personas con ceguera son mayores de 50 años y se prevé que este número aumentará con el envejecimiento de la población mundial. Dependiendo del grupo y las circunstancias, las personas con discapacidad pueden experimentar una mayor vulnerabilidad a afecciones secundarias, comorbilidad, enfermedades relacionadas con la edad y una frecuencia más elevada de comportamientos nocivos para la salud y muerte prematura.
Los trastornos de las funciones visuales pueden provocar importantes alteraciones en la vida del individuo que los padece, ocasionándole limitaciones en el desempeño o realización de las actividades propias y restricciones en su participación en situaciones vitales; si la discapacidad aparece en personas mayores, se ve modulada por las características propias de ese grupo de edad. Su aparición suele cambiar las estrategias y recursos habituales para resolver las necesidades de la vida, y conlleva un proceso de ajuste a la nueva situación; por ello, la comprensión del mismo, la identificación de las variables que lo componen y su evaluación con instrumentos psicológicos adecuados es de gran relevancia.
La pérdida de visión representa para la persona que la padece, un importante cambio en su vida. Las estrategias que utilizaba para resolver las cuestiones de la vida, desde lo más simple a lo de gran complejidad, pueden verse inutilizadas o modificadas. El desarrollo de actividades aprendidas informalmente (caminar, comer, cuidar la higiene personal o realizar actividades ligadas al ocio o al deporte) o formalmente (leer y escribir, conducir o manejar tecnología) se ve dificultado y para poder seguir desarrollándolas, deben reaprenderse o modificar sustancialmente las estrategias necesarias para su ejecución.
El afrontamiento de la vida en las nuevas circunstancias (la funcionalidad visual consecuente con la pérdida y las limitaciones y restricciones provocadas por el cambio de funcionalidad) requiere de un esfuerzo psicológico, social y funcional (incluyendo las estrategias e instrumentales emocionales y cognitivas que deban modificarse, activarse o aprenderse, y los posibles cambios sociales y contextuales).
La causa principal que da origen a este problema es el perfil de los pacientes que acuden a solicitar atención en el CEAPDV, los que presentan grados diversos de discapacidad visual, a lo que se agrega que las instalaciones del Centro no cumplen por completo con las especificaciones que se establecen en la Norma Oficial Mexicana NOM-030-SSA3-2013, Que establece las características arquitectónicas para facilitar el acceso, tránsito, uso y permanencia de las personas con discapacidad en establecimientos para la atención médica ambulatoria y hospitalaria del Sistema Nacional de Salud, circunstancia que no sólo pone en riesgo a los usuarios de la unidad, ya que también implica un riesgo aún no determinado para los servidores públicos que aquí laboran; adicionalmente, a la fecha no se cuenta con un instrumento que permita determinar el nivel de riesgo de caídas tanto para los pacientes como para el personal del Centro, acorde con las características tanto de los pacientes como del tipo de servicio que se otorga, al ser este un hospital de atención ambulatoria.
Debido a lo anterior, se realizaron los siguientes cambios al Plan de Acción originalmente desarrollado:
I. La Prevención de Caídas de Usuarios y Prestadores de Servicios en la Atención de la Salud Oftalmológica fue incluida como un proyecto particular dentro del Plan de Mejora Continua de la Calidad en Salud 2019.
According to the WHO it is estimated that currently more than one billion people, or 15% of the world population, suffer from some form of disability and it is also estimated that 82% of all people with blindness are older 50 years and it is expected that this number will increase with the aging of the world population. Depending on the group and the circumstances, people with disabilities may experience greater vulnerability to secondary conditions, comorbidity, age-related diseases and a higher frequency of behaviors harmful to health and premature death.
Disorders of visual functions can cause important alterations in the life of the individual who suffers, causing limitations in the performance or performance of own activities and restrictions on their participation in life situations; if the disability appears in older people, it is modulated by the characteristics of that age group. Their appearance usually changes the habitual strategies and resources to solve the necessities of life, and entails a process of adjustment to the new situation; therefore, the understanding of it, the identification of the variables that compose it and its evaluation with appropriate psychological instruments is of great relevance.
The loss of vision represents for the person who suffers it an important change in his life. The strategies used to solve the issues of life, from the simplest to the most complex, may be rendered useless or modified. The development of activities informally learned (walking, eating, taking care of personal hygiene or doing activities related to leisure or sports) or formally (reading and writing, driving or managing technology) becomes difficult and to continue developing them, they must be relearned or substantially modify the strategies necessary for its execution.
The coping of life in new circumstances (the visual functionality consequent with the loss and the limitations and restrictions caused by the change in functionality) requires a psychological, social and functional effort (including emotional and cognitive strategies and instruments that must be modified, activated or learned, and the possible social and contextual changes).
The main cause that gives origin to this problem is the profile of the patients that come to request attention in the CEAPDV, those presenting diverse degrees of visual incapacity, to which it is added that the facilities of the Center do not completely fulfill with the specifications that are established in the Official Mexican Standard NOM-030-SSA3-2013, Which establishes the architectural characteristics to facilitate access, transit, use and permanence of people with disabilities in facilities for ambulatory and hospital medical care of the National Health System , circumstance that not only puts at risk the users of the unit, since it also implies a risk not yet determined for the public servants that work here; in addition, to date there is no instrument to determine the level of risk of falls for both patients and Center staff, according to the characteristics of both the patients and the type of service that is granted, being this an ambulatory care hospital.
Due to the above, the following changes were made to the originally developed Action Plan:
I. The Prevention of Falls of Users and Services Providers in the Ophthalmological Health Care was included as a particular project within the Continuous Improvement Plan of the Quality in Health 2019.
Commitment Update:
Los avances obtenidos hasta este momento son los siguientes:
1. El Compromiso fue incluido en el Plan de Mejora Continua de la Calidad en Salud 2019 (Proyecto No. 6: Prevención de Caídas de Usuarios y Prestadores de Servicios en la Atención de la Salud Oftalmológica), que incluye 5 actividades (Dic/2018).
2. Se elaboró una versión beta de la Encuesta Ad Hoc: Ocurrencia y tipo de caídas entre el personal, a fin de llevar a cabo una prueba piloto y hacer las adecuaciones necesarias (Feb/2019).
The advances obtained up to this moment are the following:
1. The Commitment was included in the Plan for the Continuous Improvement of Quality in Health 2019 (Project No. 6: Prevention of User Falls and Providers of Services in Ophthalmological Health Care), which includes 5 activities (Dec / 2018 ).
2. A beta version of the Ad Hoc Survey: Occurrence and type of falls among the staff was developed, in order to carry out a pilot test and make the necessary adjustments (Feb / 2019).
Your commitment aligns with APSS
Challenge 14A - Falls and fall prevention in adults Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Elaboración de una encuesta Ad Hoc: Ocurrencia y tipo de caídas entre el personal.
2. Desarrollo de un formato propio para Identificación de Riesgo de Caídas en un Hospital de Atención Ambulatoria.
1. Development of an Ad Hoc Survey: Occurrence and type of falls among staff.
2. Development of an own format for Identification of Risk of Falls in an Ambulatory Attention Hospital.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
0 |
Lives Lost:
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Lives Spared Harm Target
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Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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La Participación Activa de la Familia en la Rehabilitación de Personas con Discapacidad Visual. View Commitment
Commitment
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
La Participación Activa de la Familia en la Rehabilitación de Personas con Discapacidad Visual.
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DIRECTOR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
-
ISABEL ELVIRA MUCHARRAZ GARCIA, JEFA DE ENSEÑANZA, INVESTIGACION Y CALIDAD
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement Commitment Name:
La Participación Activa de la Familia en la Rehabilitación de Personas con Discapacidad Visual. Commitment Start Date 06/15/2018 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Actualmente no existe una escala de evaluación que permita medir cualitativa y cuantitativamente la participación de la familia para la rehabilitación de personas con discapacidad visual en el Centro Especializado de Atención a Personas con Discapacidad Visual. Commitment Timeline
Elaboración de una cedula para la evaluación de la participación de la familia
Del 18 al 22 de junio de 2018
Evaluación Inicial
25 al 06 de julio de 2018
Capacitación a pacientes y familiares
09 a 23 de agosto de 2018
Evaluación
06 al 10 de agosto de 2018
Análisis de resultados
13 al 24 de agosto de 2018
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
no aplica
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El Lavado de Manos como Herramienta Fundamental en el Cuidado de la Salud. View Commitment
Commitment
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CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
El Lavado de Manos como Herramienta Fundamental en el Cuidado de la Salud.
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DIRECTOR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
-
DRA. ISABEL ELVIRA MUCHARRAZ GARCIA, JEFA DE ENSEÑANZA, INVESTIGACION Y CALIDAD
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
El Lavado de Manos como Herramienta Fundamental en el Cuidado de la Salud. Commitment Start Date 07/02/2018 How Many Hospitals Will This Commitment Represent? 2 Action Plan
FALTA DE APLICACION DE LA TECNICA DE HIGIENE DE MANOS EN LOS 5 MOMENTOS. Commitment Timeline
Tomas de muestra para cultivos de manos del personal de la salud y superficies de trabajo
15 al 30 de septiembre de 2018
Capacitación del equipo de trabajo para aplicar la cedula de los 5 momentos que propone la OMS
01 al 31 de agosto de 2018
Evaluar la calidad del agua
01 al 10 de agosto de 2018
Implantacion de la Cedula de Evaluacion de los 5 momentos en el CEAPDV
03 de septiembre al 14 de septiembre de 2018
Análisis de resultados
17 de septiembre al 05 de octubre de 2018
Formulación de estrategias a partir de los resultados obtenidos.
08 octubre al 19 de octubre de 2018
Impact DetailsLives Lost in Last Calendar Year:0.0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
no aplica
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LA DETECCIÓN OPORTUNA EN PACIENTES CON DISCAPACIDAD VISUAL ADQUIRIDA CON IDEA SUICIDA. View Commitment
Commitment
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
LA DETECCIÓN OPORTUNA EN PACIENTES CON DISCAPACIDAD VISUAL ADQUIRIDA CON IDEA SUICIDA.
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
-
DRA. ISABEL ELVIRA MUCHARRAZ GARCIA, JEFA DE ENSEÑANZA, INVESTIGACIÓN Y CALIDAD
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement
Commitment Name:
LA DETECCIÓN OPORTUNA EN PACIENTES CON DISCAPACIDAD VISUAL ADQUIRIDA CON IDEA SUICIDA.
Commitment Start Date:06/29/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Los pacientes con discapacidad visual adquirida presentan en un 20% ideas suicidas por lo menos una vez en proceso de depresión por duelo. Commitment Description & Detail:
A través de la Canalización adecuada y oportuna al servicio de psicología para valoración y en su caso referencia al médico psiquiatra. Action Plan:
1. Interconsulta de todos los pacientes con discapacidad visual adquirida al servicio de Psicología.
2. Evaluación Psicológica mediante test cuantitativos y cualitativos para valoración de riesgo.
3. Referir a pacientes con riesgo suicida al médico Psiquiatra según los resultados.
4. Inicia intervención y tratamiento Psicológica.
5. Inicia programa de rehabilitación visual.
6. Análisis de los resultados Psicológicos.
7. Sensibilización a las familias y al personal se salud sobre el riesgo suicida, mediante sesiones académicas y talleres.
8. Seguimiento y revaloración de los pacientes con discapacidad visual adquirida que presentaron ideas suicidas.
9. Análisis de los avances y limitaciones del programa de rehabilitación.
10. De acuerdo a los resultados obtenidos seguir con programa inicial o hacer modificaciones correspondientes
Commitment Timeline:
1. Interconsulta de todos los pacientes con discapacidad visual adquirida al servicio de Psicología del 2 al 6 de julio de 2018
2. Evaluación Psicológica mediante test cuantitativos y cualitativos para valoración de riesgo del 9 de julio al 3 de agosto 2018
3. Referir a pacientes con riesgo suicida al médico Psiquiatra según los resultados del 9 de julio al 3 de agosto
4. Inicia intervención y tratamiento Psicológica del 9 de julio al 29 de junio de 2019
5. Inicia programa de rehabilitación visual del 6 de Agosto de 2018 al 6 de agosto de 2019
6. Análisis de los resultados Psicológicos del 6 al 29 de junio de 2018
7. Sensibilización a las familias y al personal se salud sobre el riesgo suicida, mediante sesiones académicas y talleres. Del 3 de septiembre de 2018 al 29 de junio de 2019
8. Seguimiento y revaloración de los pacientes con discapacidad visual adquirida que presentaron ideas suicidas del 3 al 14 de diciembre de 2018
9. Análisis de los avances y limitaciones del programa de rehabilitación del 17 de Diciembre de 2018 al 31 de Enero de 2018
10. De acuerdo a los resultados obtenidos seguir con programa inicial o hacer modificaciones correspondientes
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LA DETECCIÓN OPORTUNA EN PACIENTES CON DISCAPACIDAD VISUAL ADQUIRIDA CON IDEA SUICIDA. – Update – 04.23.19 View Update
Commitment Update
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
LA DETECCIÓN OPORTUNA EN PACIENTES CON DISCAPACIDAD VISUAL ADQUIRIDA CON IDEA SUICIDA. – Update – 04.23.19
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: calidad.saludvisual@gmail.com
Position: DR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Commitment Details How many hospitals are represented in this commitment?
Commitment Summary:
Los pacientes con discapacidad visual adquirida presentan en un 20% ideas suicidas por lo menos una vez en proceso de depresión por duelo.
Commitment Update:
De acuerdo con la OMS, se calcula que actualmente más de mil millones de personas, o sea, un 15% de la población mundial, padece alguna forma de discapacidad y se estima también, que el 82% de todas las personas con ceguera son mayores de 50 años y se prevé que este número aumentará con el envejecimiento de la población mundial. Dependiendo del grupo y las circunstancias, las personas con discapacidad pueden experimentar una mayor vulnerabilidad a afecciones secundarias, comorbilidad, enfermedades relacionadas con la edad y una frecuencia más elevada de comportamientos nocivos para la salud y muerte prematura.
Los trastornos de las funciones visuales pueden provocar importantes alteraciones en la vida del individuo que los padece, ocasionándole limitaciones en el desempeño o realización de las actividades propias y restricciones en su participación en situaciones vitales; si la discapacidad aparece en personas mayores, se ve modulada por las características propias de ese grupo de edad. Su aparición suele cambiar las estrategias y recursos habituales para resolver las necesidades de la vida, y conlleva un proceso de ajuste a la nueva situación; por ello, la comprensión del mismo, la identificación de las variables que lo componen y su evaluación con instrumentos psicológicos adecuados es de gran relevancia.
La pérdida de visión representa para la persona que la padece, un importante cambio en su vida. Las estrategias que utilizaba para resolver las cuestiones de la vida, desde lo más simple a lo de gran complejidad, pueden verse inutilizadas o modificadas. El desarrollo de actividades aprendidas informalmente (caminar, comer, cuidar la higiene personal o realizar actividades ligadas al ocio o al deporte) o formalmente (leer y escribir, conducir o manejar tecnología) se ve dificultado y para poder seguir desarrollándolas, deben reaprenderse o modificar sustancialmente las estrategias necesarias para su ejecución.
El afrontamiento de la vida en las nuevas circunstancias (la funcionalidad visual consecuente con la pérdida y las limitaciones y restricciones provocadas por el cambio de funcionalidad) requiere de un esfuerzo psicológico, social y funcional (incluyendo las estrategias e instrumentales emocionales y cognitivas que deban modificarse, activarse o aprenderse, y los posibles cambios sociales y contextuales). De acuerdo con Ferrando Piera, Pallero y colaboradores, los modelos actuales para explicar el ajuste a la pérdida visual (Díaz y Pallero, 2003; Dodds, Craig y Flanigan, 1996), especifican una serie de variables que forman parte de este proceso y plantean las posibles consecuencias patológicas que dicho proceso puede conllevar. La variable y la consecuencia recogida con mayor frecuencia en la literatura es la presencia de sintomatología depresiva; dicha presencia se ha observado tanto en estudios con población norteamericana como española, y en ambas en porcentajes cercanos al 30% de los casos evaluados (Horowitz y Reinhardt, 2000). Entre las personas mayores, la depresión es una fuente de preocupación que además conlleva importantes costos (Schleifer, Séller y Bartlett, 1999): la OMS indicaba en su informe anual de 2006 que la depresión sería la segunda causa de discapacidad en el mundo, y en especial en las personas mayores. Parece pues evidente que la evaluación de la sintomatología depresiva en la población de mayores con discapacidad visual constituye una prioridad sanitaria, y ello implica desarrollar y validar instrumentos económicos, simples y eficaces.
Dado que los pacientes con discapacidad visual adquirida presentan ideas suicidas por lo menos una vez durante el proceso de depresión por el duelo y en el CEAPDV no se cuenta con un instrumento de detección de la ocurrencia de depresión en estos pacientes, es de suma importancia desarrollar tanto el protocolo como las herramientas para prevenir el suicidio en estos pacientes.
Debido a lo anterior, se realizaron los siguientes cambios al Plan de Acción originalmente desarrollado:
I. La Identificación de Depresión e Ideación Suicida en Pacientes con Discapacidad Visual Adquirida Irreversible fue incluida como un proyecto particular dentro del Plan de Mejora Continua de la Calidad en Salud 2019.
Los avances obtenidos hasta este momento son los siguientes:
1. El Compromiso fue incluido en el Plan de Mejora Continua de la Calidad en Salud 2019 (Proyecto No. 7: Identificación de Depresión e Ideación Suicida en Pacientes con Discapacidad Visual Adquirida Irreversible), que incluye 4 actividades (Dic/2018).
2. Se identificaron y seleccionaron los instrumentos para la detección de síntomas depresivos en los pacientes con discapacidad visual adquirida (Feb/2019).
3. Se desarrolló el diagrama de flujo y los criterios para la identificación de los pacientes con discapacidad visual adquirida irreversible (Mar/2019).
According to the WHO it is estimated that currently more than one billion people, or 15% of the world population, suffer from some form of disability and it is also estimated that 82% of all people with blindness are older 50 years and it is expected that this number will increase with the aging of the world population. Depending on the group and the circumstances, people with disabilities may experience greater vulnerability to secondary conditions, comorbidity, age-related diseases and a higher frequency of behaviors harmful to health and premature death.
Disorders of visual functions can cause important alterations in the life of the individual who suffers, causing limitations in the performance or performance of own activities and restrictions on their participation in life situations; if the disability appears in older people, it is modulated by the characteristics of that age group. Their appearance usually changes the habitual strategies and resources to solve the necessities of life, and entails a process of adjustment to the new situation; therefore, the understanding of it, the identification of the variables that compose it and its evaluation with appropriate psychological instruments is of great relevance.
The loss of vision represents for the person who suffers it an important change in his life. The strategies used to solve the issues of life, from the simplest to the most complex, may be rendered useless or modified. The development of activities informally learned (walking, eating, taking care of personal hygiene or doing activities related to leisure or sports) or formally (reading and writing, driving or managing technology) becomes difficult and to continue developing them, they must be relearned or substantially modify the strategies necessary for its execution.
The coping of life in new circumstances (the visual functionality consequent with the loss and the limitations and restrictions caused by the change in functionality) requires a psychological, social and functional effort (including emotional and cognitive strategies and instruments that must be modified, activated or learned, and the possible social and contextual changes). According to Ferrando Piera, Pallero and collaborators, current models to explain the adjustment to visual loss (Díaz and Pallero, 2003, Dodds, Craig and Flanigan, 1996), specify a series of variables that are part of this process and propose the possible pathological consequences that this process may entail. The variable and the consequence collected most frequently in the literature is the presence of depressive symptomatology; this presence has been observed both in studies with North American and Spanish population, and in both in percentages close to 30% of the cases evaluated (Horowitz and Reinhardt, 2000). Among the elderly, depression is a source of concern that also carries significant costs (Schleifer, Séller and Bartlett, 1999): the WHO indicated in its 2006 annual report that depression would be the second cause of disability in the world, and especially in the elderly. It seems clear that the evaluation of depressive symptomatology in the elderly population with visual impairment is a health priority, and this implies developing and validating economic instruments, simple and effective.
Given that patients with acquired visual disability present suicidal ideas at least once during the process of depression due to grief and in CEAPDV there is no instrument to detect the occurrence of depression in these patients, it is very important to develop both the protocol and the tools to prevent suicide in these patients.
Due to the above, the following changes were made to the originally developed Action Plan:
I. The Identification of Depression and Suicidal Ideation in Patients with Irreversible Acquired Visual Disability was included as a particular project within the Continuous Improvement Plan for Quality in Health 2019.
The advances obtained up to this moment are the following:
1. The Commitment was included in the Continuous Improvement Plan for Health Quality 2019 (Project No. 7: Identification of Depression and Suicidal Ideation in Patients with Irreversible Acquired Visual Disability), which includes 4 activities (Dec / 2018).
2. Instruments for the detection of depressive symptoms in patients with acquired visual impairment were identified and selected (Feb / 2019).
3. The flow chart and the criteria for the identification of patients with irreversible acquired visual impairment (Mar / 2019) were developed.
Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
La detección temprana de síntomas depresivos e ideaciones suicidas en los pacientes con discapacidad visual adquirida irreversible permite instituir el tratamiento oportuno de la depresión y reducir el riesgo de suicidio.
The early detection of depressive symptoms and suicidal ideation in patients with irreversible acquired visual impairment allows for the timely treatment of depression and to reduce the risk of suicide.
Your commitment aligns with APSS
Challenge 16 - Person and family engagement Impact DetailsBy implementing the APSS, what cost benefits have you attained in the following areas?:
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EL LAVADO DE MANOS COMO HERRAMIENTA FUNDAMENTAL EN EL CUIDADO DE LA SALUD. View Commitment
Commitment
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
EL LAVADO DE MANOS COMO HERRAMIENTA FUNDAMENTAL EN EL CUIDADO DE LA SALUD.
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: acastillejaq68@gmail.com
Position: DR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
-
DRA. ISABEL ELVIRA MUCHARRAZ GARCIA, JEFA DE ENSEÑANZA, INVESTIGACIÓN Y CALIDAD
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene
Commitment Name:
EL LAVADO DE MANOS COMO HERRAMIENTA FUNDAMENTAL EN EL CUIDADO DE LA SALUD.
Commitment Start Date:01/07/2018 How Many Hospitals Will This Commitment Represent? 2 Commitment Summary:
Se ha capacitado al personal del hospital:
Enfermería 95%
Optometría 60%
Medicos 25%
-Se ha realizado 1 evento conmemorativo al 5 de mayo día mundial de la higiene de manos, donde se involucraron a todas las áreas a participar en un concurso de lavado de manos donde también se les proporción material para su continua capacitación:
-trípticos
-tarjetas con la técnica de lavado de manos y los 5 momentos.
Commitment Description & Detail:
Llegar al 80% del cumplimiento del lavado de manos en los 5 momentos en los diferentes servicios que integran el CEAPDV, con la finalidad de evitar IAAS que conlleven a la pérdida de un órgano(ojo), a los pacientes de esta unidad. Action Plan:
-EVALUACIÓN DE LA CALIDAD DEL AGUA
-TOMA DE MUESTRAS PARA CULTIVOS DE MANOS Y SUPERFICIES
-CAPACITACIÓN DEL EQUIPO DE TRABAJO PARA LA APLICACIÓN DEL FORMULARIO DE OBSERVACIÓN
-IMPLEMENTACIÓN DEL FORMULARIO
-CAPACITACIÓN AL PERSONAL DEL HEMSV
-ANÁLISIS DE RESULTADOS
-DIFUSIÓN DE RESULTADOS
Commitment Timeline:
COMPROMISO DE LA LINEA DE ACCIÓN
01-10 Agosto de 2018 evaluación de la calidad del agua.
01-31 Agosto de 2018 capacitación del equipo de trabajo para la aplicación del formulario de observación (OMS).
03-14 Sept. de 2018 Implementación del formulario de observación (OMS).
15-30 Sept. de 2018 Toma de muestras para cultivos de manos y superficies.
08-19 Oct. de 2018 Formulación de estrategias a partir de los resultados obtenidos.
05-24 de 2018 Capacitación al personal por áreas.
14-26 de 2018 Aplicación del formulario de observación
28-31 de 2018 Analisis de resultados.
4-15 Febrero de 2019 Evaluación de la calidad del agua
18-27 Febrero de 2019 aplicación del formulario de observación
28 Febrero de 2019 análisis de resultados
4-15 Marzo de 2019 Toma de muestras para cultivos de manos y superficies
18-28 Marzo de 2019 Aplicación del formulario de observación
29 Marzo de 2019 Análisis de resultados
8-12 Abril de 2019 Capacitación al personal del HEMSV
15-26 Abril de 2019 Aplicación del formulario de observación
29-30 Abril de 2019 Análisis de resultados
13-17 Mayo de 2019 Análisis de resultados del formulario de observación de los 5 momentos
3-14 Junio de 2019 Difusión de resultados.
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EL LAVADO DE MANOS COMO HERRAMIENTA FUNDAMENTAL EN EL CUIDADO DE LA SALUD. – Update – 04.23.19 View Update
Commitment Update
×
CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
EL LAVADO DE MANOS COMO HERRAMIENTA FUNDAMENTAL EN EL CUIDADO DE LA SALUD. – Update – 04.23.19
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: 5555070052
Email: acastillejaq68@gmail.com
Position: DR
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Commitment Details How many hospitals are represented in this commitment?
Commitment Summary:
Se ha capacitado al personal del hospital:
Enfermería 95%
Optometría 60%
Medicos 25%
-Se ha realizado 1 evento conmemorativo al 5 de mayo día mundial de la higiene de manos, donde se involucraron a todas las áreas a participar en un concurso de lavado de manos donde también se les proporción material para su continua capacitación:
-trípticos
-tarjetas con la técnica de lavado de manos y los 5 momentos.
Commitment Update:
Dadas las características del modelo de atención que se brinda en el CEAPDV, debe adoptarse un enfoque preventivo desde la perspectiva de la atención oftalmológica, a fin de evitar las infecciones asociadas a la atención de la salud que son más frecuentes en ámbito de la salud visual – IAASOf –. El riesgo de IAAS en la atención oftalmológica tiene diversos orígenes, los que están bien identificados por lo que se refiere a la consulta externa:
a) La atención de pacientes portadores de conjuntivitis infecciosas multi-medicadas y probablemente resistentes a los antibióticos de uso convencional,
b) Los procedimientos de exploración y diagnóstico que se llevan a cabo cotidianamente y que requieren del empleo de diversos instrumentos y equipos (desde el oftalmoscopio indirecto y los lentes para la determinación de la agudeza visual, que son de uso común, hasta las lámparas de hendidura y los tonómetros), los que pueden convertirse en vehículos de contagio si no son debidamente sanitizados,
c) La incorrecta instilación de los medicamentos oftálmicos por los pacientes, y
d) La inadecuada ejecución de las técnicas de lavado e higiene de manos en los momentos de la atención.
Respecto de los procedimientos quirúrgicos que se realizan en la unidad, la prioridad corresponde a la prevención de endoftalmitis al ser esta la complicación más frecuente y riesgosa, por lo que se ha establecido un programa de desinfección de alto nivel que debe ser revisado y adecuado a las necesidades de la atención oftalmológica.
Debido a lo anterior, se realizaron los siguientes cambios al Plan de Acción originalmente desarrollado:
I. La Prevención de Infecciones Asociadas a la Atención de la Salud Oftalmológica fue incluida como un proyecto particular dentro del Plan de Mejora Continua de la Calidad en Salud 2019, siendo la Higiene de Manos la actividad fundamental de esta iniciativa.
II. Adicionalmente se desarrolló un Plan de Mejora específico de Higiene de Manos también para 2019, con base en los resultados de la Encuesta Diagnóstica de Higiene de Manos (Autoevaluación), que fue previamente contestada.
Los avances obtenidos hasta este momento son los siguientes:
1. El compromiso fue incluido en el Plan de Mejora Continua de la Calidad en Salud 2019 (Proyecto No. 5: Prevención de Infecciones Asociadas a la Atención de la Salud Oftalmológica), que incluye 7 actividades directamente relacionadas con Higiene de Manos (Dic/2018).
2. Se realizó supervisión a ocho (8) Optometristas del Centro (Ene/2019).
3. Se llevó a cabo una sesión de Capacitación al personal de Enfermería del Centro sobre Lavado de Manos y Cinco Momentos en los Cuidados de Enfermería (Feb/2019).
4. Se contestó la Encuesta Diagnóstica de Higiene de Manos – Autoevaluación (Feb/2019).
5. Se aplicó el Cuestionario sobre Conocimiento y Percepción sobre la Higiene de las Manos destinado al Personal de Salud (Feb/2019).
6. Se desarrolló un Plan de Mejora específico para Higiene de Manos para 2019 (Mar/2019).
7. Se desarrolló un formato especial para realizar la supervisión del conocimiento y ejecución de la Técnica de Higiene de Manos en los Cinco Momentos (Mar/2019).
Given the characteristics of the care model provided in the CEAPDV, a preventive approach should be adopted from the perspective of ophthalmological care, in order to avoid infections associated with health care that are more frequent in the field of visual health. - IAASOf -. The risk of IAAS in ophthalmologic care has various origins, which are well identified in terms of external consultation:
a) The care of patients with infectious conjunctivitis multi-medicated and probably resistant to conventional antibiotics,
b) Exploration and diagnostic procedures that are carried out on a daily basis and that require the use of various instruments and equipment (from the indirect ophthalmoscope and the lenses for the determination of visual acuity, which are commonly used, to the slit and tonometers), which can become contagious vehicles if they are not properly sanitized, and
c) The incorrect instillation of ophthalmic drugs by patients.
d) Inadequate execution of washing and hand hygiene techniques at the time of care.
Regarding the surgical procedures performed at the unit, the priority corresponds to the prevention of endophthalmitis being this the most frequent and risky complication, so that a high level disinfection program has been established that must be reviewed and adapted to the needs of ophthalmological care.
Due to the above, the following changes were made to the originally developed Action Plan:
I. The Prevention of Infections Associated with Ophthalmological Health Care was included as a particular project within the Continuous Improvement Plan for Quality in Health 2019, with Hand Hygiene being the fundamental activity of this initiative.
II. Additionally, a Specific Improvement Plan for Hand Hygiene was also developed for 2019, based on the results of the Hand Hygiene Diagnostic Survey (Self-Assessment), which was previously answered.
The advances obtained up to this moment are the following:
1. The Commitment was included in the Continuous Improvement Plan for Quality in Health 2019 (Project No. 5: Prevention of Infections Associated with Ophthalmological Health Care), which includes 7 activities directly related to Hand Hygiene (Dec / 2018).
2. Supervision of eight (8) Optometrists of the Center (Jan / 2019).
3. A training session was held for the nursing staff of the Center on Hand Washing and Five Moments in Nursing Care (Feb / 2019).
4. The Hand Hygiene Diagnostic Survey was answered - Self-assessment (Feb / 2019).
5. The Questionnaire on Knowledge and Perception of Hand Hygiene for Health Personnel was applied (Feb / 2019).
6. A specific Improvement Plan for Hand Hygiene was developed for 2019 (Mar / 2019).
7. A special format was developed to supervise the knowledge and execution of the Hand Hygiene Technique in the Five Moments (Mar / 2019).
Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Desarrollo de un formato especial para realizar la supervisión del conocimiento y ejecución de la Técnica de Higiene de Manos en los Cinco Momentos.
Development of a special format to perform the supervision of knowledge and execution of the Hand Hygiene Technique in the Five Moments.
Your commitment aligns with APSS
Challenge 2A - Hand hygiene Impact DetailsBy implementing the APSS, what cost benefits have you attained in the following areas?:
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FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN LA ATENCIÓN OFTALMOLÓGICA View Commitment
Commitment
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CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN LA ATENCIÓN OFTALMOLÓGICA
Contact Info
Name ARTURO CASTILLEJA QUILES
Phone: (555) 507-0052
Email: ibethfabela@gmail.com
Position: DIRECTOR / PHYSICIAN (OPHTALMOLOGIST)
Organization Name: CENTRO ESPECIALIZADO DE ATENCIÓN A PERSONAS CON DISCAPACIDAD VISUAL
Organization Address:
110 Avenida José María Morelos , Centro
Naucalpan de Juárez, 53000 Mexico
Participants:
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ALFONSO RENE BONILLA, QUALITY MANAGER
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN LA ATENCIÓN OFTALMOLÓGICA Commitment Details/h6>Commitment Summary:
De acuerdo con la OMS, se calcula que actualmente más de mil millones de personas, o sea, un 15% de la población mundial, padece alguna forma de discapacidad y se estima también, que el 82% de todas las personas con ceguera son mayores de 50 años y se prevé que este número aumentará con el envejecimiento de la población mundial. Dependiendo del grupo y las circunstancias, las personas con discapacidad pueden experimentar una mayor vulnerabilidad a afecciones secundarias, comorbilidad, enfermedades relacionadas con la edad y una frecuencia más elevada de comportamientos nocivos para la salud y muerte prematura. Action Plan:
Dependiendo del grupo y las circunstancias, las personas con discapacidad pueden experimentar una mayor vulnerabilidad a afecciones secundarias, comorbilidad, enfermedades relacionadas con la edad y una frecuencia más elevada de comportamientos nocivos para la salud y muerte prematura.
Los trastornos de las funciones visuales pueden provocar importantes alteraciones en la vida del individuo que los padece, ocasionándole limitaciones en el desempeño o realización de las actividades propias y restricciones en su participación en situaciones vitales; si la discapacidad aparece en personas mayores, se ve modulada por las características propias de ese grupo de edad. Su aparición suele cambiar las estrategias y recursos habituales para resolver las necesidades de la vida, y conlleva un proceso de ajuste a la nueva situación; por ello, la comprensión del mismo y la identificación de las variables que lo componen es de gran relevancia.
La pérdida de visión representa para la persona que la padece, un importante cambio en su vida. Las estrategias que utilizaba para resolver las cuestiones de la vida, desde lo más simple a lo de gran complejidad, pueden verse inutilizadas o modificadas. El desarrollo de actividades aprendidas informalmente (caminar, comer, cuidar la higiene personal o realizar actividades ligadas al ocio o al deporte) o formalmente (leer y escribir, conducir o manejar tecnología) se ve dificultado y para poder seguir desarrollándolas, deben reaprenderse o modificar sustancialmente las estrategias necesarias para su ejecución.
El afrontamiento de la vida en las nuevas circunstancias (la funcionalidad visual consecuente con la pérdida y las limitaciones y restricciones provocadas por el cambio de funcionalidad) requiere de un esfuerzo psicológico, social y funcional (incluyendo las estrategias e instrumentales emocionales y cognitivas que deban modificarse, activarse o aprenderse, y los posibles cambios sociales y contextuales).
Los pacientes que acuden a solicitar atención en el CEAPDV presentan grados diversos de discapacidad visual, a lo que se agrega que las instalaciones del Centro no cumplen por completo con las especificaciones que se establecen en la Norma Oficial Mexicana NOM-030-SSA3-2013, Que establece las características arquitectónicas para facilitar el acceso, tránsito, uso y permanencia de las personas con discapacidad en establecimientos para la atención médica ambulatoria y hospitalaria del Sistema Nacional de Salud, circunstancia que no sólo pone en riesgo a los usuarios de la unidad, ya que también implica un riesgo aún no determinado para los servidores públicos que aquí laboran.
Al ser este un hospital de atención ambulatoria, el perfil particular de los pacientes, la gran mayoría de ellos de la tercera edad, hace indispensable desarrollar una Cultura de Seguridad del Paciente específica con un enfoque propio que permita abordar de forma diferenciada los aspectos inherentes a la seguridad del paciente anciano con discapacidad visual.
En razón de lo anterior, se diseñaron las siguientes iniciativas:
I. La Cultura de Seguridad del Paciente fue incluida como un proyecto particular dentro del Plan de Mejora Continua de la Calidad en Salud 2019 (Proyecto No. 9: Fortalecimiento de la Cultura de Seguridad del Paciente en la Atención Oftalmológica), que incluye 12 actividades directamente relacionadas con la Cultura de Seguridad (Dic/2018), con énfasis en la observancia de seis (6) de las ocho Acciones Esenciales para la Seguridad del Paciente – AESP.
II. Adicionalmente se desarrolló un Plan de Mejora específico de Cultura de Seguridad del Paciente también para 2019, con base en los resultados del Cuestionario sobre Cultura de Seguridad del Paciente en Hospitales de México, que fue aplicado en 2018.
III. El Plan de Mejora de la Cultura de Seguridad del Paciente que se aplicará en 2020, será enfocado hacia el conocimiento y observación de las ocho Acciones Esenciales de Seguridad del Paciente, tomando en cuenta los resultados que arroje el Cuestionario sobre Cultura de Seguridad del Paciente en Hospitales de México, que fue aplicado recientemente aplicado. Impact Details Lives Saved
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| CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS” |
Estado de México |
Mexico |
Caídas y Prevención de Caídas View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Caídas y Prevención de Caídas
Contact Info
Name MARTHA ELBA GUERRA ROMERO
Phone: 7222760860 ext: 90211
Email: marthaelbaguerra@yahoo.com.mx
Position: MEDICO
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults
Commitment Name:
Caídas y Prevención de Caídas
Commitment Start Date:08/15/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Con base a la elaboración del diagnostico se identificaran los factores condicionantes de caídas en el Centro Médico ¨Lic. Adolfo López Mateos¨, a fin de plantear estrategias a través del comité de Calidad y Seguridad del Paciente. Commitment Description & Detail:
A través de herramientas administrativas como la matriz de riesgo, análisis causa raíz y lluvia de ideas del equipo multidisciplinario Action Plan:
Definir el equipo de trabajo.
Realizar la Calendarización para reuniones e integración del diagnostico.
COCASEP Presentara los resultados obtenidos al Consejo de Gobierno para su validación e implementación de acciones de mejora correspondientes.
Monitoreo de las acciones implementadas.
Retroalimentación de las acciones implementadas. Commitment Timeline:
El seguimiento de realizara trimestral y un cohorte anual
Impact DetailsLives Saved
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Caídas y Prevención de Caídas – Update – 02.18.19 View Update
Commitment Update
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Caídas y Prevención de Caídas – Update – 02.18.19
Contact Info
Name MARTHA ELBA GUERRA ROMERO
Phone: 7222760860 ext: 90211
Email: marthaelbaguerra@yahoo.com.mx
Position: MEDICO
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Commitment Details How many hospitals are represented in this commitment?
Commitment Summary:
Con base a la elaboración del diagnostico se identificaran los factores condicionantes de caídas en el Centro Médico ¨Lic. Adolfo López Mateos¨, a fin de plantear estrategias a través del comité de Calidad y Seguridad del Paciente.
Commitment Update:
Avances del Centro Médico Lic. Adolfo López Mateos del reto no. 14
18 de febrero de 2019
Programa: Diseño de plan estratégico para la atención de la Acción Esencial de Seguridad del Paciente en la “Reducción de Riesgo por Daño al Paciente por Caídas” (6A, 6B1, 6B2, 6C) para dar cuenta del cumplimiento de los objetivos y resultados obtenidos. El caso del Centro Médico “Lic. Adolfo López Mateos” del Instituto de Salud del Estado de México como programa permanente.
El Centro Médico Lic. Adolfo López Mateos ha dado continuidad al programa correspondiente al reto no. 14 “Caídas y prevención de caídas” y presenta los avances que constan de siete evidencias documentales, referentes a la difusión de la implementación del Programa para la reducción del riesgo de caídas en ésta unidad médica, dichas evidencias reflejan la difusión que se realizó del proyecto para atender dicho reto y la autorización del Director para acceder a las diferentes áreas médicas en el cumplimiento de la acciones correspondientes.
EVIDENCIA OBSERVACIÓN
1 Oficio 1428 de fecha 6 de diciembre de 2018. Se presenta plan de trabajo y uso de formatos para autorización Anexo no. 1
2 Pantalla del Sistema de Gestión Documental del Centro Médico Lic. Adolfo López Mateos, mediante el cual se hizo del conocimiento el oficio 1428. Anexo no. 2
3 Oficio 45 de fecha 18 de enero de 2019. Se Informa a la Subdirección Médico Quirúrgica sobre el inicio del plan de trabajo para atender el reto 14 Anexo no. 3
4 Oficio 48 de fecha 18 de enero de 2019. Se Informa a la Subdirección Médico Clínica sobre el inicio del plan de trabajo para atender el reto 14. Anexo no 4
5 Oficio 49 de fecha 18 de enero de 2019. Se Informa a la Subdirección de enfermería sobre el inicio del plan de trabajo para atender el reto 14. Anexo no. 5
6 Oficio 50 de fecha 18 de enero de 2019. Se solicita a la Subdirección de enfermería 10 recursos en formación para dar inicio al plan de trabajo para atender el reto 14. Anexo no. 6
7 Pantalla del Sistema de Gestión Documental del Centro Médico Lic. Adolfo López Mateos, mediante el cual se hizo del conocimiento los oficios 45, 48, 49 y 50. Anexo no. 7
Atentamente
Dra. Martha Elba Guerra Romero
Jefa de la Unidad de Enseñanza, Investigación y Calidad
Anexo no. 1. Oficio 1428 de fecha 6 de diciembre de 2018. Se presenta plan de trabajo y uso de formatos para autorización.
Anexo no. 2. Pantalla del Sistema de Gestión Documental del Centro Médico Lic. Adolfo López Mateos, mediante el cual se hizo del conocimiento el oficio 1428.
Anexo no. 3. Oficio 45 de fecha 18 de enero de 2019. Se Informa a la Subdirección Médico Quirúrgica sobre el inicio del plan de trabajo para atender el reto 14.
Anexo no. 4. Oficio 48 de fecha 18 de enero de 2019. Se Informa a la Subdirección Médico Clínica sobre el inicio del plan de trabajo para atender el reto 14.
Anexo no. 5. Oficio 49 de fecha 18 de enero de 2019. Se Informa a la Subdirección de enfermería sobre el inicio del plan de trabajo para atender el reto 14.
Anexo no. 6. Oficio 50 de fecha 18 de enero de 2019. Se solicita a la Subdirección de enfermería 10 recursos en formación para dar inicio al plan de trabajo para atender el reto 14.
Anexo no. 7. Pantalla del Sistema de Gestión Documental del Centro Médico Lic. Adolfo López Mateos, mediante el cual se hizo del conocimiento los oficios 45, 48, 49 y 50.
Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
SE REFUERZA DÍA A DÍA LA CULTURA DE LA SEGURIDAD DEL PACIENTE, Y LAS IMPRESIONES GENERALES POR PARTE DEL PERSONAL EN FORMACIÓN VAN DESDE EL APRENDER A PROPORCIONAR SEGURIDAD EN ,OS PROCESOS Y PROCEDIMIENTOS TÉCNICO MÉDICOS, HASTA EL HECHO DE OPINAR QUE EN MUCHAS OCASIONES HAN OBSERVADO MALAS PRACTICAS, PERO QUE DESCONOCÍAN A QUE INSTANCIA ACUDIR PARA REPORTAR Y/O QUE SE CORRIJAN LAS MALAS PRACTICAS
Your commitment aligns with APSS
Challenge 14A - Falls and fall prevention in adults Impact DetailsBy implementing the APSS, what cost benefits have you attained in the following areas?:Year 3 Prediction*
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FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL SERVICIO DE URGENCIAS View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL SERVICIO DE URGENCIAS
Contact Info
Name JOSE ROGEL ROMERO JOSE ROGEL ROMERO
Phone: 722 2-76-08-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DRA. MARTHA ELBA GUERRA ROMERO, GESTOR DE CALIDAD
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DR. CRYSTIAN HUGO SANTOS GONZALEZ, JEFE DE LA DIVISIÓN DE URGENCIAS
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LIC. EDUARDO AHEDO GARCIA, COORDINADOR DE ATENCIÓN AL USUARIO
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LIC. JANETH ROLDAN RUIZ, APOYO DEL GESTOR DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL SERVICIO DE URGENCIAS Commitment Details/h6>Commitment Summary:
FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL SERVICIO DE URGENCIAS DEL CENTRO MÉDICO ADOLFO LÓPEZ MATEOS
Una cultura de seguridad dentro de una organización de atención médica se refiere a un entorno seguro y confiable donde se establecen y mantienen los cimientos de la transparencia, la seguridad, la confianza y la responsabilidad entre los trabajadores de la instalación y los pacientes a los que sirve.
Lo anterior referente al Movimiento Internacional para la Seguridad del Paciente en el Desafio 1. Cultura de Seguridad, siendo importante para el Centro Médico Adolfo López Mateos, mantener y fortalecer las acciones que permita que el personal clínico lleve a cabo dentro de sus actividades operativas. Teniendo en cuenta que la Cultura de Seguridad en un hospital se define como la suma de valores, actitudes, percepciones, competencias y patrones de conducta individuales y grupales que determinan el estilo, la competencia y el compromiso de la gestión de la seguridad en una organización.
Por lo que, el siguiente Proyecto pretende para dar soluciones en beneficio de los usuarios y en el fortalecimiento y promoción de generar una Cultura que tenga como resultado la Seguridad en la Atención a la Salud del Centro Médico Lic. Adolfo López Mateos del Instituto de Salud del Estado de México (ISEM).
OBJETIVO:
Promover y desarrollar acciones de mejora que permitan fortalecer la cultura de seguridad del paciente entre los profesionales de la salud del Centro Médico “Lic. Adolfo López Mateos” a partir de tres fases: Fase de diagnóstico, Fase de intervención, Fase de evaluación; de Agosto 2019 a Mayo de 2020. Action Plan:
- Ejecución de la Fase Diagnóstica, con la aplicación del instrumento de Medición de Cultura de Seguridad del Paciente, de agosto a septiembre de 2019, al 100% del personal médico y de enfermería del servicio de urgencias de todos los turnos.
- Fase de ejecución: Analizar y planear las acciones de mejora de acuerdo a los resultados obtenidos de la aplicación del instrumento de Medición de Cultura de Seguridad del Paciente y ejecutar las actividades planeadas en el servicio de urgencias de octubre 2019 a abril 2020.
- Fase de Evaluación: Aplicar el instrumento de Medición de Cultura de Seguridad del Paciente al 100% del personal médico y de enfermería del servicio de urgencias, en seguimiento de las acciones implementadas, llevándose en el mes de mayo de 2020. Impact Details Lives Saved
Tell us about your baseline level of harm:
Se medirán los eventos adversos reportados del área de urgencias Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
Número de eventos adversos reportados analizados / número total de pacientes ingresados por periodo al servicio de urgenciasNúmero de eventos adversos presentados en el servicio de urgencias/número de pacientes ingresados al servicio de urgencias No de pacientes fallecidos debido a un evento adverso reportado desde urgencias/Número de eventos adversos presentados en urgencias Lives Spared Harm:
2386 Methodology for Determining Lives Saved:
Se toma como base la morbilidad del área de urgencias del año 2018, calculando que con base en estadísticas de otras áreas de la organización que reportan eventos adversos se tiene aproximadamente un promedio de 0.5 eventos adversos reportados del total de pacientes ingresados.
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Identificación oportuna del Delirio Post operatorio en Adultos Mayores. View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Identificación oportuna del Delirio Post operatorio en Adultos Mayores.
Contact Info
Name JOSE ROGEL ROMERO JOSE ROGEL ROMERO
Phone: 722760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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NERI ISLAS PALACIOS, DOCTOR
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ALEJANDRA GORDILLO PARRA, DOCTORA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 18 - Post-operative delirium in older adults How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Identificación oportuna del Delirio Post operatorio en Adultos Mayores. Commitment Details/h6>Commitment Summary:
Desde 1970 y hasta 2050, la población infantil tiende a disminuir mientras que la población adulta aumenta progresivamente. En 2016, en México, la población de 60 años y más es mayor que la población menor de cinco años, y para 2050 el número de personas mayores superará al grupo de jóvenes (< 15 años).En 1990, las personas de 60 años representaron menos de 6% del total de la población mexicana; 8.9% en 2010. En contraste, para 2050 serán 21.5% En el estado de México, al año de 1990 residían 450 mil 921 adultos mayores, para el año 2000 fueron 713 mil 704 y al año 2010 ascienden a un millón 137 mil 647. (Fuente INEGI 2018).
En nuestra entidad la expectativa de vida para un hombre ronda alrededor de los 73 años y para las mujeres 77.9 años siendo las principales causas de muerte las enfermedades del corazón, diabetes mellitus y tumores malignos. Los mexicanos que hoy cumplen 60 años de edad cuentan aún con una esperanza de vida de 22 años. ( Fuente: INEGI 2018)
El crecimiento de la población en edades avanzadas que el Estado de México experimentará en los próximos años, debe ser considerado como una importante preocupación social, debido a que la estructura por edad de la población se invierte.
Actualmente en el Centro Médico Lic. Adolfo López Mateos no se cuenta con ningún registro sobre la identificación oportuna de delirio en pacientes de la tercera edad posquirúrgicos, de la misma forma no se tiene cuantificado los casos de esta complicación.
Teniendo como pirámide poblacional en el hospital rangos de edad a pacientes mayores de 75 o más, un aproximado del 18% total de la población atendida.
Por lo que el hospital se propone el adherirse al desafío 18: delirio post operatorio de adultos mayores, para la implementación de un protocolo de identificación oportuna de delirio postoperatorio, evitando así mayores complicaciones, costos, y mayor día estancia. Action Plan:
1 Presentación del Desafío en COCASEP dic-19 dic-19
2 Integración de un grupo de supervisión ene-20 feb-20
3 Elaboración e implementación de un procedimiento para la identificación de delirio post operatorio. feb-20 mar-20
4 Implementación de guía para el manejo trans anestésico de pacientes con mayor riesgos de presentar delirio post operatorio. mar-20 mar-20
5 Gestión de equipo e insumos ene-20 abr-20
6 Monitorización del apego al procedimiento. may-20 dic-20
7 Análisis y acciones de mejora. jun-20 nov-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
4 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
2 Lives Saved:
2 Lives Spared Harm:
100 Methodology for Determining Lives Saved:
Vidas salvadas = nivel basal del daño - nivel basal meta / vidas sin daños x 100
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Fortalecimiento del Programa Permanente de Vigilancia del Uso de Antimicrobianos (Antimicrobial Stewardship) View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Fortalecimiento del Programa Permanente de Vigilancia del Uso de Antimicrobianos (Antimicrobial Stewardship)
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-7608-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DR.EDUARDO MARTÍNEZ HERNADEZ, MÉDICO ESPECIALISTA EN INFECTOLOGÍA
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DR. ESTEBAN JOSUE RIVERA CASADO, MÉDICO ESPECIALISTA EN INFECTOLOGÍA
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DRA. ARACELI MARTÍNEZ MARTÍNEZ, JEFA DE LA UNIDAD DE EPIDEMIOLOGI Y MP
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LIC. KATYA YULIBETH BUSTAMANTE RIOS, JEFA DE FARMACIA INTRAHOSPITALARIA
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JANETH ROLDAN RUIZ, ANALISTA DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Fortalecimiento del Programa Permanente de Vigilancia del Uso de Antimicrobianos (Antimicrobial Stewardship) Commitment Details/h6>Commitment Summary:
Existen diversos antibióticos que no están sujetos al programa de control de antimicrobianos, es decir, que no requieres pre- autorización para su prescripción. Las cefalosporinas de tercera generación son el grupo de antimicrobianos más utilizados en el Centro Médico Lic. Adolfo López Mateos de acuerdo a histórico de lo que va del año 2019 representan el 43% del consumo total de antibióticos no sujetos al programa de control.
Si bien contituyen la primera línea de tratamiento para diversas patologías, en concordancia con las recomendaciones nacionales e internacionales, una revisión de idoneidad de prescripción realizada por farmacia intrahospitalaria, infectología y epidemiologia (Estimación de la prevalencia puntual sobre el uso de antibióticos en el Centro Médico “Lic. Adolfo López Mateos” durante 2019), demostró que en aproximadamente en 45% de los casos la indicación de empleo puede ser optimizada.
Actualmente no se cuenta con una medición estandarizada del consumo de antibióticos, por lo que con el presente proyecto durante el pilotaje se pretende medir el valor basal en días de tratamiento por 1000 días pacientes y la estimación de la meta en un periodo de cuatro meses (abril a julio de 2020 y posteriormente implementarlo de forma permanente).
El proyecto de fortalecimiento del Programa permanente de vigilancia del uso de antimicrobianos pretende mejorar las practicas de prescripción a fin de evitar el abuso de medicamentos no sujetos al programa de control de antimicrobianos (cefalosporinas de tercera generación, fluroquinolonas, clindamicina y metronidazol) mediante la incorporar de personal de farmacia intrahospitalaria para el seguimiento activo del uso de antimicrobianos. Action Plan:
1.-Diseñar el programa de capacitación que incluya las GPC locales para el manejo de padecimientos infecciosos más frecuentes en el mes de enero de 2020 por los Médicos Infectologos.
2.- Gestión para Incorporar personal de la farmacia intrahospitalaria en la vigilancia activa del uso de antimicrobianos en el mes de enero de 2019, por los Médicos Infectologos
3.-Integrar las Guías de Practica Clínica locales para el manejo de padecimientos infecciosos más frecuentes en el periodo de febrero de 2020 a marzo de 2020, por los Médicos Infectólogos.
4.-Enviar listado de Guías de Practica Clínica al Departamento de Tecnologías de la Información para su difusión en la Intranet del Hospital, en el mes de mazo de 2020 por los Médicos Infectologos.
5.- Capacitar al personal médico y de farmacia intrahospitalaria en el uso de antimicrobianos de marzo a abril de 2020por los Médicos Infectologos.
6.-Pilotear el programa de vigilancia por parte de médicos infectologos y personal de farmacia, en el área de medicina interna, de abril a julio de 2020.
7.-Analizar los resultados de idoneidad de prescripción de antibióticos no sujetos al programa de control de antimicrobianos en el mes de agosto de 2020 por los Médicos Infectologos.
8.-Implementación del programa permanente en el hospital de septiembre 2020 a septiembre 2021, por los Médicos Infectologos y personal de Farmacia intrahospitalaria.
9.- Presentación de avances del proyecto en el Subcomité de Uso racional de Antibióticos de febrero 2020 a marzo 2021, por los Médicos Infectologos.
10.-Presentación de avances del proyecto en el Comité de Calidad y Seguridad del Paciente en los meses de diciembre 2019, marzo, junio y noviembre 2020, por los Médicos Infectologos Impact Details Lives Saved
Methodology for Determining Lives Saved:
Numero Total de Días de Tratamiento(DOT) / No Total de días paciente * 1000
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Rediseño y estandarización del procedimiento para la de instalación, verificación, vigilancia y retiro de la Sonda Nasogástrica View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Rediseño y estandarización del procedimiento para la de instalación, verificación, vigilancia y retiro de la Sonda Nasogástrica
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
NORMA ANGELICA SANTAMARIA ARRIAGA, LICENCIADA EN ENFERMERÍA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric tube (NGT) placement and verification Commitment Name:
Rediseño y estandarización del procedimiento para la de instalación, verificación, vigilancia y retiro de la Sonda Nasogástrica Commitment Details/h6>Commitment Summary:
La instalación de una sonda nasogástrica (sonda de Levin) es un procedimiento muy frecuente a nivel hospitalario; por tal razón, debe ser una maniobra ampliamente conocida por todo el personal que participa en la atención del paciente. Además de desarrollar las habilidades y destrezas necesarias para su instalación, es necesario identificar aquellas situaciones en las que está indicada y contraindicada su instalación. Es de gran importancia en el ámbito de la enfermería el conocimiento de la técnica de inserción y retirada de este tipo de sondaje, así como los cuidados requeridos durante su mantenimiento, independientemente de la finalidad de este.
Desde 2011 – 2016, se utilizaron más de 3 millones de sondas nasogástricas (NG) y orogástricas (OG) en el Reino Unido (Parker, 2016).
En pacientes adultos, la colocación incorrecta de SNG causa un daño grave en 1 a 3% de las sondas colocadas (Gilberto, Rogers y Ukoumunne, 2011; Bourgault y Halm, 2009).
La autoridad de seguridad del paciente de Pennsylvania documento 44 inserciones de SNG en el pulmón desde 2011-2013, y se notó que 24 causaron daños graves al paciente (Powers, Fischer, Ziemba-Davis, Brown y Philips, 2013).
Actualmente el proceso de instalación de sonda nasogástrica se lleva a cabo en el Centro Médico “Lic. Adolfo López Mateos” por el personal de enfermería, en mínimas ocasiones por personal médico, se cuenta con el insumo de la sonda tipo Levin en diferentes calibres (12, 14, 16, 18), sin embargo, en la mayoría de los procedimientos no se realiza mediante un proceso estandarizado que defina las barreras de seguridad durante la instalación, verificación, vigilancia y retiro de la SNG.
Se ha observado en la mayoría de las instalaciones que el personal ocupa como método la técnica NEMU (Nose, Earlobe, Mid-Umbilicus). Para la verificación de la colocación se aplican métodos no basados en evidencia como la auscultación, aspirado u observación de burbujas; para la vigilancia no se aplican de manera uniforme medidas de higiene, fijación estandariza o se presentan salidas accidentales totales o parciales, para el retiro de la SNG de igual forma no se tiene establecida una técnica basada en la mejor evidencia disponible.
Actualmente para verificar que la SNG este bien colocada, no se tiene una política establecida sobre el tomar una placa de rayos X de control o la comprobación con tiras indicadoras de PH, así mismo los incidentes que se presentan durante la instalación, vigilancia y retiro no son registrados en el sistema de identificación y reporte eventos adversos del hospital. Action Plan:
1 Presentación del Desafío 4 en COCASEP dic-19 dic-19
2 Rediseño del procedimiento de la instalación, verificación, vigilancia y retiro de la SNG en pacientes hospitalizados del C.M. L.A.L.M. ene-20 feb-20
3 Difusión del proceso de la Instalación, verificación, vigilancia y retiro de la SNG en pacientes hospitalizados. abr-20 may-20
4 Implementación del procedimiento. may-20 jun-20
5 Monitoreo y análisis de resultados al apego del procedimiento. jun-20 nov-20
6 Gestión de insumos y dispositivos. ene-20 mar-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
38 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
16 Lives Saved:
0.87 Lives Spared Harm:
18234 Methodology for Determining Lives Saved:
VIDAS SALVADAS = Nivel basal inicial / días sonda nasogástrica x 1000
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Elevar el porcentaje de apego a la Higiene de Manos View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Elevar el porcentaje de apego a la Higiene de Manos
Contact Info
Name JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
ARACELI MARTINEZ MARTINEZ, JEFA DE LA UNIDAD DE EPIDEMIOLOGIA Y MEDICINA PREVENTIVA
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ANGEL RODOLFO GARCIA VELA, DIRECTOR ADMINISTRATIVO ADJUNTO
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Elevar el porcentaje de apego a la Higiene de Manos Commitment Details/h6>Commitment Summary:
La gestión hospitalaria de la UVEH, implica el conseguir resultados óptimos en beneficio de los pacientes, disminuyendo el riesgo de contraer una infección asociada a la atención de la salud, si se realiza la higiene de las manos como lo marca la estrategia Multimodal de la OMS.
En el Centro Médico Lic. Adolfo López Mateos se tiene un apego de higiene de manos de un 30% general, de acuerdo al último reporte cuatrimestral realizado de mayo-agosto del año en curso; con una tasa de IAAS del mismo periodo (mayo-agosto) de 4.4.
En el hospital de manera anual participa en el Marco de Autoevaluación para la Higiene de Manos” desde el año 2017 – 2019 con los siguientes resultados:
Nivel alcanzado en el MARCO DE AUTOEVALUACIÓN DE HIGIENE DE MANOS (MAHM)
2017 Nivel alcanzado en el MAHM INSUFICIENTE/BASICO
2018 Nivel alcanzado en el MAHM INTERMEDIO
2019 Nivel alcanzado en el MAHM AVANZADO
Con lo anterior, el hospital se pone como propósito que con las estrategias a implementar se eleve el porcentaje de apego de la higiene de manos en el personal clínico y no clínico dentro de lo establecido por la OMS. Action Plan:
1 Continuar con la participación del hospital en el Marco de Autoevaluación de la Higiene de Manos de forma anual. feb-20 feb-20
2 Dar cierre al Plan de Mejora de Higiene de Manos 2019. nov-19 nov-19
3 Elaboración del Plan de Mejora de Higiene de Manos 2020 que incluya la capacitación a pacientes, familiares y visitantes. mar-20 mar-20
4 Coparticipación de pacientes y familiares en la vigilancia de higiene de manos del personal de salud. abr-20 nov-20
5 Dar seguimiento al abasto de insumos para la higiene de manos en áreas clínicas. ene-20 dic-20
6 Implementación de un sistema electrónico para el registro de los datos de medición. feb-20 feb-20
7 Seguimiento de los resultados en el CODECIN para el análisis, retroalimentación. ene-20 dic-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
4.1 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
3.0 Lives Spared Harm:
9600 Methodology for Determining Lives Saved:
Numero de pacientes con infección asociada a la atención de la salud / Numero de egresos hospitalarios x 100
datos obtenidos de manera mensual.
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Implementación de un Programa de Prevención Sistemática y Reanimación en Paro Cardiaco. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Programa de Prevención Sistemática y Reanimación en Paro Cardiaco.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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Dr. Alejandro Negrete Peña, Jefe de Terapia Intensiva
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Dra. Yolanda Miranda Coss, Directora Médica Adjunta
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Mtra. Karla Rivas Martínez, Jefa de Calidad
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Lic. Adriana Pérez Velázquez, Jefa de Enfermeria deTerapia Intensiva
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Dr. Marco Antonio Silva Medina, Subdirector de Medicina Crítica
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Dra. Tania Patricia MuñozMata, Médica Adscrita a Medicina Interna
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Dr. Abad Quetzalcoatl Ortega Pérez, Médico adscrito de Terapia Intensiva
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Dr. José Luis Barona Damián, Jefe de Cirugía General
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic prevention and resuscitation of in-hospital cardiac arrest How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Programa de Prevención Sistemática y Reanimación en Paro Cardiaco. Commitment Details/h6>Commitment Summary:
A partir del mes de noviembre de 2018 se integra el Equipo de Respuesta Rápida en el Centro Médico Lic. Adolfo López Mateos, teniendo una tasa de muerte relacionado a paro cardíaco no previsto de 19.05/ 1000 admisiones hospitalarias del periodo de mayo de 2018 a octubre 2018, queriendo alcanzar como meta con el proyecto una tasa de 15/1000 admisiones hospitalarias
Aún con la integración del equipo de respuesta rápida se ha identificado la falta de detección oportuna de datos clínicos de deterioro de los pacientes hospitalizados para la prevención de paro cardiaco.
Además de la falta de seguimiento del proceso de activación estandarizando los criterios para solicitar la atención del equipo de respuesta rápida. La falta de análisis de los datos recuperados en la atención de pacientes graves, con paro cardiaco. Action Plan:
Presentación del proyecto en COCASEP 26 de noviembre de 2019 por la Jefatura de Terapia Intensiva, formalizar el equipo multidiciplinario en todos los turnos del hospital en el mes de enero de 2020 por la Jefatura de Terapia Intensiva y Subdireccion Medica Adjunta, elaboracion e implementacion de un programa de reanimación que incluya el compromiso de los lideres del hospital del de febrero 2020 a abril de 2020 por la Jefatura de Terapia Intensiva y Subdireccion Medica Adjunta, análisis bimmestral de casos (activacion del equipo de respuesta rapida de febrero 2020 a diciembre 2020) por el equipo de respuesta rápida, elaboración de un formato para casos de paro cardiorespiratorio de enero 2020 a febrero de 2020 por la Jefatura de Terapia Intensiva y Subdireccion Medica Adjunta, Subdirección de Medicina Critica y Subdirección de Medicina Interna, gestion de equipos de monitoreo de enero 2020 a junio 2020 por la Jefatura de Terapia Intensiva y Dirección Administrativa Adjunta. Impact Details Lives Saved
Predicted Lives Spared Harm:
16.05000000000001 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
17
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Difusión e implantación del paquete de control de las Bacteremias Asociadas a Catéter Venoso Central. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Difusión e implantación del paquete de control de las Bacteremias Asociadas a Catéter Venoso Central.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-7608-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DRA. ARACELI MARTÍNEZ MARTÍNEZ, JEFA DE LA UNIDAD DE EPIDEMIOLOGIA Y MEDICINA PREVENTIVA
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LIC. ENF. VERONICA TLAZOLA RIVERA, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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LIC. ENF. MARÍA GUADALUPE GÓMEZ FLORES, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DRA. ELENA LEÓN SÁNCHEZ, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. BENITO ZAMARRIPA AYALA, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. SALVADOR HERNÁNDEZ VEGA, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. EDUARDO MARTÍNEZ HERNÁNDEZ, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. ESTEBAN JOSUÉ RIVERA CASADO, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. EDUARDO LÓPEZ CHÁVEZ, SUBDIRECTOR MEDICO CLÍNICO
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LIC. SANDRA SALAZAR HERNÁNDEZ, RESPONSABLE DE CLÍNICA DE CATÉTERES
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Difusión e implantación del paquete de control de las Bacteremias Asociadas a Catéter Venoso Central. Commitment Details/h6>Commitment Summary:
Contar con una metodología que permita unificar criterios, para identificar la fuente de infección y el mecanismo de transmisión de las infecciones asociadas a la atención de la salud (IAAS), e implementar medidas de control y prevención que favorezca la reducción de las mismas, impactando en la morbilidad y mortalidad del Centro Médico “Lic. Adolfo López Mateos”, mediante la aplicación de los paquetes de medidas preventivas para el control integral de las IAAS de acuerdo a los programas prioritarios de nivel Nacional.
Actualmente la Tendencia mensual de las IAAS, corresponde el 5% a Bacteriemia Asociada Catéter Venoso Central siendo esta en mayor número en el servicio de Medicina Interna, se pretende disminuir el número de pacientes con éste tipo de infección en el periodo de diciembre 2019 a diciembre 2020.
Con lo anterior el hospital se encuentra con valor basal de: Tasa: 0.52, teniendo como meta con las estrategias a implementar, alcanzar un 80% (0.10) de disminución de Bacteriemia Asociada a Catéter Venoso Central.
Conjunto de acciones sistematizadas, aplicando las mejores prácticas de prevención de infecciones asociadas a la atención de la salud, basadas en evidencia científica, que cuando se realizan en conjunto, en forma confiable y permanente han demostrado impacto en reducir las tasas de infecciones, siendo una forma estructurada de mejora en los procesos de la atención de los pacientes del Centro Médico “Lic. Adolfo López Mateos". Action Plan:
1.- Difusión e implantación del paquete de control de las bacteremias asociadas a catéter venoso central, mediante oficio circular y CODECIN de diciembre 2019 a enero 2020 por la Jefa de la Unidad de Epidemiología.
2.- PILOTAJE: Aplicación del formato del paquete de control de las bacteremias asociadas a catéter venoso central en el área de hospitalización de medicina interna de febrero 2020 a marzo 2020 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
3.- Supervisión de la Aplicación del formato del paquete de control de las bacteremias asociadas a catéter venoso central en el área de hospitalización de medicina interna de marzo 2020 a abril 2020 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
4.- Implementación del paquete de control de las bacteremias asociadas a catéter venoso central en el área de hospitalización de medicina interna de mayo 2020 a diciembre 2020 por el personal médico y de enfermería de medicina interna.
5.-Evaluación de los resultados de marzo 2020 a febrero 2021 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
6.-Análisis de los resultados de marzo 2020 a febrero 2021 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
7.- Presentación en CODECIN en febrero 2021 por la Jefa de la Unidad de Epidemiología y Medicina Preventiva.
8.- Presentación en COCASEP de diciembre 2019 a marzo 2021 por la Jefa de la Unidad de Epidemiología y Medicina Preventiva. Impact Details Lives Saved
Lives Spared Total:
1.184 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
2
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Implementación de un Plan de Atención Colaborativa para la Detección y Manejo de pacientes en Salud Mental. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Plan de Atención Colaborativa para la Detección y Manejo de pacientes en Salud Mental.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 276 0860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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EDUARDO AHEDO GARCÍA, PSICOLOGO
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MARISOL CRUZ GARCÍA, PSIQUIATRA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 13B - Collaborative care planning in mental health How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Plan de Atención Colaborativa para la Detección y Manejo de pacientes en Salud Mental. Commitment Details/h6>Commitment Summary:
La seguridad del paciente en psiquiatría, es una preocupación para el Centro Médico “Lic. Adolfo López Mateos”, además de ser una parte importante del proceso de atención integral al paciente, por lo que se debe hacer una identificación de pacientes a través de una escala a todos los que ingresan, para determinar a quienes necesiten el apoyo psicológico y/o psiquiátrico.
Actualmente en el hospital, se cuenta con un tamizaje psicológico a cargo del área de atención al usuario, pero no se lleva de manera formal con la implicación de un equipo multidisciplinario, lo que hace débil su funcionalidad, y la falta de seguimiento permanente, debilitando la detección oportuna de atención al paciente en el ámbito psicológico y/o psiquiátrico. Teniendo antecedente de pacientes con intento de suicidio, o autolesión, así como agresión al personal clínico, contando solo con lo registrado en el expediente clínico.
Aun cuando no se lleva de manera formal un proceso para la identificación de casos de salud mental de manera multidisciplinaria y estandarizada, aun así se cuenta con un análisis de lo detectado a pacientes durante un periodo de pilotaje, en el cual se detectaron: depresión, crisis de ansiedad, esquizofrenia, estrés, brote psicótico entre otros, los cuales han provocado en algunos paciente recurrentes reingresos por situaciones derivadas de su situación emocional en crisis, siendo referidos a la consulta externa de psiquiatría y psicología. Siendo importante mencionar que se observó en el pilotaje, bajo el número de quejas expuestas por los pacientes al tener una intervención directa, reduciendo el grado de ansiedad al sentirse escuchados.
De acuerdo a las principales causas de atención en el Centro Médico “Lic. Adolfo López Mateos” en los consultorios de psicología y psiquiatría se reporta lo siguiente:
- Psiquiatría con número de consultas de enero a octubre 2019 de 1617, con las cinco principales causas de atención de: Trastorno de ansiedad generalizada, esquizofrenia paranoide, Retraso mental moderado, Trastorno depresivo recurrente moderado y Trastorno depresivo recurrente leve.
- Psicología con número de consultas de enero a octubre 2019 de 3558, con las cinco principales causas de atención de: Episodio depresivo leve, Trastorno de adaptación, Episodio depresivo moderado, Trastorno de ansiedad generalizada, Trastorno mixto de ansiedad y depresión.
Por lo anterior, el hospital se pone como propósito que con las estrategias a implementar se identifique oportunamente al paciente que requiera intervención psicológica y/o psiquiátrica antes de presentar eventos indeseables tanto intra como extrahospitalaria. Action Plan:
1 Presentación del Desafío 16 en COCASEP dic-19 dic-19
2 Elaboración del plan de atención colaborativa para la detección y manejo de pacientes en salud mental que incluya el apoyo de los líderes del hospital (mediante la Guía del Plan de Confort y Kits de herramientas de Confort). ene-20 feb-20
3 Implementación del Plan. mar-20 nov-20
4 Empoderar el involucramiento de la familia en la atención del paciente. mar-20 nov-20
5 Monitorear el oportuno tamizaje y atención del paciente. may-20 nov-20
6 Análisis de resultados para toma decisiones. jun-20 dic-20
7 Presentación de resultados en COCASEP mar-20 nov-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
0.004 Lives Saved:
20.684 Lives Spared Harm:
5171 Methodology for Determining Lives Saved:
Vidas salvadas previstas = Vidas salvadas Daño previsto * Tasa de mortalidad
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Implementación de un Protocolo de Prevención de la Depresión Respiratoria inducida por Opioides. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Protocolo de Prevención de la Depresión Respiratoria inducida por Opioides.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
DRA. ALEJANDRA GORDILLO PARRA, JEFA DE ANESTESIOLOGÍA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for opioid-induced respiratory depression How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Protocolo de Prevención de la Depresión Respiratoria inducida por Opioides. Commitment Details/h6>Commitment Summary:
La gestión hospitalaria implica el conseguir resultados estadísticos que nos orienten y nos den un diagnostico situacional para verificar que tan severo es el problema de depresión respiratoria en pacientes postoperatodos en el Centro Médico Lic. Adolfo López Mateos, y nos den pautas a seguir para evitar las lesiones y muertes por esta causa.
En el hospital no se cuenta con una evidencia de registro para que llevemos a cabo el análisis y por ende, implementar acciones de mejora pertinentes, a pesar de lo anterior, se tiene conocimiento que el número de casos presentados es de 1 caso por mes aproximadamente (tasa de 0.24) presentados en la unidad de cuidados postanestesicos, aun así lo casos quedan registrados en las notas médicas de los expedientes clínicos de los pacientes, omitiendo el reporte de casos a la Jefatura de Anestesiología, o al Sistema de Notificación de Eventos Adversos. Cabe señalar que a pesar de que no se tiene evidencia de los casos, se llevan a cabo actividades de prevención por parte del equipo multidisciplinario, en apego a la Norma Oficial Mexicana NOM-006-SSA3-2011, para la práctica de la anestesiología, de manera no formal, ya que no se cuenta con un protocolo de atención escrito, ni estandarizado.
Siendo importante el implementar un Protocolo de Prevención de la Depresión Respiratoria inducida por Opioides en el área quirúrgica. Action Plan:
1 Presentación del Desafío 4 en COCASEP dic-19 dic-19
2 Implementación del reporte de eventos adversos en el servicio de anestesiología. ene-20 dic-20
3 Integración de un anestesiólogo por turno al equipo de respuesta rápida. ene-20 ene-20
4 Elaboración de un Protocolo de Prevención de Depresión Respiratoria por Opioides. ene-20 feb-20
5 Implementación del Protocolo. mar-20 abr-20
6 "Medición al apego del protocolo. may-20 dic-20
7 Análisis y acciones de mejora jun-20 nov-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
0.24 Lives Spared Harm:
0.0002 Methodology for Determining Lives Saved:
Número de casos con depresión respiratoria inducida por opioides en cirugías electivas / Numero de cirugías electivas x 1000
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Implementación de un Proceso Multidisciplinario ara la Instalación, Mantenimiento y Retiro de Sonda Vesical. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Proceso Multidisciplinario ara la Instalación, Mantenimiento y Retiro de Sonda Vesical.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
FARYDE RUBIO FIGUEROA, LICENCIADA EN ENFERMERÍA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Sonda Vesical How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Proceso Multidisciplinario ara la Instalación, Mantenimiento y Retiro de Sonda Vesical. Commitment Details/h6>Commitment Summary:
La Organización Mundial de la Salud (OMS), estima que en los próximos 10 años las infecciones asociadas a la atención de la salud (IAAS), serán uno de los problemas de salud pública considerados como un evento adverso durante la atención de los servicios de salud.
Las infecciones de vías urinarias (IVU), representan del 40 al 80% de las IAAS, de acuerdo a la guía de práctica clínica “Intervenciones de Enfermería para la Instalación de Sonda Vesical” (CENETEC, 2016), hasta un 80% de los casos de infecciones urinarias nosocomiales están asociadas al catéter vesical y cerca del 50% de las aplicaciones de sonda urinaria son innecesarias.
En el Centro Medico “Lic. Adolfo López Mateos”, en los años 2017, 2018 y 2019 se ha registrado una tasa de IVUS de 24, 13 y 12.6 (enero-octubre) respectivamente. Los resultados evaluados a través del sistema INDICAS en el Centro Medico durante los años 2014 a 2018 han reportado en el indicador “ Prevención de Infecciones de Vías Urinarias en pacientes con Sonda Vesical Instalada” un rango de apego entre 86 y 89%. En una evaluación de buenas prácticas del personal de enfermería en la estandarización del cuidado al paciente con sonda vesical, realizada de Mayo a Diciembre del 2018 en el Centro Medico se encontró que el 13% de los casos evaluados no contaba con una indicación médica de instalación de sonda vesical y en el 20% no se orienta a paciente y familiar sobre cuidados de sonda y en un 22% no se contaba con indicación médica para el retiro. De los diferentes procedimientos realizados en el área urogenital donde es frecuente el empleo de sondas vesicales ya sea transuretral o supra púbica, no existe un consenso unificado para la instalación, tiempo de duración, características de la sonda (calibre, tipo de material), manejo estandarizado, uso de antibióticos profilácticos, tipo de drenaje por ello es de suma importancia implementar medidas preventivas estandarizadas para la instalación, mantenimiento y retiro del dispositivo de sonda vesical en el Centro Medico “Lic. Adolfo López Mateos”. Action Plan:
1 Presentación del desafío a COCASEP 10/12/2019 10/12/2019
2 Revisión bibliográfica basada en evidencia para la estandarización de la técnica de instalación de sonda vesical transuretral y suprapubica. 16/01/2020 16/02/2020
3 Rediseño del protocolo para la instalación, mantenimiento y retiro de sonda vesical. 16/02/2020 16/03/2020
4 Elaboración e implementación de un programa de capacitación. 01/04/2020 30/04/2020
5 Implementación del protocolo. 01/06/2020 30/10/2020
6 Supervisión y Evaluación al apego de la estandarización del protocolo. 01/06/2020 30/11/2020
7 Análisis de resultados. 01/05/2020 30/10/2020 Impact Details Lives Saved
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Diseño de un Programa de Capacitación Continúa en la Formación de Seguridad del Paciente Durante el Internado Médico y Residencias Médicas. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Diseño de un Programa de Capacitación Continúa en la Formación de Seguridad del Paciente Durante el Internado Médico y Residencias Médicas.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-7608-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
DR. JESÚS ERIC MARTÍNEZ CASTRO, JEFE DE ENSEÑANZA
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DRA. ARACELI MARTÍNEZ MARTÍNEZ, JEFA DE DIVISIÓN DE EPIDEMIOLOGIA Y MEDICINA PREVENTIVA
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LIC. KATIA YULIBETH BUSTAMANTE RIOS, JEFA DE FARMACIA INTRAHOSPITALARIA
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MTRA. ALEJANDRA AGUILAR SANTA FE, SUBDIRECTORA DE ENFERMERÍA
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MTRA. KARLA RIVAS MARTÍNEZ, JEFA DE CALIDAD
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LIC. JANETH ROLDAN RUIZ, ANALISTA DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 17 - Patient Safety Curriculum How Many Hospitals Will This Commitment Represent?
1 Does your hospital, college or health professional program currently have explicit and meaningful patient safety education embedded into the curriculum?
No Commitment Name:
Diseño de un Programa de Capacitación Continúa en la Formación de Seguridad del Paciente Durante el Internado Médico y Residencias Médicas. Curriculum QuestionsDoes your organization/program currently use simulation to teach patient safety?
No If you selected “Yes”, please check what types of simulators you are using to access and evaluate clinical skills.
What types of resources does your organization/program use to teach patient safety?
- Patient Videos & Stories
- Clinical cases
- Local experience
- Didactic resources
- Reading material
- Reflection
- Other
Other:
TALLERES What types of teaching methods does your organization/program use to teach patient safety?
- Reflections
- Small group discussions
- Didactic presentations
- Learning in the clinical environment
- Self-directed learning
Please indicate which domains you commit to incorporating into your curriculum.
- Error Science
- Human Factors
- Technology
- Teamwork & Communication
- Leadership & Leading Change
- Culture of Safety
- Patient-Oriented Safe Care
Please indicate what type of learner you plan to teach the patient safety curriculum.
For the learners you listed above, please indicate the stage of education you are teaching. Ex: First year resident, nursing student years 1 and 2.
- Year 1
- Year 2
- Year 3
- Year 4
- Year 5
- Year 6
What is the entry skill level of your learners as reflected in our curriculum? [Please indicate all that apply]
- Novice
- Advanced Beginner
- Competent
- Proficient
- Expert
Commitment Details/h6>Commitment Summary:
Con el paso de los años la atención médica ha sufrido cambios importantes en diferentes vertientes, desde el aspecto epidemiológico con el aumento en enfermedades crónico degenerativas, y neoplásicas y la disminución de la morbimortalidad de afecciones infecciosas. La farmacoterapia, la especialización y la tecnología son factores relevantes que a la par de su desarrollo confieren mayor complejidad en la atención médica, aumentando riesgos a la atención de nuestros pacientes en lo que se refiere a su seguridad, ya en 1999 la Academia de Medicina (anteriormente Instituto de Medicina) en su publicación “Errar es Humano”, así como diversas publicaciones recientes, han puesto de manifiesto la relevancia de la seguridad del paciente, por tres principales situaciones, la primera: la alta incidencia, ya que se calcula que uno de cada 10 pacientes atendido en hospitalización y uno de cada 100 atendido en consulta externa presenta un evento adverso atribuido a esta atención médica, inclusive en listas mundiales de causas de enfermedades, los eventos adversos relacionados a la atención se encuentran en el puesto 14, al mismo nivel que la tuberculosis y malaria. El segundo: se refiere a la gravedad de los daños, se dice que un 16% de los pacientes presentara un daño grave, un 39% un daño moderado y un 45% un daño leve , todo estos asociado a la atención médica, y el tercer aspecto: son los costos económicos, que afecta los costos institucionales secundarios y los costos particulares que pueden afectar al profesional involucrado.
Nos encontramos en una época en que la seguridad del paciente es un prioridad para las autoridades y los sistemas de salud, recordemos que desde el 2001 la Organización Mundial de la Salud (OMS) crea la alianza mundial para la seguridad del paciente, las estrategias actuales en seguridad del paciente se sitúan en dos grandes áreas: Un cambio cultural en los profesionales y la implementación de prácticas seguras. No hay que olvidar que la formación en seguridad del paciente es el primer paso para mejorar la cultura de seguridad y un elemento imprescindible para que médicos en formación entiendan que son necesarias las iniciativas de seguridad en el paciente. La formación en seguridad en el paciente deberá implementarse tanto en el pre-grado como en el pos-grado, así como parte de una formación continua.
Existen dos iniciativas notables en seguridad del paciente:
El “Marco Australiano” publicado dese el 2005, el marco se divide en niveles de conocimientos, habilidades y conductas según la posición de la persona y la responsabilidad clínica que reviste dentro de una organización. El marco está diseñado para colaborar con las organizaciones y ayudar a las personas a desarrollar programas curriculares educativos y cursos de capacitación que distingue 7 categorías en el aprendizaje en seguridad: comunicación eficaz, uso de evidencia, eventos adversos, trabajo seguro, conducta ética, enseñanza y aprendizaje.
El “Marco Canadiense”, publicado en el 2009, desglosa la competencia en seguridad en 6 dominios: contribuir a la cultura de seguridad, trabajar en equipo, comunicarse eficientemente, manejar los riesgos, optimizar los factores humanos y ambientales, reconocer y responder ante eventos adversos y notificarlos.
La OMS ha desarrollado una Guía Curricular específica en seguridad en el paciente en el 2011, que es base para la orientación en la formación de seguridad de aplicabilidad en el pre-grado y posgrado en formación de recursos de la salud. La realidad es que actualmente no se ha integrado de manera universal la seguridad en el paciente ni de manera transversal ni longitudinal en la formación de médicos ni de pre-grado ni de pos-grado, existen esfuerzos publicados en la literatura médica, como el que le da soporte a la propuesta de nuestra Institución, realizada por M.I. González Anglada en España, en donde soporte a una capacitación por grado académico.
La capacitación a nivel de internado de pre-grado deberá contemplar curso básico de seguridad en el paciente, así como talleres básicos de seguridad, dicha capacitación se realizar al ingreso al internado.
En cuanto a las actividades formativas dentro de las residencias médicas, estarán contempladas dentro de su programa operativo, de la misma manera, la capacitación es continua durante toda la formación de su residencia médica, abarcando diversas modalidades de enseñanza desde cursos teóricos que den cimiento a los conceptos básicos de seguridad en el paciente hasta el análisis de casos críticos en las etapas finales de la residencia médica.
El presente programa contempla 3 diferentes estrategias de capacitación acorde al grado de residencia; para residente de primer y segundo año contemplará un curso básico de seguridad de 6 sesiones de una hora y talleres, mientras que para residentes de tercer año en adelante, considerando la madurez académica, se realizará el análisis de incidentes críticos y eventos adversos que se presenten en su trabajo operativo, así como aprendizaje por simulación de casos hipotéticos referidos en la literatura.
2 sesiones al mes de seguridad en el paciente
Curso de seguridad en el paciente.
Implica incorporar conceptos de seguridad desde el ingreso de médicos residentes que incluye seguridad de la información, seguridad profesional y del paciente, siempre con énfasis en los problemas de seguridad en el ámbito hospitalario. Ya el segundo año de residencia el curso de seguridad es más avanzado que les permita identificar los incidentes o las situaciones imprevistas que pueden producir o no daño al paciente, los eventos adversos (incidentes con daño) y los casos centinelas (cuando causa la muerte o graves daños físicos o psicológicos), con la practica entienden el riesgo clínico o la probabilidad de que se produzca un incidente y aprenden del error analizando un caso centinela, durante esta etapa de formación deberán entender la importancia del factor humano, del trabajo en equipo y la comunicación. Y en una etapa final de su formación deberán contemplar la comunicación honesta del evento adverso. Action Plan:
1.- Diseñar el programa de capacitación con enfoque en seguridad del paciente durante el periodo de diciembre 2019 a enero 2020 por el Jefe de Enseñanza
2.-Presentación del la propuesta del programa de capacitación con enfoque en seguridad del paciente en el Subcomité de Enseñanza durante el periodo de febrero a marzo de 2020 por el Jefe de Enseñanza.
3.-Presentación de la propuesta de programa de capacitación con enfoque en seguridad del paciente en el Consejo de Gobierno en el mes de marzo 2020 por el Jefe de Enseñanza.
4.-Ejecución del programa de marzo 2020 a febrero 2021 por el Jefe de Enseñanza, personal de Epidemiología, Farmacia Intrahospitalaria, Enfermería y Calidad.
5.-Medición del indicador de marzo a febrero 2021 por el Jefe de Enseñanza
6.- Presentación en el Comité de Calidad y Seguridad del Paciente durante el periodo de diciembre 2019 a marzo 2021, por el Jefe de Enseñanza.
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Falta de apego a las medidas de higiene por personal médico y de enfermería para el cuidado, control y aspiración de secreciones bronquiales en los pacientes con ventilación mecánica. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Falta de apego a las medidas de higiene por personal médico y de enfermería para el cuidado, control y aspiración de secreciones bronquiales en los pacientes con ventilación mecánica.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-7608-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
DRA. ARACELI MARTÍNEZ MARTÍNEZ, JEFA DE LA UNIDAD DE EPIDEMIOLOGIA Y MEDICINA PREVENTIVA
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LIC. ENF. VERONICA TLAZOLA RIVERA, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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LIC. ENF. MARÍA GUADALUPE GÓMEZ FLORES, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DRA. ELENA LEÓN SÁNCHEZ, MED. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. BENITO ZAMARRIPA AYALA, MED. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. SALVADOR HERNÁNDEZ VEGA, MED. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. EDUARDO MARTÍNEZ HERNÁNDEZ, MED. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR.ESTEBAN JOSUÉ RIVERA CASADO, MED. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. EDUARDO LÓPEZ CHÁVEZ, SUBDIRECTOR MEDICO CLÍNICO
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DR. ALEJANDRO NEGRETE PEÑA, JEFE DE DIVISIÓN DE LA UNIDAD DE CUIDADOS INTENSIVOS
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-associated pneumonia (VAP) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Falta de apego a las medidas de higiene por personal médico y de enfermería para el cuidado, control y aspiración de secreciones bronquiales en los pacientes con ventilación mecánica. Commitment Details/h6>Commitment Summary:
Contar con una metodología que permita unificar criterios, para identificar la fuente de infección y el mecanismo de transmisión de las infecciones asociadas a la atención de la salud (IAAS), e implementar medidas de control y prevención que favorezca la reducción de las mismas, impactando en la morbilidad y mortalidad del Centro Médico “Lic. Adolfo López Mateos”, mediante la aplicación de los paquetes de medidas preventivas para el control integral de las IAAS de acuerdo a los programas prioritarios de nivel Nacional.
Actualmente la Tendencia mensual de las IAAS, corresponde el 50% a Neumonía Asociada a Ventilación Mecánica, siendo esta en mayor número en el servicio de Terapia Intensiva adultos y Medicina Interna, se pretende disminuir el número de pacientes con éste tipo de infección en el periodo de diciembre 2019 a diciembre 2020.
Con lo anterior el hospital se encuentra con valor basal de: Tasa: 11.94, teniendo como meta con las estrategias a implementar, alcanzar un 50% (5.97) de disminución de Neumonía Asociada a Ventilación Mecánica.
Conjunto de acciones sistematizadas, aplicando las mejores prácticas de prevención de infecciones asociadas a la atención de la salud, basadas en evidencia científica, que cuando se realizan en conjunto, en forma confiable y permanente han demostrado impacto en reducir las tasas de infecciones, siendo una forma estructurada de mejora en los procesos de la atención de los pacientes del Centro Médico “Lic. Adolfo López Mateos". Action Plan:
1.- Difusión e implentación del paquete paquete de control de las neumonías asociadas a la ventilación mecánica mediante oficio circular y CODECIN
de diciembre 2019 a enero 2020 por la Jefa de la Unidad de Epidemiología.
2.- PILOTAJE:Aplicación del formato del paquete de control de lasneumonías asociadas a la ventilación mecánica en las áreas de terapia intensiva adultos y medicina interna de febrero 2020 a marzo 2020 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
3.- Supervisión de la Aplicación del formato del paquete de control de las neumonías asociadas a la ventilación mecánica en las áreas de terapia intensiva adultos y medicina interna de marzo 2020 a abril 2020 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
4.-Implementación del paquete de control de las infecciones del paquete de control de las neumonías asociadas a la ventilación mecánica en las áreas de terapia intensiva adultos y medicina interna de mayo 2020 a diciembre 2020 por el personal médico y de enfermería de terapia intensiva adultos y medicina interna.
5.-Evaluación de los resultados de marzo 2020 a febrero 2021 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
6.-Análisis de los resultados de marzo 2020 a febrero 2021 por los Integrantes del equipo y Jefa de la Unidad de Epidemiología y Medicina Preventiva.
7.- Presentación en CODECIN en febrero 2021 por la Jefa de la Unidad de Epidemiología y Medicina Preventiva.
8.- Presentación en COCASEP de diciembre 2019 a marzo 2021 por la Jefa de la Unidad de Epidemiología y Medicina Preventiva. Impact Details Lives Saved
Lives Spared Total:
13.967999999999998 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
14
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Reforzar la estandarización del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Reforzar la estandarización del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2766008
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
SANDRA MARICELA MARTÍNEZ ALVARADO, MAESTRA EN ENFERMERIA COMUNITARIA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Reforzar la estandarización del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. Commitment Details/h6>Commitment Summary:
Derivado de la falta de un protocolo estandarizado para la implementación de una técnica correcta de eliminación de secreciones Traqueobronquiales que se apegue a las buenas prácticas por enfermería y aunado al hecho de no contar con un equipo o kit de trabajo especialmente diseñado para tal fin, lo cual se traduce en un incremento de riesgos e incidentes con relación al paciente con cánula orotraqueal (taponamientos, desalojos y bronco aspiración por mal manejo de secreciones), se promueve la implementación de acciones de mejora orientadas a mejorar los resultados en el Centro Médico “Lic. Adolfo López Mateos”
La incidencia de eventos adversos (obstrucción de vía aérea por tapón mucoso) registrados en los últimos cinco años en pacientes con Cánula Orotraqueal COT es la siguiente: año 2015 (0/ sin reporte), año 2016 (0/ sin reporte), 2017 (1 caso reportado), 2018 (4 casos reportados) y de enero a octubre 2019 (6 casos reportados) eventos; con respecto al total de eventos adversos relacionados a vía aérea (desalojo del COT, desalojo de traqueotomía, incidentes con el globo COT, incidentes con el globo de traqueotomía, obstrucción con tapón mucoso, bronco aspiración,). Por año en 2015, 4 eventos, 2016, 19 eventos, en 2017, 30 eventos, en 2018, 39 eventos y en 2019 un total de 32 eventos. Derivado de la situación referida se plantea la necesidad de reforzar la estandarización del proyecto de mejora para disminuir las incidencias relacionadas al problema, con el cual se logra estandarizar el proceso de valoración, intervención, evaluación y reevaluación para la eliminación de secreciones Traqueobronquiales de manera oportuna y segura en los pacientes del Centro Medico Lic. Adolfo López Mateos. Action Plan:
1 Presentación de proyecto en COCASEP. dic-19 dic-19
2 Analizar la dimensión del problema y causas raíz de la obstrucción de vía por taponamiento mucoso nov-19 dic-19
3 Actualización del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. feb-20 feb-20
4 Difusión del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. mar-20 sep-20
5 Monitoreo del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. abr-20 dic-20
6 Análisis de resultados de la fase de implementación del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. jul-20 nov-20
7 Replanteamiento del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. ago-20 ago-20 Impact Details Lives Saved
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Adopción y Adaptación de un Protocolo de Prevención y Detección Oportuna de Tromboembolismo Venoso en el Paciente Quirúrgico y no Quirúrgico. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Adopción y Adaptación de un Protocolo de Prevención y Detección Oportuna de Tromboembolismo Venoso en el Paciente Quirúrgico y no Quirúrgico.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
NERI ISLAS PALACIOS, DOCTOR
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous thromboembolism (VTE) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Adopción y Adaptación de un Protocolo de Prevención y Detección Oportuna de Tromboembolismo Venoso en el Paciente Quirúrgico y no Quirúrgico. Commitment Details/h6>Commitment Summary:
El tromboembolismo venoso (TEV) se asocia con una mayor mortalidad, malos resultados para los pacientes, mayor duración de la estadía y disminución de la satisfacción del paciente. Es la complicación hospitalaria prevenible más común, así como la causa más común de mortalidad prevenible en los hospitales.
La ETV se presenta en más del 25% de pacientes quirúrgicos hospitalizados. La guía de práctica clínica (9° Edición) de la American College of Chest Physicians (ACCP) para la prevención de ETV sugiere una estratificación de riesgo basado en el modelo de las tasas de síntomas de ETV. Este modelo se clasifica en pacientes con muy bajo riesgo (< 0.5%), bajo riesgo (0.5%-1.5%), riesgo moderado (1.5%-3.0%), y alto riesgo (> 3%).
Actualmente en el hospital Centro Médico Lic. Adolfo López Mateos, no existe una identificación de casos de ETV, por tal motivo, tampoco se cuenta con una notificación de eventos adversos relacionados.
De acuerdo a la Unidad de Expediente y Archivo Clínico del hospital, en el primer semestre del presente año, se reportaron 16 pacientes con diagnóstico de Flebitis, tromboflebitis, embolias y trombosis venosas representando una tasa de 1.3%.
Siendo importante la adopción y adaptación de un protocolo de prevención y detección oportuna de tromboembolismo venoso en el paciente quirúrgico y no quirúrgico. Action Plan:
1 Presentación del Desafío 12 en COCASEP dic-19 dic-19
2 Implementación de reporte de eventos tromboticos venosos ene-20 dic-20
3 Integración de un equipo multidisciplinario ene-20 ene-20
4 Gestión de dispositivos mecánicos de compresión. ene-20 mar-20
5 Adopción y adaptación de un protocolo de estadificación de riesgo de eventos tromboticos venosos. ene-20 feb-20
6 Implementación del Protocolo. mar-20 abr-20
7 "Medición al apego del protocolo. may-20 dic-20
8 Análisis y acciones de mejora jun-20 nov-20 Impact Details Lives Saved
Lives Spared Total:
1.196 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
2
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Manejo de la Sangre View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Manejo de la Sangre
Contact Info
Name JOSE ROGEL ROMERO
Phone: 2760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
DR. SERGIO ANGEL MARIN SANTIAGO, ENCARGADO DE BANCO DE SANGRE
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DR. NERI ISLAS PALACIOS, JEFE DE SERVICIO DE MEDICINA INTERNA
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DR. GERARDO QUINO CHACHA, SUBDIRECTOR DE APOYO AL DIAGNÓSTICO Y TRATAMIENTO
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DRA. ALEJANDRA GORDILLO PARRA, JEFA DE DIVISION DE ANESTESIOLOGIA
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DR. JOSE LUIS BARONA DAMIAN, JEFE DE SERVICIO DE CIRUGIA GENERAL
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MTRA. JANETH ROLDAN RUIZ, ANALISTA DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient blood management How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Manejo de la Sangre Commitment Details/h6>Commitment Summary:
1.- En el Centro Médico Lic. Adolfo López Mateos el 90 % de los paciente anémicos sometidos a cirugía son transfundidos
El Manejo de hemoderivados, es el uso apropiado de prácticas oportunas basadas en evidencia, para el control de pacientes con anemia. Las causas de anemia incluyen pérdida de sangre, problemas en la formación y desarrollo de glóbulos rojos y malnutrición.
Mientras que el personal sanitario normalmente usa la transfusión sanguínea como tratamiento para la anemia, no suelen tratar la causa subyacente, lo cual permiten un error considerado como factor de riesgo en el paciente cada vez que recibe una transfusión. Los errores en el uso de los componentes de la sangre es una causa significativa de daño y muerte en pacientes hospitalizados.
Estas prácticas disminuirán la necesidad de transfusiones, los riesgos de errores que presentan, y las muertes prevenibles de los pacientes relacionados a este problema.
Los síntomas usuales de la anemia incluyen sensación de debilidad, agotamiento, y problemas para la concentración. Los proveedores de salud pasan por alto o ignoran la anemia, ya que esos síntomas son vagos y forman parte de la vida diaria de muchas personas.
Es por ello, que para el Centro Médico “Lic. Adolfo López Mateos es de gran importancia disminuir la transfusiones protocolarias e innecesarias en nuestros pacientes teniendo una tasa de transfusión en pacientes anémicos que serán sometidos a un procedimiento quirúrgico de 90%, poniéndonos como meta bajar una tasa del 50 % en el año 2020. Action Plan:
1
REUNIÓN CON RESPONSABLES DIRECTOS (QUIRÚRGICOS, MEDICINA INTERNA, ANESTESIOLOGIA, MEDICINA TRANSFUSIONAL CALIDAD)
7/11/2019 7/11/2019 MARIN SANTIAGO SERGIO ANGEL OBTENER MINUTA Y ACUERDOS
2
DIFUSIÓN DE LA GUÍA PARA EL USO CLÍNICO DE LA SANGRE EN LA INTRA NET DEL CENTRO MEDICO LIC. ADOLFO LOPEZ MATEOS 20/NOV/2019
22/12/2019 TEGNOLOGIAS.
3
RECABAR INFORMACIÓN MENSUALMENTE PARA LOS INDICADORES
1 A 5 DE CADA MES DE OCT 2019 A DIC 2020
4
PRESENTAR EN COCASEP
26/11/2019,
6
PRESENTAR EN COCASEP TRIMESTRAL AVANCES
7
HACER Y DARLE SEGUIMIENTO AL PROTOCOLO DE TRANSFUSIÓN QUIRÚRGICO CADA MES EN EL COMIDE DE MEDICINA TRANSFUSIONAL CON LOS SERVICIOS Y JEFES DE MEDICINA INTERNA, QUIRÚRGICAS ANESTESIOLOGIA MEDICINA TRANSFUSIONAL
MEJORA Y CIRUGÍA Impact Details Lives Saved
Lives Saved Predicted Calculaton:
8 Methodology for Determining Lives Saved:
SE TOMA COMO BASE LOS DATOS PROPORCIONADOS, POR LA UNIDAD DE ESTADÍSTICA Y ARCHIVO CLÍNICO DEL CENTRO MEDICO LICENCIADO ADOLFO LOPEZ MATEOS, RESPECTO AL REPORTE DE PROCEDIMIENTOS QUIRÚRGICOS ELECTIVOS, Y LAS DEFUNCIONES CON PRODECIMIENTO QUIRURGICO, ASI COMO LOS REPORTE DE REACCIONES ADVERSAS ALA TRANSFUSIÓN SANGUÍNEA DEL BANCO DE SANGRE DEL PERIODO DE ENERO A SEPTIEMBRE DEL 2019
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Implementación de un Algoritmo para la Identificación, Instalación y Mantenimiento de Vía Aérea. View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Algoritmo para la Identificación, Instalación y Mantenimiento de Vía Aérea.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
ALEJANDRA GORDILLO PARRA, DOCTORA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Algoritmo para la Identificación, Instalación y Mantenimiento de Vía Aérea. Commitment Details/h6>Commitment Summary:
En el Centro Médico Lic. Adolfo López Mateos, no se cuenta con un protocolo estandarizado de identificación y de manejo de vía aérea, que implique la participación multidisciplinaria en todo el hospital, siendo un objetivo en primer lugar el reforzar la notificación de eventos relacionados a la vía aérea fallida. Por lo que los objetivos a enfocarse serán: el reforzar la notificación de eventos adversos por área médica y a la implementación de un Algoritmo de actuación para la instalación y mantenimiento de la vía aérea que incluya la participación del equipo multidisciplinario del hospital.
Durante el año 2019 se tiene un registro de notificación de eventos adversos relacionado a instalación y mantenimiento de vía aérea de 15 de los cuales 1 caso fue centinela a causa de no poder rescatar la vía aérea.
Por tal motivo, la importancia de implementar acciones de mejora, que permita una mejor seguridad en el manejo de la vía aérea en el hospital por personal capacitado. Action Plan:
1 Presentación del Subdesafío 8A en COCASEP dic-19 dic-19
2 Implementación del reporte de eventos adversos en relación a intubaciones fallidas y fortuitas. ene-20 dic-20
3 Integración de un anestesiólogo por turno al equipo de respuesta rápida. ene-20 ene-20
4 Gestión para abasto de material de carro de vía aérea. ene-20 mar-20
5 Implementación de una base de datos electrónica para el registro de los eventos fallidos y fortuitos. ene-20 ene-20
6 Adopción y adaptación de un algoritmo para la identificación, instalación y mantenimiento de vía aérea. ene-20 feb-20
7 Implementación. mar-20 dic-20
8 Continuar con el programa de capacitación continua. mar-20 nov-20
9 Medición al apego del algoritmo. may-20 nov-20
10 Análisis del reporte de eventos adversos mar-20 dic-20
11 Análisis y acciones de mejora. jun-20 nov-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
0.15 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
0.075 Lives Spared Harm:
1218.44 Methodology for Determining Lives Saved:
Vidas salvadas de daño = Línea de base de tasa de extubación no planificada - Medida de extubación no planificada) X línea de base de días de intubación
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ATENCIÓN Y REPERFUSIÓN DE PACIENTES, ENFERMEDAD VASCULAR CEREBRAL TIPO ISQUEMICA View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
ATENCIÓN Y REPERFUSIÓN DE PACIENTES, ENFERMEDAD VASCULAR CEREBRAL TIPO ISQUEMICA
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-7608-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DR. MARCO ANTONIO SILVA MEDINA, SUBDIRECTOR DE MEDICINA CRITICA
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DR. CRYSTIAN HUGO SANTOS GONZALEZ, JEFE DE LA DIVISIÓN DE URGENCIAS
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MTRA. KARLA RIVAS MARTÍNEZ, JEFA DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
INFARTO CEREBRAL ISQUEMICO How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
ATENCIÓN Y REPERFUSIÓN DE PACIENTES, ENFERMEDAD VASCULAR CEREBRAL TIPO ISQUEMICA Commitment Details/h6>Commitment Summary:
La gestión hospitalaria implica el conseguir resultados estadísticos que nos orienten y nos den un diagnostico situacional para verificar que tan severo es el problema del retraso en la atención oportuna de paciente con enfermedad vascular cerebral (EVC) isquémica en el Centro Médico Lic. Adolfo López Mateos, y nos den pautas a seguir para evitar secuelas y muertes por esta causa.
En el hospital no se cuenta con una evidencia de registro para que llevemos a cabo el análisis y por ende, implementar acciones de mejora pertinentes, a pesar de lo anterior, se tiene conocimiento que el EVC es la cuarta causa de muerte, la primera causa de discapacidad del adulto mayor, y la segunda causa de demencia en México., incidencia reportada por el estudio (BASID) 232 casos por 100,000 habitantes. Tomando en cuenta que el estado de México cuenta con una población aproximada de 17,363,387 habitantes y que la población que atendemos en el instituto de salud del estado de México es de 7, 077,133, la incidencia de EVC en esta población seria de 16,419 casos en el año y como mas de 70% de los EVC son isquémicos, nuestra incidencia actual calculada y donde tendríamos oportunidad de impactar en mejora en la calidad de vida y a su vez previniendo muertes, es de 13,135 casos por año según la CONAPO y ENSANUT. El tratamiento se lleva a cabo en algunas ocasiones en base a guías de práctica clínica pero no se cuenta con un protocolo de atención escrito, ni estandarizado.
Por lo anterior es prioritario la implementación de un protocolo de atención y reperfusión farmacológica del paciente con evento vascular cerebral isquémico agudo Centro Médico Lic. Adolfo López Mateos. Action Plan:
1.-Presentación del Desafío en el Comité de Calidad y Seguridad del Paciente en el mes de diciembre de 2019 por el Subdirector de Medicina Criticas y el Jefe de la División de Urgencias.
2.-Capacitación al equipo multidisciplinario en la atención del paciente con Evento Vascular Cerebral Isquémico en el periodo de enero a febrero 2020 por el Subdirector de Medicina Critica y el Jefe de la División de Urgencias.
3.-Implementación del protocolo de atención de los pacientes con Evento Vascular Cerebral Isquémico en el periodo de febrero a diciembre 2020 por el Subdirector de Medicina Critica y el Jefe de la División de Urgencias.
4.-Registro y seguimiento de casos de pacientes con Evento Vascular Cerebral Isquémico en el periodo de marzo a diciembre 2020 por el Subdirector de Medicina Critica y el Jefe de la División de Urgencias.
5. Medición al apego del protocolo en el periodo de marzo a diciembre 2020 por el Subdirector de Medicina Critica y el Jefe de la División de Urgencias.
6. Análisis y acciones de mejora de marzo a mayo de 2020, por el Subdirector de Medicina Critica y el Jefe de la División de Urgencias.
7.- Presentación de resultados en el Comité de Calidad y Seguridad del Paciente en los meses de marzo, junio y noviembre de 2020. Impact Details Lives Saved
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Implementación de un Programa de Detección Temprana y Tratamiento de Sepsis View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Programa de Detección Temprana y Tratamiento de Sepsis
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
ALEJANDRO NEGRETE PEÑA, DOCTOR
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 9B - Early detection and treatment of sepsis for low- and middle- income countries How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Programa de Detección Temprana y Tratamiento de Sepsis Commitment Details/h6>Commitment Summary:
La sepsis grave constituye una de las enfermedades más frecuentes en los hospitales, y su incidencia aumenta, generando un importante consumo de recursos relacionados al uso y consumo de antibióticos, mayor estancia hospitalaria y mayor mortalidad.
La identificación temprana del proceso séptico, así como la instauración de un manejo oportuno y adecuado a través de un protocolo de actuación guiado por determinados objetivos clínicos puede mejorar la probabilidad de sobrevivencia de los pacientes hospitalizados.
Por lo anterior el Centro Médico Lic. Adolfo López Mateos se pone como objetivo el implementar un Equipo de Trabajo: “Código Sepsis” que estará compuesto por un grupo multidisciplinario de médicos de diferentes especialidades y personal de enfermería, el cual permitirá reconocer tratar precozmente la sepsis grave y choque séptico a través de intervenciones como un programa educacional, guías de actuación clínica, guía de antibioticoterapia empírica inicial y registro de actividades para la inclusión y seguimiento de pacientes.
Al término de la intervención se medirán resultados pertinentes para comparar la tasa de mortalidad hospitalaria, tasa de infección hospitalaria, días de estancia hospitalaria y reducción en los costos de uso y consumo de antibióticos. Actualmente la Unidad de Vigilancia Hospitalaria reporta una tasa de infecciones hospitalaria promedio del año 2018 de 4.2, sin embargo se reportaron tasas de hasta 7.3 en el mes de abril, para el año 2019 se tiene reportado una tasa de 4.5 por cada 100 egresos; el impacto va desde el incremento en los costos de atención hospitalaria hasta presencia de casos de muertes asociados a infecciones, en este contexto en el año 2018 se tuvo una tasa de mortalidad asociada a sepsis de 4.2 por cada 100 egresos (2 casos), en el año 2019, de enero a septiembre se reporta en 0 (0 casos). Action Plan:
1 Presentación del Sudesafío en COCASEP dic-19 dic-19
2 Integración de Equipo de Trabajo: Código Sepsis. ene-20 ene-20
3 Elaboración e implementación de un programa de trabajo Código Sepsis (que incluya el compromiso de los líderes del hospital) feb-20 may-20
4 Análisis bimestral de casos de activación del equipo de trabajo Código Sepsis. jul-20 nov-20
5 Elaboración de un formato para casos de sepsis. feb-20 feb-20
6 Gestión de equipo de monitoreo y abasto suficiente de antibióticos y medios de cultivo. ene-20 may-20
7 Seguimiento a la medición y análisis de indicadores ene-20 dic-20
8 Presentación de resultados en COCASEP mar-20 nov-20 Impact Details Lives Saved
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Diseño e implementación de un Sistema de notificación de errores de Medicación View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Diseño e implementación de un Sistema de notificación de errores de Medicación
Contact Info
Name JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: Director
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
-
LIC. KATIA YULIBETH BUSTAMANTE RÍOS, JEFA DE FARMACIA
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication errors How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Diseño e implementación de un Sistema de notificación de errores de Medicación Commitment Details/h6>Commitment Summary:
En el Centro Médico Lic. Adolfo López Mateos cuenta con el servicio de Farmacia Intrahospitalaria, la cual implemento el programa de farmacovigilancia en el año 2015, iniciando con los Eventos Adversos Relacionados a la medicación derivados de las propiedades farmacológicas de los medicamentos (Reacciones Adversas). En el año 2017 se actualizó la Norma Oficial Mexicana NOM-220-SSA1-2016, Instalación y operación de la farmacovigilancia, incluyendo la notificación de todo el universo de los Eventos Adversos relacionados a la medicación, incluyendo a los Errores de Medicación.
Sin embargo, la Unidad de Farmacovigilancia y el área de enfermería de este nosocomio únicamente ha captado y notificado 2 Errores de Medicación en el periodo de enero – septiembre de 2019 a través del sistema de registro de Eventos Adversos de donde, dicha situación pone en evidencia la problemática que se tiene en cuanto a la infranotificación de este tipo de eventos. (Infranotificación: Baja notificación de errores de medicación).
Por consiguiente resulta de vital importancia que la Unidad de Farmacovigilancia de este nosocomio adecúe las actividades que conlleven a la captación de todos los Errores de Medicación, mediante el diseño e implementación de un sistema de notificación de estos errores, para así promover la cultura de seguridad con la finalidad de prevenir o disminuir la probabilidad de que ocurran eventos adversos por errores de medicación. Action Plan:
1 Presentación del Desafío 16 en COCASEP dic-19 dic-19
2 Gestión de uso de software de notificación de Eventos Adversos de la unidad de investigación del hospital. dic-19 dic-19
3 Elaboración de programa de capacitación 2020. dic-19 ene-20
4 Elaboración de material didáctico para difusión ene-20 nov-20
5 Elaboración de procedimiento de seguimiento farmacoterapeutico a pacientes hospitalizados dic-19 ene-20
6 Análisis de notificaciones abr-20 dic-20
7 Diseño e Implementación de un programa de prevención de errores de medicación como acción de mejora acorde al subdesafío 3A jul-20 dic-20 Impact Details Lives Saved
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Infecciones del Tracto Urinario Asociado a Catéteres (CAUTI) View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Infecciones del Tracto Urinario Asociado a Catéteres (CAUTI)
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2-76-08-60
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DRA. ARACELI MARTÍNEZ MARTÍNEZ, JEFA DE LA UNIDAD DE EPIDEMIOLOGIA Y MEDICINA PREVENTIVA
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LIC. ENF. VERONICA TLAZOLA RIVERA, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGÍA Y MP
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LIC. ENF. MARIA GUADALUPE GÓMEZ FLORES, ENF. ADSCRITA A LA UNIDAD DE EPIDEMIOLOGÍA Y MP
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DRA. ELENA LEÓN SÁNCHEZ, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. BENITO ZAMARRIPA AYALA, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. SALVADOR HERNÁNDEZ VEGA, MED. ADSCRITO A LA UNIDAD DE EPIDEMIOLOGIA Y MP
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DR. EDUARDO LÓPEZ CHÁVEZ, SUBDIRECTOR MÉDICO CLÍNICO
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JANETH ROLDAN RUIZ, ANALISTA DE CALIDAD
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Infecciones del Tracto Urinario Asociado a Catéteres (CAUTI) Commitment Details/h6>Commitment Summary:
Contar con una metodología que permita unificar criterios, para identificar la fuente de infección y el mecanismo de transmisión de las infecciones asociadas a la atención de la salud (IAAS), e implementar medidas de control y prevención que favorezca la reducción de las mismas, impactando en la morbilidad y mortalidad del Centro Médico “Lic. Adolfo López Mateos”, mediante la aplicación de los paquetes de medidas preventivas para el control integral de las IAAS de acuerdo a los programas prioritarios de nivel Nacional.
Actualmente la Tendencia mensual de las IAAS, corresponde el 10% a Infección de vías urinarias asociado a catéter, siendo esta en mayor número en el servicio de Medicina Interna, se pretende disminuir el número de pacientes con éste tipo de infección en el periodo de diciembre 2019 a diciembre 2020.
Con lo anterior el hospital se encuentra con valor basal de: Tasa: 1.58, teniendo como meta con las estrategias a implementar, alcanzar un 50% (0.79) de disminución de Infección de vías urinarias asociado a catéter.
Conjunto de acciones sistematizadas, aplicando las mejores prácticas de prevención de infecciones asociadas a la atención de la salud, basadas en evidencia científica, que cuando se realizan en conjunto, en forma confiable y permanente han demostrado impacto en reducir las tasas de infecciones, siendo una forma estructurada de mejora en los procesos de la atención de los pacientes del Centro Médico “Lic. Adolfo López Mateos". Action Plan:
1.- Difusión e implentación del paquete paquete de control de las infecciones del tracto urinario, mediante oficio circular y CODECIN de diciembre 2019 a enero 2020 por la Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
2.- PILOTAJE:Aplicación del formato del paquete de control de las infecciones del tracto urinario en el área de hospitalización de medicina interna e febrero 2020 a marzo 2020. por integrantes del equipo y Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
3.- Supervisión de la Aplicación del formato del paquete de control de las infecciones del tracto urinario en el área de hospitalización de medicina interna de marzo a abril 2020 por integrantes del equipo y Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
4.- Implementación del paquete de control de las infecciones del tracto urinario en el área de hospitalización de medicina interna de mayo a diciembre de 2020 por el personal médico y de enfermería de medicina interna.
5.- Evaluación de los resultados de marzo 2020 a febrero 2021 por integrantes del equipo y Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
6.- Análisis de los resultados de febrero a diciembre de 2020, por los integrantes del equipo y Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
7.- Presentación en CODECIN en febrero 2021, por la Jefa de la Unidad de Epidemiologia y Medicina Preventiva.
8.- Presentación COCASEP en diciembre 2019 y en marzo 2021 Impact Details Lives Saved
Lives Spared Total:
0.40249999999999997 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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Disminución de la Prevalencia Cruda de Lesiones por Presión Originada en Pacientes Hospitalizados. View Commitment
Commitment
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CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Disminución de la Prevalencia Cruda de Lesiones por Presión Originada en Pacientes Hospitalizados.
Contact Info
Name JOSE ROGEL ROMERO
Phone: 722 2760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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DALIA GUADALUPE RAMIREZ NAVA, MAESTRA EN ENFERMERÍA CON ÉNFASIS EN ADMINISTRACIÓN DE HOSPITALES
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
LESIONES POR PRESIÓN How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Disminución de la Prevalencia Cruda de Lesiones por Presión Originada en Pacientes Hospitalizados. Commitment Details/h6>Commitment Summary:
La clínica de heridas del Centro Médico “Lic. Adolfo López Mateos” lleva funcionando 9 años, durante los primeros años (2010 al 2011) se inició atendiendo a pacientes con heridas crónicas y aguadas. A partir del enero del 2012 inicia la atención y vigilancia a pacientes de hospitalización con diagnóstico de ulceras por presión.
Las lesiones por presión son una importante complicación para los pacientes en hospitalización la cual repercute en: incremento de días estancia, inicio de curaciones, tiempo de enfermería, tiempo de médicos, riesgo de infección, incremento de insumos básicos para la asepsia de la herida, utilización de materiales especiales para la cicatrización de la herida, tiempo de familiar, dolor del pacientes, y cambio del estilo de vida. Las úlceras por presión son un importante problema de salud que produce daño en los pacientes y que son evitables en un alto porcentaje de casos.
Un referente que se tiene a nivel nacional es un artículo llamado “Magnitud del evento adverso. Úlceras por presión”, por Guillermina Vela-Anaya, Coordinación Normativa de Enfermería de la Dirección General de Calidad y Educación en Salud (DGCES), Secretaría de Salud. México, año 2012, refieren que “Se obtuvo información de 175 unidades médicas de segundo nivel de atención, de 32 entidades federativas, con un total de 13 137 pacientes valorados, de los cuales 1 697 presentaron una o más UPP, con un total de 2 754 UPP reportando una ¿ porcentaje promedio de prevalencia cruda del 12.92 %”
Los resultados de la vigilancia a pacientes hospitalizados en el Centro Médico Lic. Adolfo López Mateos” durante 2017, 2018 y 2019 han sido los siguientes: Se valoraron pacientes (2116,5115, y 3743 en cada año respectivamente). Durante el 2017, 185 pacientes desarrollaron lesión por presión (LPP) lo que representa una prevalencia cruda de 8.7, de las cuales un 77% se desarrollaron en el hospital, mientras que un 23% en su domicilio. Siendo el tipo más frecuente la causada por presión (82%). La región anatómica fueron los talones con una frecuencia de 30% y los estadios I y II visualizado los más frecuentes. En 2018 se valoraron 5115 obteniendo 114 pacientes con LPP con una prevalencia bruta de 3.1, el 43% de pacientes con ulceras desarrolladas en el hospital y 57% en su domicilio. El tipo más frecuente fue el de por presión (86%), su localización más frecuente fue en el sacro (49%) pacientes, variando de un estadio I y II. De enero a julio del año 2019 se han valorado 3743 obteniendo 114 pacientes con LPP lo que representa prevalencia cruda de 4.7, el 59% desarrolladas en el hospital. Siendo el tipo más frecuente es por presión (80%), su localización en los sacro con una frecuencia de 32% y estadios I y II.
Derivado de lo anterior se ve la necesidad de tomar acciones de mejora con el objetivo de reducir este tipo de incidencias. Action Plan:
1 Presentación del Desafío en COCASEP dic-19 dic-19
2 Implementar a todos los turnos y servicios de hospitalización la Guía Práctica de Prevención de Lesiones por Presión en Pacientes Hospitalizados. ene-20 sep-20
3 Vigilancia el apego de la aplicación de las medidas preventivas en pacientes con riesgo de desarrollar lesiones por presión. feb-20 nov-20
4 Retroalimentación permanente de forma incidental a personal respecto al apego a las medidas de prevención. feb-20 nov-20
5 Implementación de un programa de capacitación dirigido al cuidador y paciente para desarrollar habilidades y detectar necesidades de aprendizaje. mar-20 nov-20
6 Analizar los resultados de apego a la Guía Práctica de Prevención y al Programa de Capacitación para las acciones de mejora feb-20 nov-20 Impact Details Lives Saved
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Implementación de un Programa de Involucramiento del Paciente y Familia (PFE). View Commitment
Commitment
×
CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Implementación de un Programa de Involucramiento del Paciente y Familia (PFE).
Contact Info
Name JOSE ROGEL ROMERO JOSE ROGEL ROMERO
Phone: 7222760860
Email: jan_2205@hotmail.com
Position: DIRECTOR
Organization Name: CENTRO MÉDICO “LIC. ADOLFO LÓPEZ MATEOS”
Organization Address:
s/n Av San Juan Delegación San Lorenzo Tepaltitlán I , Delegación San Lorenzo Tepaltitlán
Toluca de Lerdo, 50010 Mexico
Participants:
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LIC. EDITH VERDEJA GARCÍA, JEFA DE TRABAJO SOCIAL
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LIC. EDUARDO AHEDO GARCÍA, COORDINADOR DE ATENCIÓN AL USUARIO
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Implementación de un Programa de Involucramiento del Paciente y Familia (PFE). Commitment Details/h6>Commitment Summary:
La participación del paciente y familia (o responsable del cuidado del paciente), es de suma importancia para el cuidado y/o recuperación de la salud. En el Centro Médico Lic. Adolfo López Mateos, no se cuenta con un programa formal para el involucramiento del paciente y familia (PFE), solo se ha llevado de manera aislada en contados servicios, sin estructura y sin la participación ya sea del paciente o del cuidador primario lo que ha conllevado a complicaciones o retrasos en el restablecimiento de la salud, además de omitir desde los registros en el expediente clínico la evidencia de manera multidisplinaria de la educación otorgada al paciente y familia durante el proceso de atención en el hospital.
Por lo anterior el hospital, tiene el compromiso de fortalecer las actividades que mejoren las condiciones de atención tanto hospitalaria como ambulatoria del paciente, se pone el objetivo de elaborar e implementar un programa de involucramiento del paciente y familia (PFE) con la participación multidisciplinaria del equipo clínico del hospital. Action Plan:
1 Presentación del Desafío 16 en COCASEP nov-19 nov-19
2 Implementación de las políticas de PFE (modelo de seguridad del paciente). feb-20 dic-20
3 Elaboración del programa de Orientación y Educación del Paciente y la Familia de manera multidisciplinaria en todo el hospital. ene-20 feb-20
4 Generar evidencia de la orientación y educación del paciente y familia en el expediente clínico. feb-20 dic-20
5 Retroalimentación por parte de pacientes y familiares para fortalecer el Programa PFE. mar-20 nov-20
6 Medición de manera mensual de la implementación de PFE. mar-20 dic-20
7 Involucrar al aval ciudadano en la medición de PFE. feb-20 feb-20
8 Análisis de resultados de PFE para las acciones de mejora en COCASEP. mar-20 nov-20 Impact Details Lives Saved
Tell us about your baseline level of harm:
2375 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
1425 Methodology for Determining Lives Saved:
Nivel basal de daño - Valor deseable a alcanzar = vidas salvadas
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| CHENG CHING HOSPITAL |
Taichung City |
Taiwan |
Improvement of the Appropriate Use of Antimicrobials View Commitment
Commitment
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CHENG CHING HOSPITAL
Improvement of the Appropriate Use of Antimicrobials
Contact Info
Name CHINGLIN CHEN
Phone: +8864-24632000#66289
Email: 10522@ccgh.com.tw
Position: Administrator
Organization Name: CHENG CHING HOSPITAL
Organization Address:
, Xitun District
, 407 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship
Commitment Name:
Improvement of the Appropriate Use of Antimicrobials
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
1. Reduce the risk of healthcare associated infection(HCAI)
2. Improve the evaluation rate of antibiotic prescriptions for inpatients within 24 hours
3. Reduce clinical specimens monitor bacterial resistance ratio Commitment Description & Detail:
1.Create an antimicrobial stewardship committee
2.Preparation of an antibiotic management manual
3.Organize employee education training
4.Setup monitoring indicators for antibiotic use Action Plan:
1.Create an antimicrobial stewardship committee (include Superintendent, deputy superintendent (medical), Infection control physician and nurse, pharmacist, medical technologist, etc)to monitor the appropriate use of antimicrobials
2.Infection control physicians review the rationality of antibiotic use every month
3.Preparation of antibiotic control policies and manuals, including outpatient, inpatient and prophylactic antibiotics
4.Handling antibiotic related education and training for employees and public health education activities for patients Commitment Timeline:
Start from 2015
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| CHOC Children’s Hospital |
California |
United States |
Improving Hand Hygiene rate in the NICU by 20% View Commitment
Commitment
×
CHOC Children’s Hospital
Improving Hand Hygiene rate in the NICU by 20%
Contact Info
Name Sudeep Kukreja
Phone: (714) 585-1920
Email: sudeepmd@yahoo.com
Position: Director of CHOC NICU at SJH
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
Improving Hand Hygiene rate in the NICU by 20% How Many Hospitals Will This Commitment Represent? 1 Action Plan
1. Share the current hand hygiene compliance rate in the NICU with everyone involved in the care of babies in our NICU
2. Buy in from all the stakeholders.
3. Education of everyone involved in the care of babies in our NICU Commitment Timeline
One year
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Preventing Patient Deterioration View Commitment
Commitment
×
CHOC Children’s Hospital
Preventing Patient Deterioration
Contact Info
Name James Cappon
Phone: (714) 509-7814
Email: jcappon@choc.org
Position: Medical Director of Quality and Patient Safety
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Participants:
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Anthony Chang, Cardiology Division Chief
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Matthew Gerlach, Executive Vice President and Chief Operating Officer
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Preventing Patient Deterioration How Many Hospitals Will This Commitment Represent? 1 Action Plan
Active interventions included: 1) the development of a Rapid Response Team, to bring critical care assistance to the bedside of a worsening non-ICU patient, which included the ability of patient families to call for such help; 2) proactive identification and night time rounding on patients felt to be most at risk; and 3) the implementation of a Pediatric Early Warning System (PEWS), in which all non-ICU patients are monitored for standardized physiological status and that status is continuously displayed on unit electronic whiteboards and in the EHR for local and/or remote viewing. Commitment Timeline
We are gratified by this improvement in patient safety for our patients and families. Furthermore, we believe that the stabilized rate represents the true baseline status of non-preventable non-ICU codes in hospitalized U.S. children (examples of such events are sudden apnea, seizures and adverse drug reactions). The CHOC Children’s ongoing commitment is to further study this vulnerable group of patients, typically either very young or with complex medical disease, to determine if this rate can in fact reach zero. This program is but one example of the substantial patient safety successes achieved within the U.S. medical industry, upsetting the previously widely held notion that “getting to zero” was simply not reasonable.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Following the above interventions, the CHOC Children’s Non-ICU Code rate declined substantially from a baseline of 0.8 codes/1000 patient days to 0.1 codes/1000 patient days, a reduction of 87%, which has been stable for five years. This represents a potential annual event avoidance of 45 codes per year. Moreover, although most pediatric codes are respiratory in nature, we have even further reduced non-ICU cardiac resuscitations-with their associated poor prognosis, with only one such event in the last 1500 days.
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Preventing Patient Deterioration – Update – 10.15.18 View Update
Commitment Update
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CHOC Children’s Hospital
Preventing Patient Deterioration – Update – 10.15.18
Contact Info
Name James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Commitment DetailsCommitment Start Date: 01/01/2013 How many hospitals are represented in this commitment?
Action Plan:
Active interventions included: 1) the development of a Rapid Response Team, to bring critical care assistance to the bedside of a worsening non-ICU patient, which included the ability of patient families to call for such help; 2) proactive identification and night time rounding on patients felt to be most at risk; and 3) the implementation of a Pediatric Early Warning System (PEWS), in which all non-ICU patients are monitored for standardized physiological status and that status is continuously displayed on unit electronic whiteboards and in the EHR for local and/or remote viewing.
Commitment Update:
The CHOC Children's program to reduce non-ICU resuscitations quickly expanded backward in time to identify children in earlier and earlier stages of clinical deterioration. This primarily occurred via the serial implementation in Years 1 and 2 of a Rapid Response Team (RRT) and Pediatric Early Warning System (PEWS), respectively. Subsequently, family members were brought into the fold and educated at patient admission that they could initiate RRTs of their own accord. The most important change, however, was that of culture, where hospital staff of all levels came to find non-detected and/or non-escalated patient deterioration as fundamentally unacceptable, which further advanced the pace, breadth and intensity of all efforts.
The gratifying overall result is that the CHOC Non-ICU Code Rate dropped approximately 85% in the first two years of the program and has remained at that low level for the past 10 years. This means that hundreds of children have avoided preventable respiratory, cardiac and neurologic arrests. Moreover, millions of dollars of unnecessary healthcare costs have been avoided.
Your commitment aligns with APSS
1 (Culture of Safety), 4 (Failure to Rescue), 9 (Early Detection of Sepsis) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Changing culture to a state in which early detection of and response to deterioration are the only acceptable workflows is the key to success. So built-in is this mentality that even a small blip in our Non-ICU Code Rate leads to considerable investigation and process improvement.
The past year, for example, led to the development of and initiation of a "Watcher Program," where patients who have subtle changes, perhaps even prior to their PEWS score changing and/or well-before meeting RRT criteria, are identified as "Watchers," or children bearing watching. A bedside multidisciplinary huddle (including family) is initiated, a mitigation plan created, and a follow up done at 2 hours to see if the desired outcomes have been achieved. Early results show an increase in RRTs, a decrease in RRTs requiring ICU transfer, and a reduction in Non-ICU Code Rate.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-45 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
51 |
Lives Spared Harm Target for following calendar year
48 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
45 |
Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
0 |
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Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department View Commitment
Commitment
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CHOC Children’s Hospital
Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department
Contact Info
Name Heather Huszti
Phone: (714) 509-8481
Email: hhuszti@earthlink.net
Position: Chief Psychologist
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department How Many Hospitals Will This Commitment Represent? 1 Action Plan
1.) Identified and hired a licensed psychologist who had previous training in implementing an intensive mental health intervention in ED’s along with a licensed social worker who also had experience in acute psychiatric crises
2.)Training provided by the Orange County Healthcare Agency to allow staff access to county based services (to make appointments and recommendations)
3.) Adjust EMR to allow for specialized charting and tracking of patients
4.) Mental health team will see patients as soon as they are roomed and begin evaluation and intervention, will make appropriate recommendations to the family, and will work with the medical team to provide clearance for the patient when possible or to find inpatient placement if warranted
5.) Receive additional training in intensive mental health intervention designed for patients with psychiatric disorders who present in the ED from Dr. Wharff, Boston Children’s Hospital
6.) Provide ongoing education and consultation to medical staff in ED regarding service and how it works
7.) Staff provide coverage 8 hours per day, 6 days per week at present. Commitment Timeline
Began in April 2016. Acceptance by families and patients has been high. Acceptance by medical staff has also been high. Data being gathered includes, length of time in ED, percent transferred to inpatient psychiatric unit, percent discharged home, patient engagement in treatment at one week follow-up call, returns to ED within 1 month, hospitalization in psychiatric unit within 1 week of discharge, and suicide attempts within 1 week of discharge.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Multiplying the rate of youth suicide for Orange County (6.4) per 100,000 by the population in Orange County of children under 18 years of age (approximately 750,000).
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APSS #4: Monitoring for Opioid Induced Respiratory Depression View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #4: Monitoring for Opioid Induced Respiratory Depression
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for opioid-induced respiratory depression
Commitment Name:
APSS #4: Monitoring for Opioid Induced Respiratory Depression
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Opioid-induced respiratory depression is a leading cause of preventable patient death and serious patient harm events across the medical industry. Hospital leadership must under understand, appreciate and commit to eliminating these events. Implementing an effective program to reduce opioid-induced respiratory depression will require an organized plan which includes both effective monitoring and intervention limbs and also an effort to minimize use of unnecessary narcotics and sedatives. Commitment Description & Detail:
As a tertiary-quaternary regional children's hospital, we have patients of many ages, types and conditions who require use of analgesics for pain, well beyond surgery alone. Thus, the comprehensive use of our Rapid Response Team and Pediatric Early Warning System assessment and monitoring of all non-ICU patients has led to an approximately 85% reduction in non-ICU codes of all types, sustained for nine consecutive years. All such events (N less than 10 per year) are rigorously investigated, including for possible medication-related contributions. There were none of the latter in the last year.
All CHOC patients receiving narcotics are monitored for oxygen saturation at a minimum by policy. Utilizing best practice trigger methodology, all uses of naloxone are investigated for circumstances requiring usage.
In alignment with the Patient Safety Movement Foundation Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for the below checklist items.
Action Plan:
-Implement continuous electronic monitoring on all floors where patients are being administered opioids, per hospital policy.
-Monitoring should consist of a minimum SET (Measure Through Motion and Low Perfusion) pulse oximetry with local and central alarms. Direct communication can be sent to bedside personnel versus in-house phone network.
-Respiratory rate alarms are set at age-appropriate, evidence-based parameters to minimize alarm fatigue.
-A rapid response notification system should be in place to alert staff if the patient is deteriorating. A plan for escalation of rapid response alarm to another staff member should also be in place. At CHOC, beginning in mid-2017, a "Watcher Program" for non-ICU patients was established, which identified patients at the earliest stages of deterioration and thus bore "watching." This occurs via a rapid briefing including multidisciplinary clinicians and establishment of a mitigation plan to be achieved within two hours. This is in addition to our PEWS and Rapid Response Team programs, and is meant to achieve even earlier detection of possible deterioration.
-Hospital governance should commit to a plan that includes:
Reviewing all reported preventable patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the preventable event. A review of all previous closed malpractice claims related to opioid-induced respiratory depression should also be undertaken.
-Identifying and prioritizing common contributing factors from those serious preventable events.
-Identifying continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition which includes a rapid response approach that ensures appropriate interventions are initiated in a timely manner.
-Providing the resources necessary to implement the chosen plan.
-Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.
-CHOC Children's Hospital has two hospital “champions” who are accountable for successful implementation, education and evaluation of efforts to both minimize the untoward side effects of narcotics and reduce the use of these agents overall. In addition, we are in early stages of joining with another children's hospital in an organized program designed to reduce controlled substance utilization across inpatient and outpatient networks.
• CHOC has a Resuscitation Coordinator RN, who oversees all aspects of the resuscitation program, including, vitally, their prevention by intervening at the earliest signs of deterioration. This role also includes interfacing with local unit leaders to ensure ongoing full compliance with the patient monitoring plan as described above. CHOC also has a longstanding dedicated Pain Nurse Practitioner who coordinates the programmatic efforts at pain prevention and management. In children, extensive multidisciplinary efforts are expended at various forms of distraction therapy. In addition, the benefits of 24/7 parental presence cannot be ignored.
-We are currently working to develop an educational plan for all staff, patients and family members that shares common contributing factors leading to opioid-induced respiratory depression as well as the implementation plan that strives to eliminate current risks associated with opioids.
• Anesthesiology-directed Pain Service
• Pain NP rounds daily
• Orthopedic, Cardiovascular and General Surgery organized protocols to minimize narcotic use Commitment Timeline:
This CHOC Children's program and checklist items are currently in place. Our commitment to this APSS will be ongoing and reported annually to PSMF.
Impact DetailsLives SavedMethodology for Determining Lives Saved:
The CHOC Non-ICU Code Prevention program, which incorporates all such patients, not just surgical, measures Non-ICU codes per 1000 hospital days. Of the six events last year, none were related to medications or post-operative patients; hence, a rate for this metric of zero. There is no known pediatric benchmark for comparison, so no true way to measure lives saved.
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APSS #5: Anemia and Transfusions View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #5: Anemia and Transfusions
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient blood management
Commitment Name:
APSS #5: Anemia and Transfusions
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Errors in the use of blood products are a significant cause of hospital patient morbidity and mortality. To eliminate these errors, hospitals must implement an effective Patient Blood Management program. Children are no different in this regard, and given their at times very small size and normal physiologic nadir of hemoglobin in early infancy, are at risk for anemia and related transfusion need, and risks of both the clinical condition and associated treatments. Similarly, children are not immune to potential adverse reactions of transfused products, and all due care must be undertaken.
Commitment Description & Detail:
CHOC continues its comprehensive blood management program this year, which spans the realm of blood collection, pheresis, clinical guidelines to reduce lab testing, practices to reduce laboratory blood test volumes, surgical/procedural practices, transfusion safety, and post-transfusion monitoring. As a tertiary-quaternary regional children's hospital, vulnerable patients are common here, with concomitant transfusion risks and benefits associated with their often chronic conditions.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal of using the below checklist items. Our Transfusion Committee has the annual goal of 100% compliance with metrics involving consent and appropriate use of four types of blood products. Our clinical goal is zero adverse events associated with preventable transfusion-related complications, including severe anemia, severe transfusion reactions and Transfusion-Related Acute Lung Injury (TRALI). There were zero such events last year. Action Plan:
-A Commitment from hospital leadership to support a Patient Blood Management program that closes the performance gap by reducing unnecessary transfusions while speeding up needed blood transfusion and care for patients who truly need it.
-Clinical and safety leadership endorse the plan and drive implementation across all providers and systems.
-Establish the Patient Blood Management Committee, which replaces the traditional hospital transfusion committee, and appoint an MD chairperson to be responsible and accountable for leading this group.
• CHOC uses Transfusion, Ancillary and Diagnostics, Operating Room, Patient Safety and Joint Leadership Committees to co-manage related functions
-On a regular basis, distribute the blood product usage report by clinicians across the hospital to hospital leaders.
• Done at CHOC by the Transfusion Committee to individual practitioners. Individual performance is also tracked by the organizational medical staff peer review committee.
-Implement interdisciplinary blood conservation modalities, including:
• Reductions of unnecessary laboratory tests, frequency of blood sampling, and “discard” volumes.
• A consistent protocol for preoperative management of platelet inhibitors and other anticoagulants.
-Technology that has been shown to improve patient care, such as continuous non-invasive hemoglobin monitoring and red cell recovery technology in the operating room (OR).
• CHOC perioperative practice has changed to incorporate regular blood gas sampling that includes hemoglobin. Cell-saving technologies are applied operatively in all appropriate settings, and are a part of many Care Guidelines.
-CHOC is currently working to establish protocols for anemia management, including:
• Screen, diagnose and appropriately treat anemia prior to surgery, allowing adequate lead time to correct the anemia before surgery.
• Identify patients at risk for needing transfusion.
• Increase hemoglobin levels before surgery.
• Minimize the risk of hitting levels that require blood transfusions.
-When appropriate, establish single unit transfusion policy and advocate for restrictive transfusion practices.
-Document hemoglobin levels before the transfusion of each RBC unit, when possible.
-Consider alternative therapies to RBC transfusions, such as intravenous iron or erythropoietin stimulation agents (ESAs).
-Continuously monitor the effectiveness of the Patient Blood Management program, and use the results of this monitoring in medical staff educational sessions as a part of Continuous Quality Improvement (CQI).
-We are currently working to develop a Patient Blood Management education program for emergency and elective hospital admissions, targeting medical students, physicians, nurses, pharmacists and other healthcare staff.
• As an example, the CHOC Electronic Health Record (EHR) CPOE and Decision Support functions provide real time guidance to personnel ordering blood products, particularly for products ordered when evidence-based practice guidelines do not provide clear cut management.
Commitment Timeline:
These checklists items are currently in place at CHOC Children's. Our commitment to this APSS will be ongoing and reported annually to PSMF.
Impact DetailsLives SavedMethodology for Determining Lives Saved:
The CHOC Children's transfusion medicine program follows all patients, surgical and medical, for transfusion-associated morbidity and mortality. There were zero events of moderate or severe TRALI or hemolytic reactions, and zero mortalities in the last two years.
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APSS #2F: CLABSI View Commitment
Commitment
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CHOC Children’s Hospital
APSS #2F: CLABSI
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI)
Commitment Name:
APSS #2F: CLABSI
Commitment Start Date:07/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Central line-associated bloodstream infection (CLABSI) is a potentially severe, even life-threatening complication of medical management of complex care scenarios. It is the most frequent HAC for those children hospitalized in children's hospitals in the U.S., and is also the most costly to treat. It has also proved to be perhaps the most challenging HAC to improve, despite significant efforts.
In order to implement a program to reduce and eliminate CLABSI, CHOC Children's Hospital is actively working on an implementation plan that will require actionable steps. Commitment Description & Detail:
CHOC Children's has been preventing catheter-associated urinary tract infections since well before 2013, when our formal involvement with the Children's Hospitals' Solutions for Patient Safety (CHSPS) began. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC). CHOC uses best practice bundles for central line insertion and maintenance care in an effort to reduce CLABSI.
CLABSI is one of the more frequent HACs, including in children. Despite the focus on central line management best practices (both insertion and maintenance) as well as effective efforts to reduce the duration of time central lines are in place, the incidence has not been dropping as fast as desired. Some of this is due to the types of patients in which central lines are required, i.e., "simple" central line patients have their lines discontinued early. Moreover, it is now known that such catheters are entered multiple times daily. Thus, another avenue for intervention is an active program designed to reduce the number of central line entries each day by "bundling" lab draws, medication administration and IV fluid changes. At CHOC, CLABSI rates are tracked monthly and quarterly, and results distributed broadly across the organization. Tellingly, the "days since last" CLABSI is announced each morning at the CHOC Daily Safety Briefing.
CHOC will continue its efforts at best practice delivery and clinical outcomes in CLABSI prevention for both catheter insertion and ongoing management. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
Commitment from hospital leadership to support a program to reduce and eliminate CLABSIs.
Implement evidence-based guidelines to prevent the occurrence of CLABSIs, including: insertion, maintenance, and standardized access procedures.
Doctors and other clinicians should:
• Perform a “time-out”.
• Wash their hands with soap.
• Clean the patient’s skin with chlorhexidine antiseptic.
• Put sterile drapes over the entire patient.
• Wear a sterile mask, hat, gown and gloves.
• Put a sterile dressing over the catheter site.
Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention, insertion and maintenance of central lines.
Encourage continuous process improvement through the implementation of quality process measures and metrics.
Standardize a central-line kit based on the needs of your facility, and implement technology that will have a significant return on investment (ROI).
Efforts should be focused on eliminating all blood draws from central access catheters. This includes patient with longer-standing catheters (e.g. dialyses catheters).
• Current organization-wide practice change to reduce central line blood draw frequency
All CLABSIs should have a root cause analysis (RCA) completed by the unit where the infection occurred with multidisciplinary participation including nursing, physicians and infection prevention specialists. All learnings from the RCA should be implemented.
- All CLABSIs at CHOC undergo an Apparent Cause Analysis (ACA) and are discussed in the multidisciplinary Hospital-Acquired Infection team meeting.
CHOC is finding that maintenance care rather than catheter placement is the area of highest risk for the development of CLABSI. Commitment Timeline:
These checklists items are currently in place and our commitment will be ongoing.
Impact DetailsLives SavedLives Spared Total:
0.4994999999999998 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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APSS #6: Hand-off Communications View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #6: Hand-off Communications
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off communications
Commitment Name:
APSS #6: Hand-off Communications
Commitment Start Date:01/01/2011 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Accurate and complete hand-off communications (HOC) are vital to patient safety. Modern healthcare practices, particularly inpatient, result in an increased number of potential handoffs. Examples include covering physicians, notably resident physicians due to duty hour restrictions, nursing mandated breaks and required coverage, and increased throughput effectiveness, which can shorten length of time in any given location. When HOC information is incomplete or erroneous, serious patient harm can occur. The establishment of accurate, complete, effective HOC requires an implementation plan, checklists and mindful participation. In some circumstances, families can provide valuable information and clarity; in all cases, lack of communication continuity amongst caregivers is a negative patient experience satisfier. Commitment Description & Detail:
CHOC Children's began formalized work on Handoff Communication in 2011 with participation in a national collaborative of the Children's Hospital Association. In conjunction with some 30 partner children's hospitals, best practices were tested and developed to effectively and accurately communicate essential information in standardized fashion amongst caregivers of multiple types.
This progressed to more recent CHOC activities in this area including electronic, templated bedside shift change handoffs between nurses that include parents. A recent Performance Improvement team concluded its work in that realm, but reducing communication failures which have clinical consequences remains an annual goal of the organization's Patient Safety Committee. Specifically, the Patient Safety Goal is "Reduce Care Failures Due to Handoff Communication." Such events are captured in our electronic Safety Reporting System, and due to safety culture improvements, self-reporting is on the rise.
Our expanding Good Catch program frequently harvests examples of communication failures and rescues amongst its accumulated safety reports.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for utilizing the below checklist items. Action Plan:
-Educate all hospital staff on the following principles and requirements for effective HOC:
-We have identified seventeen different categories of HOC that commonly occur in hospitals or other care units. Each of these categories requires a specific HOC checklist. We have developed the first 6, ready to be implemented:
§ 1b – Emergency Department to Operating Room
§ 2f – Hospital Unit to Home (discharge)
§ 2g – Hospital Unit Shift Change
§ 3b – Operating Room to Hospital Unit
§ 3c – Operating Room to Home
§ 4c – Hospital to Outside Care Unit
In addition, an essential handoff in our organization in from Emergency Department to Inpatient Unit, and Emergency Transport Team to Inpatient Unit.
Commitment Timeline:
CHOC Children's currently has these checklists items are in place. Our commitment to this topic is deep will be ongoing, with annual reporting on this APSS to PSMF.
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APSS #7A: Optimal Neonatal Oxygen Targeting View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #7A: Optimal Neonatal Oxygen Targeting
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 7A - Optimal neonatal oxygen targeting
Commitment Name:
APSS #7A: Optimal Neonatal Oxygen Targeting
Commitment Start Date:01/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Hypoxia in pre-term infants can result in mortality and morbidity. Supplemental oxygen administration helps avoid hypoxia but hyperoxia can cause retinopathy of prematurity (ROP) and increase risk for other conditions including chronic lung disease. Implementing an optimal oxygen targeting strategy can improve neonatal outcomes. For over a decade, CHOC Children's has taken actionable steps to address suboptimal oxygen targeting. The development of a "Small Baby NICU," a freestanding neonatal unit dedicated to the care of Extremely Low Birthweight (ELBW) neonates of less than 28 weeks gestational age or 1000 grams birthweight, has allowed for super-specialized care for these most vulnerable babies. This special, dedicated environment, staff and protocols have furthered the advancement of care for ELBW neonates, and improved outcomes across standard NICU measures, including ROP. Commitment Description & Detail:
CHOC Children's has rigorous neonatal quality improvement plans in place to deliver effective and safe oxygen concentrations to NICU infants. This includes standardized ordering plans and monitoring parameters and associated action steps. CHOC Retinopathy of Prematurity (ROP) rates are historically favorable versus international, national and state benchmarks, including Vermont Oxford Network (VON) and California Perinatal Quality Care Consortium (CPQCC). ROP is also a target of a the Children's Hospitals Neonatal Consortium (CHNC), a group of about 35 children's hospitals Level 4 NICUs, of which CHOC is a member.
As an ongoing goal, CHOC will continue to endeavor to reduce its neonatal ROP annual rate by 10%.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for utilizing the below checklist items. Action Plan:
-Make an organization-wide commitment by administrative, clinical, and patient engagement leaders to address neonatal patient safety related to oxygen administration.
-Assess opportunities to improve oxygen administration and monitoring for the prevention of adverse events due to lack or excess of oxygen.
-Implement interdisciplinary strategies and develop an action plan with a timeline with concrete milestones to implement an optimal oxygen policy for neonates.
-Select technologies that have been shown to improve neonatal outcomes, including but not limited to: blenders, pulse oximetry, and heated humidifiers.
-Determine the oxygen targeting policy that healthcare providers should implement:
¨ The SpO2 for a pre-term baby breathing supplemental oxygen should not exceed 95%.
¨ The SpO2 for other larger infants and neonatal patients should stay in the range of 88-95% or 90-96% depending on infant and condition.
-When the saturation or SpO2 dips below 88%, avoid a response that would induce hyperoxia.
-In order to accomplish this, the oxygen saturation monitor alarms should always be on and active when an infant is breathing supplemental oxygen.
-The high SpO2 alarm should be set to 95%, depending on the infant. The low SpO2 alarm should be set to 85% or as required for special infant circumstances, eg., congenital heart disease.
-Alarms signaling should receive attention from the appropriate bedside clinicians.
-When a baby is not breathing supplemental oxygen, but is being monitored for desaturations, the low SpO2 alarm should in general be set at 85% and the high alarm can be turned off.
-Implement your action plan for including educational activities, workshops, and tools for all members of the neonatal healthcare team.
-Develop a process for continuous improvement by communicating with staff and implementing measures to improve processes in order to meet the oxygen targeting objective. Commitment Timeline:
These checklists items are currently in place at CHOC Children's. Our commitment to this clinical topic and APSS is ongoing and will be reported annually to the PSMF.
Impact DetailsLives Saved
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APSS #15: NG Tube Placement and Verification View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #15: NG Tube Placement and Verification
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric tube (NGT) placement and verification
Commitment Name:
APSS #15: NG Tube Placement and Verification
Commitment Start Date:07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
A nasogastric or NG tube is a plastic tubing device that allows delivery of nutrition directly into the stomach (feeding), or removal of stomach contents (drainage). It is typically passed via the nose and oropharynx into the upper gastrointestinal (GI) tract. Occasionally, these tubes can be malpositioned, leading to significant harm and even death. The most common serious misposition is into the lungs. The National Health Service Improvement (NHSI) in the United Kingdom has placed this type of incident on their “Never Events” list; Never Events are “errors in medical care that are identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (National Quality Forum). Commitment Description & Detail:
Nasogastric tubes (NGTs) are a commonly used intervention in clinical practice for GI tract decompression or for administration of enteral nutrition, fluids and medications. Misplacement of NGTs can lead to significant morbidity and even death.
CHOC Children's, as a tertiary-quaternary regional children's referral center, supports the care of thousands of fragile children with both acute and chronic, often complex conditions. In many cases, such children are unable to feel orally on their own, yet their gastrointestinal systems are otherwise functional and can receive the optimal form of nutrition. An NGT is thus a frequent adjunct to the acute and occasionally sub-acute care of such children, and when correctly used, can be of great benefit to recovery, growth and outcome. Because of frequent small size, cardiopulmonary, and/or gastrointestinal diseases or conditions, auscultation alone cannot reliably be utilized to confirm NGT placement in these patients.
CHOC has a policy in place to ensure all patients requiring a nasogastric tube are safe throughout the organization. This includes radiographic evidence of NGT location at the time of placement. Action Plan:
• Use only NGTs that are radio-opaque throughout their length with external centimeter length markings to be used to detect post-insertion tube movement.
• Ensure that all staff who place NGTs are specifically trained in this procedure
• Accurately measure the length of the NGT prior to insertion using the NEMU method (Nose→Earlobe→Mid-Umbilicus)
• Confirm NG tube placement with a radiograph per our policy.
• Ensure all staff who read radiographs are specifically trained in reading the radiograph using the following four criteria:
- Does the tube path follow the esophagus and avoid contours of the bronchi?
- Does the tube clearly bisect the carina or the bronchi?
- Does the tube cross the diaphragm in the midline?
- Is the tip clearly visible below the left hemi-diaphragm?
• Document the confirmation of NG tube in the EMR as well as the method of confirmation .
• Secure tubes to the patient after confirmation in such a way that the depth mark is visible at the naris.
• Document this mark in the medical record and used as a point of reference for other caregivers to gauge movement of the tube.
• Observe for signs of respiratory distress or gagging/vomiting and remove tube if these signs are present as NG tube may have been dislodged into the airway or lungs.
• Develop a mandatory reporting system to track nasogastric feeding tube misplacements as a percentage of all tubes placed.
Commitment Timeline:
At CHOC Children's, these checklists items are currently in place. Our commitment to perfect safety in this area is ongoing, and updates to this PSMF APSS will be made annually.
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APSS #1: Creating a Culture of Safety View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #1: Creating a Culture of Safety
Contact Info
Name James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety
Commitment Name:
APSS #1: Creating a Culture of Safety
Commitment Start Date:07/01/2011 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Since at least 2000, CHOC Children's Hospital has been steadfastly working to improve the culture of safety within our organization. While this is a continuous journey, not a destination (James Reason, "Managing the Risks of Organizational Accidents;" Ashgate Publishing Ltd; Hants, England, 1997), one measurable output is the Serious Harm Rate, which objectively measures the most severe types of preventable patient harm.
In the mid 2000s, CHOC adopted a quality goal, subsequently an organizational goal in 2011, to Reduce the Serious Harm Rate. It is the highest level measure of the effectiveness of our safety systems and culture to improve the patient safety domain of our organization quality program. Simultaneously, CHOC has been regularly measuring, learning from and responding with action to the validated and widely used Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey.
Patient Safety simply cannot sustain improvement and performance without a relentless approach to recognizing and modifying organizational safety culture. While discrete safety events can often be prevented through best practice adherence and other campaigns, the fundamental imperatives of just culture, error prevention techniques, human factors engineering and high-reliability can neither be effectively introduced nor maintained without cultural buy in. While this is a journey measured in years, not days, it is one in which patients and their families cannot afford the hesitation of a single step.
Commitment Description & Detail:
CHOC Children's uses the Healthcare Performance Improvement (HPI) Inc. Safety Event Classification (SEC) event classification system to label harm and potential harm events. The CHOC Serious Harm Rate uses the denominator of 1000 inpatient days. Potentially preventable patient harm events are identified from multiple sources, including Daily Safety Briefing, the online Safety Reporting System, morbidity and mortality conferences, and peer review. There are three broad categories within the SEC: Serious Harm, Precursor Safety Event, and Near Miss Event (in order of increasing frequency). The five types of serious harm are: Death, Permanent Severe, Temporary Severe, Permanent Moderate and Temporary Moderate (in order of increasing frequency). All serious safety events undergo detailed analysis, typically root cause level. Analytic efforts then lead to answering the fundamental question of how to improve our systems and culture to prevent recurrence and advance reliability.
Since inception a decade ago, CHOC Children's has reduced its Serious Harm Rate 97.9% to the current 0.05/1000 patient days. While this is a notable improvement, rates alone can be impersonal. For this reason, we also track and discuss the actual number of such children harmed, which can be very impactful, particularly at leadership and lay levels.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is very close to reaching our goal for all of the below checklist items. As the items contain references to "create culture," it is doubtful that such a checklist can - or should - ever be signed off as truly completed.
Action Plan:
Achieving a culture of safety in a healthcare organization requires transformational change which is owned and led by the executive leaders of the organization, including the board, encouraging accountability and transparency. Leadership’s primary goal must be to make their hospital a safe haven for patients.
• Address unexpected outcomes with open disclosure and prompt resolution.
• If patient harm results from a preventable medical error, adopt the CANDOR (Communication and Optimal Resolution) or similar approach: apologize as soon as possible, pay for all care related to the preventable harm, seek a just resolution, and provide ongoing support for patients and families. Clinicians (the “second victims” of patient harm events) may also require attention and support (Lambert et al., 2016).
Create an open and transparent culture that encourages staff to speak up and self-report
Apologize within 60 minutes of discovery
No charge for care related to event
Incentivize lawyers to settle fast
Do event reviews to avoid reoccurrence
Within 30 days of any event review disseminate learning out to the patient, family, hospital system and externally
• Create a standard of care to ensure that clinicians speak with family members to explain what will be changed so this event won’t happen again. Offer family members an opportunity to be involved and witness the change in procedure, etc.
• Create a reliable means to capture and analyze good catches/near-misses. Set a goal that includes aspirations that all errors and incidents are preventable and that zero is the most important goal.
• Implement an electronic adverse event reporting system that allows for both authored and anonymous reporting, tracking, trending and response to aggregate safety data.
• Implement thoughtful and memorable internal branding to keep safety expectations and aligned behaviors top of mind throughout an organization.
Commitment Timeline:
These patient safety culture checklists items are currently in place at CHOC Children's. Our commitment to this APSS will be ongoing and reported yearly.
Impact DetailsLives SavedPredicted Lives Spared Harm:
0.39999999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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Challenge #2A: Hand Hygiene View Commitment
Commitment
×
CHOC Children’s Hospital
Challenge #2A: Hand Hygiene
Contact Info
Name James Cappon
Phone: 7145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene
Commitment Name:
Challenge #2A: Hand Hygiene
Commitment Start Date:07/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
The lack of consistent, appropriate hand hygiene in all patient care areas can be considered a “medical error” that can result in avoidable infections, morbidity and mortality. The World Health Organization (WHO) continues to describe hand washing as the most effective way of preventing the spread of infections.
In order to implement a program to improve hand hygiene and reduce HAIs, CHOC Children's has been actively engaged in a hand hygiene surveillance and performance improvement plan that has required actionable steps. This has required substantial enterprise-wide commitment to awareness, education and tracking. With this, organization-wide hand hygiene compliance for the recently completed fiscal year was 96%. Commitment Description & Detail:
The measurement of hand hygiene performance proves to be quite difficult. Self-reporting is notoriously optimistic, "secret shopper" methodology can introduce bias and is hampered by logistics, and technologic modalities are in early stages and in the case of pediatrics, unproven and largely untested. Remote video observations, akin to cardiac telemetry, are fraught with similar human factors limitations.
Given the above, for the past 7 years, CHOC has used a secret shopper observation methodology of hand hygiene "5 Moments" compliance, which technologic solutions cannot fully capture at this time. Results are reported and widely displayed by unit and role, including in Communication Boards in each unit. Patients, families and visitors can view this data. Last year's high performance was garnered from over 3500 blinded observations, and is part of a 7 year improvement trend. Ongoing education of staff, physicians, volunteers and families and visitors is an integral aspect of this performance improvement project.
CHOC Children's has offered to be a willing partner in pilot projects to test additional techniques of hand hygiene compliance measurement in children.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is continuously improving hand hygiene compliance and surveillance system plan and will report our results on an annual basis. Action Plan:
• Accountability for Performance Improvement at facility and unit leadership levels as part of an overall Organizational Hand Hygiene Guideline. Ensure that alcohol-based hand rubs and soap are available as close to the point of care as possible.
• Establish a multi-disciplinary hand hygiene team responsible for implementation of the Hand Hygiene Protocol, including nursing, physicians, infection preventionists and administration.
• The protocol must include mandatory training for all healthcare workers (HCWs) upon hire and at least once annually.
• Training to include:
• Proper technique for hand rubbing and soap and water washing
• Indications for hand rubbing vs soap and water washing (WHO or CDC Guideline)
• How to speak up when fellow HCWs do not comply.
• Education for patients, family members and visitors.
• Performance Evaluation and Feedback
• Hand hygiene compliance must be measured using a validated method of capturing and reporting all hand hygiene events. Such compliance systems have been shown to lead to sustainable improvement, reduced infections and costs and a positive impact on patient safety culture (Bouk, Mutterer, Schore and Alper, 2016) (Kelly, Blackhurst, McAtee and Steed, 2016)(Michael, Einloth, Fatica, Janszen and Fraser, 2017)(Son et al., 2011).
• Provide performance feedback to unit leadership and frontline staff on a regular basis, using evidence-based behavior change feedback models (Welsh, Flanagan, Hoke, Doebbeling and Herwaldt, 2012).
• Reminders in the workplace, such as posters, brochures, leaflets, badges, stickers, can be used, provided they are consistent with the overall Hand Hygiene Protocol.
- Regarding direct monitoring of hand hygiene compliance through hand hygiene monitoring technologies:
- CHOC research found no pediatric experience with three compliance technology vendors, and thus volunteered to be a pediatric test site for evidence-based investigations. At this time, the value has not been established for this methodology in the pediatric population. Commitment Timeline:
This implementation plan has been in place at CHOC Children's for over a decade and our commitment will be ongoing and reported annually.
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APSS #10: Reducing Non-ICU Codes View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #10: Reducing Non-ICU Codes
Contact Info
Name James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic prevention and resuscitation of in-hospital cardiac arrest
Commitment Name:
APSS #10: Reducing Non-ICU Codes
Commitment Start Date:07/01/2008 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Reducing preventable deaths by recognizing the early signs of pediatric deterioration requires a multi-disciplinary, multi-specialty collaborative team. CHOC Children's began work on this topic nearly a decade ago by proof of concept (which was positive), followed by implementation of a Rapid Response Team, Pediatric Early Warning System, and more recently, a "Watcher Program," each focusing on ever-earlier detection and mitigation of patient deterioration. Commitment Description & Detail:
In the first two years of the Reducing Non-ICU Codes effort, non-ICU codes dropped by 85%. Gratifyingly, they have remained at this lower rate for the past 9 years. As an example, there were only 6 total non-ICU arrests last fiscal year. Moreover, the great bulk of the remaining events are respiratory events; cardiac arrests have become vanishingly small. As an example of the latter, CHOC has achieved one interval of >1000 days between Non-ICU cardiac arrests.
We calculate there have been 433 avoided codes in hospitalized CHOC children since the inception of this effort.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and implemented the below checklist items.
Action Plan:
-An institutional resuscitation outcome program should target preventable deaths for a particular hospital or healthcare organization.
-A multi-disciplinary institutional group should be designated as primarily responsible for the resuscitation program.
-The CHOC Code White Committee oversees resuscitation and related escalation and deterioration detection and prevention activities
-A formal mechanism for input data (Afferents) should be identified. This should include both external sources of information, such as guidelines and scientific literature, as well as internal (institutional) data.
-The institutional ROSC should have input into the Efferent actions in response to Afferent data and perceived institutional resuscitation needs.
- An effective resuscitation program will engage individual providers and enhance their personal sense of ownership and accountability. Ultimately, this program should become the primary vehicle to reduce preventable deaths and ensure an institutional culture of safety.
-Outcome data should be presented to the hospital medical executive board bimonthly.
-An organized approach to data collection and performance improvement should target various etiologies of cardiopulmonary arrest with regard to reducing arrest incidence, increasing arrest survival and improving end-of-life discussions with patients and families.
-Institutional resuscitation protocols should consider available evidence, technology, and performance improvement data.
-Provider training should ensure optimal resuscitation performance and be specific to provider type and clinical unit.
-Cardiopulmonary arrest resuscitation should emphasize optimal chest compressions and controlled ventilations as recommended by the AHA in their ACLS protocol.
-Post-resuscitative care should focus on optimizing supportive critical care and consideration of age-appropriate temperature management.
-End-of-life discussions should provide patients and families with compassionate but realistic expectations regarding goals of therapy and various therapeutic options.
-Cardiopulmonary arrest prevention should emphasize early recognition of the deteriorating patient by technology that can present an early warning system.
-Perfusion technologies include sphygmomanometry, ECG, capnometry, clinical assessment (mental status, capillary refill, pulse quality, extremity temperature), pulse oximetry including
related perfusion indices, laboratory measures of acidosis (pH, base deficit, lactate, anion gap), and newer modalities (near-infrared spectroscopy, heart-rate
variability).
-Oxygenation technologies include pulse oximetry, blood gas analysis, near-infrared spectroscopy, and clinical assessment.
-Ventilation technologies include respiratory volumetrics (tidal volume, respiratory rate), blood gas analysis, capnometry, capnography, apnea monitoring, transcutaneous CO2 monitoring, and clinical assessment. Commitment Timeline:
CHOC Children's will report progress to the PSMF on eliminating preventable Non-ICU codes and deaths on an annual basis. Our commitment to this topic and APSS will be ongoing.
Impact DetailsLives Saved
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APSS #14: Falls & Fall Prevention View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #14: Falls & Fall Prevention
Contact Info
Name James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults
Commitment Name:
APSS #14: Falls & Fall Prevention
Commitment Start Date:01/01/2015 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Although a more significant problem in hospitalized adults, pediatric patients are also at risk for injury from falls. By far the most common are "developmental falls," in which the child is developing ambulation and self-protection skills appropriate for age and is simultaneously hospitalized or in other health care settings. Less common but generally more potentially serious are falls in ill or injured older children and young adults, similar in etiology to those in older adults. Often this group is characterized by chronic diseases of adolescence with long hospital lengths of stay, perhaps best characterized by oncologic conditions. It is this group that has long been our targeted focus for fall risk detection and injury prevention.
Commitment Description & Detail:
Reducing harm from moderate and severe falls is a Children's Hospitals' Solutions for Patient Safety (CHSPS) HEN network Hospital-Acquired Condition (HAC) being measured and improved. The goal is to have zero moderate or severe harm from preventable falls at CHOC.
Notably, with our risk identification and fall mitigation program in place, there have been zero such falls at CHOC for over 24 months.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has reached our goal and completed our implementation plan around this APSS challenge. Action Plan:
CHOC will continue to implement both PSMF and CHSPS processes around Serious Fall Prevention and will report on an annual basis.
Patient falls are a major cause of in-patient injury and even death. Healthcare administration must develop, revise and support the plan through the following actionable steps: (“Preventing falls in hospitals: a toolkit for improving quality of care.”, 2013; Boushon et al., 2008)
• Assess the existing fall prevention and protection from injury policies, procedures, protocols, and educational programs in relation to current evidence and emerging research.
• Identify existing needs or gaps in the fall prevention and protection from injury policies, procedures, protocols, and knowledge application for employees.
• Identify Opportunities for Improvement and Set Aims (Goodwin et al., 2014; Mion et al., 2012; Mccurley and Pittman, 2014; Waters et al., 2015).
− Collect fall and injury data to assist in advancing precision performance of fall prevention and protection from injury program.
− Debrief all falls, including non-injury falls. Analyze for trends or patterns that assist in advancing performance of the fall prevention and protection from injury strategy.
− Consider bundling evidence-based recommendations to achieve greater outcomes.
− Consider provider training on how to partner with patients and their loved ones on safety strategies to prevent falls and protect from injuries.
− Consider technological advancements to advance performance and reduce injuries.
− Develop a multidisciplinary team to create, implement, and sustain fall prevention and protection from injury initiatives. This team should include, but is not limited to, Executive sponsor, Environmental Manager, Risk Manager, Physical Therapist, Occupational Therapist, Medical Doctor, Unit Manager, frontline nursing staff, or Certified Nursing Assistant. Efforts should be made to get as many representatives from all shifts.
− Develop fall champions throughout all departments who further drive organizational knowledge and action in the healthcare setting.
− Provide clear and concise communication regarding the champion’s role and responsibilities.
− Develop feedback mechanisms to learn what is working and what can be improved upon in the fall prevention and protection from injury plan from the champion’s perspective.
Commitment Timeline:
The CHOC Children's commitment to this APSS will be ongoing and reported annually to the PSMF.
Impact DetailsLives Saved
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“We aspire to partner with children and families to deliver what matters to them” View Commitment
Commitment
×
CHOC Children’s Hospital
“We aspire to partner with children and families to deliver what matters to them”
Contact Info
Name Sandra Schultz
Phone: 7145098683
Email: sschultz@choc.org
Position: Customer Service Manager
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Participants:
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Jim Cappon, MD, Chief Quality & Patient Safety Officer
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement
Commitment Name:
“We aspire to partner with children and families to deliver what matters to them”
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
At CHOC Children's, we believe that the health and well-being of children are dependent upon partnering with families, those who surround, comfort, love, and are responsible for the child. To meet the unique needs of each child, we will partner with families in designing individual health care that honors and respects their beliefs, culture, values, and knowledge. We will encourage their questions and contributions, respect their choices, and strive to ease stress upon families of children who seek our support. When it comes to delivering high quality, safe care and exceptional experience, we will improve our communication, build stronger relationships, enhance our practices and systems that involve patient and family participation to ensure safety. Our process for identifying experience gaps will involve patients and families to create goals that will deliver a great care experience. Commitment Description & Detail:
Effective shared communication among patients, parents and the care team continue to be a top priority for both our organization and our families. The resulting coordination of care and improved communication produces better health outcomes and a more positive experience of care. Our approach to help minimize the communication breakdown that can occur among the care team, is to provide our associates with the skills and strategies that will help them connect through Relationship-Centered Care, recognizing emotions and responding with relations, human connection and empathy. Our hospital - wide improvement efforts have extended to include a committed core of volunteer Parent Advisory Council members who sit as active participants who collectively contribute their time attending monthly meetings, bringing to the table the patient/parent and family voice. This year, they have set a committee goal to collaborate with hospital associates in this initiative, which includes, parents, patients, nurses, doctors, ancillary services, and front-line associates on the development of a parent/healthcare team communication video. This will become part of the hospital’s new associate onboarding process and will be presented at various hospital forums. The goal of this parent - driven communication video will help enhance the partnership between the patient/parent and the healthcare team from the patient/parent perspective. Caring with kindness, compassion, listening and understanding the child and family a whole is “complete care” which is what we strive to provide. Action Plan:
Person and family engagement – often referred to as “PFE” – is an underutilized resource for achieving the goal of zero harm. An effective program to implement and sustain PFE should include the following actionable steps:(HRET, n.d.).
• Ensure that all members of the care team listen to the person and their family members’ questions and concerns, and avoid being short or curt with patients,
• Assess strengths and gaps in your organization’s PFE efforts by using this checklist:
− Elicit feedback from your senior leadership team, staff, patients and families about PFE efforts.
Inventory policies, processes, position descriptions and training programs to determine whether PFE is included.
− Discuss findings and conclusions with leadership, staff and patients to create awareness and lay the groundwork for improvement efforts.
• Deploy a system to implement PFE and monitor progress on improving PFE using the following:
− Develop an infrastructure that brings the patient and family voice systemically into your patient safety improvement work, such as:
o Appoint persons who identify as patients or patient advocates to your governing body,
o Establish patient and family advisory bodies that contribute to organizational safety initiatives,
o Include patient advocate input into improvement committees or root cause analysis teams, and/or
o Establish a functional area within your organization whose role and accountability is to engage patients and families.
− Select measures that will allow you to see whether processes and patient safety outcomes are changing.
− Ensure systems are in place so that needed data can be collected and shared.
− Compile results in a format that is easy to understand and monitor.
− Share results with staff, senior leadership, board, community and public.
Our commitment to our patients and their families is to improve their overall CHOC experience and provide exceptional care. To achieve this goal, we will utilize the 4 core concepts of Patient - and Family - Centered Care as our guiding principles: Respect and Dignity, Collaboration, Participation and Information Sharing. We will track and trend our improvement efforts utilizing our patient experience survey scores and feedback. Patient experience scores and feedback are disseminated throughout the organization monthly, quarterly and annually and publicly displayed on CHOC’s Communication/Quality and Patient Safety Boards. The survey measures used for tracking are organizational progress will be the following:
1. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your child's stay?
2. During this hospital stay, how often did your child's doctors/nurses/providers treat you with courtesy and respect?
3. During this hospital stay, how often did your child's doctors/nurses/providers listen carefully to you?
4 During this hospital stay, how often did your child's doctors/nurses/providers explain things to you in a way that was easy to understand?
Actionable Steps
• Mandatory 4-hour training sessions for all new hires within 90 days, “Living the Value of Service” (parent video)
• Physician resident training forums, Advocacy, Child Abuse, Community, and Teaching, (ACT 1) Pediatric Resident Rotation (parent video)
• Registered nurse resident, Service Excellence, Clinical Orientation (parent video)
• New volunteer orientation, “Living the Value of Service training for Volunteers” (parent video)
• Communication video will be made available on CHOC’s intranet to be used during any departmental training session (parent video)
• 4-hour skills practice session for providers, “RELATIONS For Healthcare Transformation” (effective communication in creating a culture of excellence)
CHOC Children’s will continue to utilize the Patient Safety Movement Executive Summary checklist recommendations in conjunction with its internal plans.
Commitment Timeline:
Implemented by June 30, 2019
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APSS #12A: Venous Thromboembolism (VTE) View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #12A: Venous Thromboembolism (VTE)
Contact Info
Name James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous thromboembolism (VTE)
Commitment Name:
APSS #12A: Venous Thromboembolism (VTE)
Commitment Start Date:01/01/2015 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Current research and quality improvement work is uncovering that VTE is not just a disease of adults. The nature of most pediatric disease is venous thrombosis rather than embolism, although detection of the latter can be challenging. The majority of non-adolescent pediatric VTE disease is related to central lines, due to a combination of the catheter itself, which by definition occupies a greater proportion of the patient vessel lumen, and the underlying clinical state requiring the line to be in place. Adolescent VTE pathophysiology becomes more similar to that seen in adults, with similar risk factors and presentation.
In order to establish a program to eliminate VTE, an implementation plan with the following actionable steps is recommended as best practice science to reduce patient harm. The following core action items and prevention strategies are outlined below using an interdisciplinary, best practice approach.
Commitment Description & Detail:
CHOC participates as a member of the Children's Hospitals' Solutions for Patient Safety (CHSPS) network, a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, with the goal of reducing harm in children. CHOC is a Pioneer Group member of the Venothromboembolism (VTE) hospital-acquired condition (HAC), which has identified that VTE is indeed a pediatric entity, and one of the most common HACs in overall incidence. This group is identifying both the incidence and early aspects of best practice prevention and therapy for the pediatric population.
CHOC uses an internally developed VTE risk assessment tool on all patients 12 years and older, which is mandated to be used at admission, transfer to a different care level setting, and/or every 7 days. Risk stratification leads to linked recommendations for EHR ordering of scaled VTE prophylaxis. VTE events and rates are measured monthly locally and across the network.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
-Hospital governance and senior administrative leadership must champion efforts in raising awareness around the high incidence of VTEs and prevention strategy measures.
-Healthcare leadership should support the design and implementation of standards and provider training programs on VTE reduction and prevention strategies by:
• Accurately stratifying risk by ensuring that providers perform a VTE risk assessment
• Measure appropriate quality measures related to VTE to close performance gap
• Complete in depth chart review for hospital-associated thrombosis events to identify opportunities for improvement and then acting on lessons learned
• Adhere to VTE best practices from national organizations such as Agency for Healthcare Research and Quality’s VTE Safety Toolkit. The toolkit contains 10 components that are evidence-based guidelines for preventing, diagnosing, treating, and educating patients and providers about VTE. The components are as follows:
-VTE prophylaxis guidelines, VTE risk assessment tool, VTE treatment pathway
-Creating of a standardized inpatient anticoagulant order set
- CHOC belongs to the Children’s Hospitals’ Solutions for Patient Safety (CHSPS) VTE Pioneer Group, developing and monitoring VTE practice and events in North American children
-Ensure healthcare professionals receive, at the least, annual training on new VTE policies and processes
- Assess risk for VTE among patients hospitalized with:
o Injury to vein: fracture, surgery
o Slow blood flow: bedrest, limited mobility, paralysis
o hormone replacement therapy
o Chronic illness: cancer, heart/lung disease, inflammatory bowel disease, kidney disease;
o Other: personal or family history of DVT/PE, obesity, central lines, or clotting disorders.
-Educate patient and families on VTE risks, complications, and importance of mechanical and medication prophylaxis.
-Select technologies that show early evidence to reduce VTEs and positively impact both patient and provider outcomes in the clinical settings
-Implement an EHR with prompt decision making support to ensure that every appropriate patient has a valid VTE prevention plan in place at all times during their hospitalization.
Commitment Timeline:
The CHOC commitment to VTE reduction is ongoing and will be reported annually.
Impact DetailsLives SavedLives Spared Total:
0.5616 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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8B – Unplanned Extubations in Children View Commitment
Commitment
×
CHOC Children’s Hospital
8B – Unplanned Extubations in Children
Contact Info
Name James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Participants:
-
Ms. Patricia Huddleson, Manager of Clinical Quality
-
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned extubation
Commitment Name:
8B – Unplanned Extubations in Children
Commitment Start Date:01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Unplanned extubation (UE) of the trachea in children can be a life threatening complication of mechanical ventilation support. These events are by definition sudden, unexpected and have variable outcomes, with a meaningful percentage of patients requiring re-intubation with its associated risks and complications (addressed in PSMF APSS 8A). Both pediatric and adult literature show that adverse effects of UE include increased length of mechanical ventilation and ICU stay, increased risk of pneumonia, increased mortality and increased costs. Reviews of adult UE suggest 10,000 or more associated deaths annually with this adverse event.
Neonates, particularly premature ones, are the most likely pediatric patient to experience UE. This is in part because of their anatomically very short trachea and also due to the general neonatology practice and preference for minimal sedation. Unfortunately, premature infants also physiologically poorly tolerate any dramatic changes in their sensory environment, which certainly includes those of a UE, with adverse vital sign changes persisting for minutes to hours after even seemingly modest inputs such as loud noise or bright light.
UE often occurs in patients who are being prepared to be liberated from mechanical ventilation, which often includes a reduction in sedation. Finding this "sweet spot" between successful conversion to spontaneous breathing while minimizing the risk of UE is a current challenge and focus for many hospitals and healthcare collaboratives. It is also of note that efforts to reduce ventilator-associated events (VAE, previously largely characterized by ventilator-associated pneumonia [VAP]) have also had the seemingly desirable effect of shortening mechanical ventilation duration, but may predispose rapidly weaning patients to the risks of UE or otherwise failed extubation. Commitment Description & Detail:
CHOC Children's has been focused on reducing UE since at least 2011, recognizing the importance of this event at the patient safety and patient and family experience level well ahead of the mainstream movement. UE has been a tracked metric since that time, and efforts at improvement have included standardization of endotracheal tube (ETT) selection, securement, and depth measurements, as well as patient sedation and ETT suctioning protocols.
In 2016, the Children's Hospitals' Solutions for Patient Safety (CHSPS) added UE to its growing collection of pediatric-relevant hospital-acquired conditions (HAC) targeted for reduction. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC). Best practices are identified, and both adherence to these care bundles and outcomes are tracked and benchmarked within the network.
While the incidence of UE at CHOC has dropped gratifyingly over time, events still occur and ongoing vigilance is required. At CHOC, UE rates are tracked monthly and quarterly, and results distributed broadly across the organization. UEs are among the events discussed at the CHOC Daily Safety Briefing; moreover, they have been a longstanding Key Driver of the CHOC high level organizational goal of reducing serious patient harm. All UEs are fully investigated in Apparent Cause Analyses with learnings widely spread.
CHOC will continue its efforts at best practice delivery and clinical outcomes in UE prevention. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items. Action Plan:
Unplanned extubation, both in the field and in the hospital, is a common and costly problem, resulting in significant morbidity and mortality.
• Assemble a core multidisciplinary airway safety leadership team
− VP of Quality / Safety
− Physician, nursing, and respiratory care team leaders across all hospital units to ensure recognition of the problem and support development of systems that will eliminate unplanned extubation and its associated complications, especially preventable deaths.
• Determine baseline rate of unplanned extubation (See Metrics Section below).
• Determine baseline rate of complications (oral mucosa and facial skin pressure injuries, pneumonia, vocal cord injury, hypoxemia, brain injury, death) caused by unplanned extubation.
• Perform a root cause analysis (RCA) for all incidences of unplanned extubation.
− Utilize a multidisciplinary team including physicians, nurses and respiratory therapists to evaluate the root cause of every unplanned extubation, determine a plan to eliminate the root cause, implement the plan and track results.
• Implement the core unplanned extubation dataset as defined in the Metrics Section of this APSS.
− Every (endotracheally) intubated, mechanically ventilated patient should have the entire PSMF Core Dataset for extubation recorded in the patient’s medical chart.
− Evaluate your hospital’s Electronic Health Record (EHR) to determine if the entire core dataset is included in the EHR.
o If included, educate all providers of airway management how to properly track UE.
o If not included, contact the EHR company and request they add the dataset; Develop a system for temporarily tracking the dataset until the EHR Company institutes the dataset.
• Develop a Quality Management Process to promote and ensure continuous improvement with an initial goal of eliminating preventable deaths from unplanned extubation and ultimately eliminating all incidences of unplanned extubation.
− Require tracking and reporting of all incidences of unplanned extubation and complications of unplanned extubation (hypoxemia, pneumonia, vocal cord injury, brain injury and death).
• Provide periodic education for all airway management providers.
− Educate providers regarding the importance of prevention of unplanned extubation and the need for accurate data tracking.
− Include unplanned extubation as part of every presentation of management of the difficult airway patient.
• Implement Clinical Best Practices for Preventing Unplanned Extubation.
− Standardize tracheal tube restraint devices, utilizing the most proven methods/devices.
− Implement systems for alerting clinicians to patients with a known difficult airway.
− Formalize systems for appropriate sedation and patient restraint to decrease the risk of unplanned self-extubation.
Commitment Timeline:
CHOC Children's will work with PSMF to update this commitment annually in an ongoing basis.
Impact DetailsLives SavedLives Spared Total:
0.39599999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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8A – Safer Airway Management View Commitment
Commitment
×
CHOC Children’s Hospital
8A – Safer Airway Management
Contact Info
Name James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management
Commitment Name:
8A – Safer Airway Management
Commitment Start Date:01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Difficult airways are a fundamental, constant challenge in the care of children, whose anatomy and physiology predispose them to unique approaches and training in airway management. Infants, particularly premature infants, are anatomically the most difficult humans to intubate. In addition, supportive airway and breathing equipment is not always available or even manufactured with the precision of fit and function for all sizes and ages of children. Those healthcare professionals dedicated to the support of ill and injured children are prepared to deal with these realities, but constant evolution of knowledge, preparation and equipment will have a favorable impact on airway safety. Commitment Description & Detail:
A named difficult airway program was begun at CHOC Children's in 2014, with multidisciplinary participation by pediatric critical care, neonatology, anesthesiology, emergency medicine and ENT. This included the creation of difficult airway carts, which contain advanced airway support and visualization equipment. The collaborative approach to improving capability and escalation of response has improved the pathways of approaching and managing the challenging airway patient.
CHOC has a wide breadth of personnel able to assist in difficult airway scenarios, including the 24/7 presence of attending physicians in critical care, neonatology, emergency medicine, trauma surgery and anesthesiology, as well as seasoned leaders in respiratory therapy and nursing.
All airway challenges, including adverse patients events and near misses, are addressed by the organization, with learnings widely shared. CHOC Children's will collaborate with the PSMF to advance its safe airway management program in concordance with the following checklist items. Action Plan:
Failures of airway management (e.g., inability to mask ventilate or oxygenate, unplanned extubation, failure to intubate) are potential major causes of inpatient morbidity and mortality.
• Assemble a core multidisciplinary leadership team to advance airway safety, including: ED, ICU, Hospitalist, ENT and Anesthesiology Physician Leaders.
− ED, ICU Nursing Leaders.
− Respiratory Therapy Leaders.
− Quality Improvement/Safety Leadership (VP or higher level)
• Under the co-leadership of a physician anesthesiologist, develop a comprehensive airway toolkit method (e.g., the Safer Airway Bundle). Start implementation in the ED and ICUs, and then move to floor units and other departments. Include the following Key Components: Failed Airway Path, Airway Cart, Airway Checklist, Quality Assurance, and Team Training.
− Implement Safer Airway Essential Components, as described in Appendix A: Safer Airway Essential Components.
• Require tracking and reporting of “near misses” and complications of airway management.
• Identify adverse outcomes that are iatrogenic and preventable (eg. multiple attempts, esophageal intubation, SpO2 decline of <10%, dental or soft tissue injury).
− Use these case data in medical staff educational sessions to prevent recurrences, as a part of Continuous Quality Improvement (CQI).
• Provide periodic airway management education for all care providers. This will include:
− identification of airway problems,
− selection and use of appropriate intervention, and
− understanding when and how to call for expert assistance (e.g. from Anesthesiology)
Commitment Timeline:
Airway safety in children, including management of the difficult airway, is an essential and evolving aspect of pediatric care. Progress on adherence to the recommendations and best practices contained within this APSS will be tracked annually.
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Challenge 2B – CAUTI Prevention View Commitment
Commitment
×
CHOC Children’s Hospital
Challenge 2B – CAUTI Prevention
Contact Info
Name James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI)
Commitment Name:
Challenge 2B – CAUTI Prevention
Commitment Start Date:01/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Catheter-associated urinary tract infection (CAUTI) is a frequent and potentially severe healthcare-acquired infection (HAI). It is the second most common HAI in children, after lower respiratory tract infection, e.g., pneumonia. CAUTI can lead to sepsis, particularly in those at the extremes of age or with underlying complex or chronic medical conditions. As a tertiary-quaternary regional children's hospital, CHOC Children's has long been trying to achieve the right balance between urinary catheter usage for high quality care and the risks of related complications.
Evolving medical knowledge and practice has led to the development of best practices for urinary catheter management, including placement, maintenance care, and timely discontinuation. CHOC aims to continue and advance these practices in conjunction with the Patient Safety Movement Foundation to reduce and eliminate CAUTIs and their consequences. Commitment Description & Detail:
CHOC Children's has been preventing catheter-associated urinary tract infections since well before 2013, when our formal involvement with the Children's Hospitals' Solutions for Patient Safety (CHSPS) began. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC).
CAUTI is one of the more frequent HACs, including in children. Due to focus on catheter management best practices (both insertion and maintenance) as well as effective efforts to reduce the duration of time urinary catheters are in place, the incidence has dropped gratifying over time; however, events still occur and ongoing vigilance is required. As part of the vigorous Infection Prevention program at CHOC, CAUTI rates are tracked monthly and quarterly, and results distributed broadly across the organization. Tellingly, the "days since last" CAUTI is announced each morning at the CHOC Daily Safety Briefing.
CHOC will continue its efforts at best practice delivery and clinical outcomes in CAUTI prevention. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
Catheter-associated Urinary Tract Infections (CAUTI) are a frequent cause of morbidity and mortality in hospitals.
• Insert catheters only for appropriate indications
• Ensure that only properly trained persons insert and maintain catheters
• Insert catheters using aseptic technique and sterile equipment
• Perform perineal care routinely for patients who have indwelling catheters to reduce the risk of skin breakdown and irritation
• Remove catheters as soon as possible
• Following aseptic insertion, maintain a closed drainage system
• Select technology has shown early success to reduce infections and positively enhance outcomes of patients
Commitment Timeline:
The CHOC commitment to CAUTI reduction is ongoing and will be reported annually.
Impact DetailsLives SavedLives Spared Total:
0.022999999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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APSS #9: Early Detection and Treatment of Sepsis View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #9: Early Detection and Treatment of Sepsis
Contact Info
Name James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 9 - Early detection and treatment of sepsis
Commitment Name:
APSS #9: Early Detection and Treatment of Sepsis
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Sepsis extracts a high toll of morbidity and mortality in children and adults alike. It is the leading cause of death in hospitalized children, claiming as many as 5,000 lives each year. Tens of thousands more children are treated for annually for sepsis, but that's not the end of it - at least half of survivors will be readmitted and over one-third of survivors of severe sepsis will develop a long term disability. The vast majority of pediatric sepsis is treated in a pediatric intensive care unit, and each hospitalization costs approximately $75,000. Nationally, sepsis has been estimated to consume 16% of pediatric inpatient expenditures.
As one approach, CHOC Children's Hospital is one of some 50 national children's hospitals working together to both improve outcomes and reduce the incidence of severe sepsis and septic shock in children. We aim to reduce the incidence of severe sepsis and septic shock by 75% in three years locally and nationally, including the onset of hospital-onset sepsis. By increasing the awareness, detection and response to early findings of sepsis in children, we aim to decrease mortality by an additional 75% as well. Sepsis is often treatable, but early detection and action are key. The stakes are high to master the collective approach to this oft-understood and frequently very serious illness. Commitment Description & Detail:
CHOC is basing many of its efforts with the Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) national collaborative. In this collaborative, best practices, monthly data submissions, and benchmarked reports for quality improvement and outcome enhancement are integrated locally and nationally over at least the next three years. An inpatient program is rolling out including efforts across the continuum from ED to medical, surgical and oncology wards, to intensive care units. These activities are in concert with those of the PSMF Sepsis APSS, with its details described herein.
One specific tactic of the CHOC plan is the use of Sepsis Huddles when there are strong criteria (3 or more electronic triggers) or other suspicion of sepsis. This briefing includes the immediate clinical caregivers at the bedside and includes the formulation of an action plan. Parents and guardians are a part of that gathering, as possible. Furthermore, when possible, specific indicators of possible sepsis will be included in CHOC's already robust program to detect and prevent clinical deterioration, including non-ICU codes.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is actively working on the below checklist items. Action Plan:
-Commitment from hospital governance and senior administrative leadership to support early detection and appropriate management of sepsis in their healthcare system.
-Develop a team approach to implement a protocol for early sepsis identification and treatment.
-Appoint an MD chairperson to be responsible and accountable for leading this group.
-CHOC participates in the Children's Hospitals Association Improving Pediatric Sepsis Outcomes (IPSO) national collaborative to reduce severe sepsis by 75%
-CHOC IPSO structure includes Steering, Operations and Unit-based committees
-Implement a Sepsis Rapid Response Team or incorporate early detection of sepsis into your existing medical emergency teams (e.g. Rapid Response Teams).
-Formalize a process to screen patients for signs of sepsis throughout the entire institution. (In progress, although PEWS and RRT criteria also capture the bulk of these)
-IPSO screening currently in place in ED
-Expands to Hematology-Oncology and wards this year
-Implement an effective monitoring system to accomplish continuous monitoring and notification based on acute changes to the following patient data:
o Fever or Hypothermia (temperature age-based norms for pediatric populations);
o Tachypnea per age-based norms for pediatric populations;
o Altered mental status;
o Hyperglycemia (per pediatric normative values) in the absence of diabetes;
o Leukocytosis or Leukopenia per age-based norms. Normal WBC count with greater than 10% immature forms;
o Plasma C-reactive protein above the standardized value;
o Plasma procalcitonin more than two standard deviations above the normal value (N/A currently at CHOC);
o Hypotension per age-based pediatric norms;
o Hypoxemia;
o Acute oliguria (per pediatric norms);
o Thrombocytopenia;
o Hyperlactatemia (> 2mmol/L [CHOC Children's Lab]); or
o Prolonged capillary refill time or mottling.
-Select an EHR to serve as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool and allows for continuous analysis and surveillance will be most beneficial.
-Implementation of automated electronic screening based on existing data (SIRS criteria, MEWS or any other warning system being used).
-CHOC has used the Pediatric Early Warning System (PEWS) for all inpatients since 2009.
-Design a workflow specific to level of alert: (In progress)
o SIRS met – assess for infection.
o If patient has sepsis – increase monitoring or assessment for presence of severe sepsis.
-Implement a process for continuous monitoring of electronic systems and protocols: (In progress)
o Compliance, efficacy and outcome measures.
-Implement case reviews for outliers.
-For severe sepsis:
-Implement workflow for rapid assessment and intervention at the bedside.
-Initiate severe sepsis bundle (3 hour elements):
-Obtain blood cultures prior to administration of antibiotics.
-Administer broad spectrum antibiotics.
-Administer appropriate volume expansion for hypotension or lactate ≥4 mmol/L.
-Build electronic documentation of process of care (fluids, antibiotics, clinical assessment etc.).
-For septic shock:
o Implement workflow for rapid assessment, intervention and need for higher level of care.
-Initiate septic shock bundle (6 hour elements):
-Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] ≥ low normal range for age).
-In the event of persistent hypotension despite volume resuscitation (Septic Shock) or initial lactate ≥4 mmol/L (36 mg/dL):
-Measure central venous pressure (CVP).
-Measure central venous oxygen saturation (ScvO2).
-Remeasure lactate if initial lactate was elevated.
Commitment Timeline:
CHOC Children's will continue to work on these checklist items, international bundle elements and more in our sepsis prevention program. Our commitment to this disease and APSS is strong, ongoing, and will be reported to PSMF annually.
Impact DetailsLives Saved
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APSS #13: Mental Health View Commitment
Commitment
×
CHOC Children’s Hospital
APSS #13: Mental Health
Contact Info
Name James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 13B - Collaborative care planning in mental health
Commitment Name:
APSS #13: Mental Health
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Children's mental health is as important as their physical health. It is not always obvious when a child is struggling emotionally, but recognizing the symptoms and seeking early and effective mental health services are important for long-term health. As at least one in five children will experience a mental health challenge while growing up, the issue is critical. Stories of courageous children battling medical illnesses abound, yet the mental health crisis is much more shrouded in secrecy. The result? Only one-third of children receive the mental health services they need. And suicide is the second leading cause of death between 10 and 24 years of age.
CHOC Children's opened an inpatient pediatric mental health unit earlier in 2018. This is the capstone of a comprehensive program with an ambulatory program of graded intensity, including an outpatient day program. The needs for such resources are dire, as at least 20% of children have a mental health challenge in the first 18 years of life. Similar to the rest of the U.S., the inpatient capacity for pediatric mental health in California is minimal and declining, particularly for those less than 13 years of age. As an example, by opening 18 beds in the CHOC Mental Health Inpatient Center (MHIC), the number of such beds in the entire state increased by 20%.
A reliable pediatric mental health system of care has the potential to turn lives around, providing services that reach the children while the developing brain still has the greatest potential to respond. Furthermore, and akin to physical health, treating children early can also have a major effect on the adult mental health crisis.
Commitment Description & Detail:
CHOC Children's, in partnership with committed organizations and community groups, aspires to create an outstanding mental health system of care for all children, teens and young adults in Orange County, CA and surrounding areas. Our goal is to provide a comprehensive approach to pediatric mental illness. Our vision for a mental health system of care recognizes and address the unmistakable link between mental and physical health. Without early identification and treatment, children with early signs are unlikely to escape the long-term impacts on their health and well-being. At CHOC, we believe mental health should be fully integrated with physical health treatment. When needed, the psychology and psychiatry teams work closely with the medical team to attend to patients' emotional, behavioral and developmental needs through inpatient and outpatient therapy.
With this potential for benefit comes risk. The CHOC Children's MHIC was designed with the best current designs for safety and effectiveness of therapy, including novel environments which instill normalcy into daily routines. Most uniquely, parents are even invited partners for the duration of care. But as this PSMF APSS underscores, great care must be taken during all aspects of mental health care delivery. This seriousness of purpose and care delivery is integrated into all aspects of patient care flow and monitoring.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is actively working on our implementation plan. Action Plan:
Executive Plan:
-Provide low barrier ways for staff and patients to collaborate on care planning.
-Promote patients to take more of an active role in identification and management of symptoms.
-Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others.
-Be evaluated with metrics such as Client Satisfaction Surveys, patient lengths of stay, patient readmission rates, Code and escalation frequency, and seclusion room use.
Leadership Plan:
• Provide infrastructure. Use an appropriateToolkit to systematically build patient and support skills development in an effective and efficient manner. Collaborative care planning appears to have particularly strong effects in patients with more severe disorders, and even low levels of collaboration can have positive outcomes (Craven et al., 2006). This is particularly important in acute inpatient psychiatry settings, where psychiatric severity tends to be high, and staff often are time and resource constrained (Porter, 1992).
• Provide scope. Develop a guide for staff and physicians to determine appropriate family and supports to be involved in care planning.
• Provide capacity. Protect time to engage in patient comfort planning.
• Provide capability. Educate staff on how to leverage comfort planning, how to engage patients to identify their triggers, and when to seek additional resources.
• Provide motivation. Highlight the importance of patient involvement in patient outcomes, empower staff to take action to proactively assess and include patients in their treatment.
• Provide outcomes. Systematically track and iteratively improve patient engagement by collecting data about outcomes, success rates, adverse events.
Commitment Timeline:
Our commitment to a comprehensive continuum of outpatient and inpatient children's mental and behavioral health will be ongoing and reported to the PSMF APSS on an annual basis.
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Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications View Commitment
Commitment
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CHOC Children’s Hospital
Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications
Contact Info
Name Grace Magedman
Phone: 714-509-4332
Email: gmagedman@choc.org
Position: Director of Pharmacy Services
Organization Name: CHOC Children’s Hospital
Organization Address:
1201 West La Veta Avenue
Orange, 92868 United States
Participants:
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Shannon Bertagnoli, Pharmacy Medication Safety and Quality Coordinator
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric adverse drug events Commitment Name:
Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications Commitment Start Date 11/01/2016 How Many Hospitals Will This Commitment Represent? 1 Action Plan
The smart pump oversight committee will continue to meet quarterly, and data obtained will continue to be utilized to adjust the drug libraries to maximize safe use and minimize program errors. Severe adverse drug events averted and potential costs avoided will be monitored along with this data. Good catches and nursing education on common errors or near misses observed will be disseminated quarterly also. Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
This value is based on the number of infusions reprogrammed, cancelled infusions, and severe ADEs averted, which is monitored on a quarterly basis.
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| Calvert Health Medical Center |
Maryland |
United States |
Safer Airway View Commitment
Commitment
×
Calvert Health Medical Center
Safer Airway
Contact Info
Name Heather Wright, BSRT, RRT
Phone: (410) 535-8311
Email: heather.wright@calverthealthmed.org
Position: Director, Cardiopulmonary Services
Organization Name: Calvert Health Medical Center
Organization Address:
100 Hospital Road , Calvert County, 2, Prince Frederick
Prince Frederick, 20678 United States
Participants:
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Drew Fuller, MD, MPH, FACEP, RRT, Alteon Health, Chief Safety Officer
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Susan Dohony, RN, CPHQ, Vice President, Chief Quality Officer
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management
Commitment Name:
Safer Airway
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Intubations can be high risk and a missed airway can have devastating results. Factors to reduce complications include preparedness, assessment, planning, communication, teamwork, skill with multiple techniques, and situation awareness. Most airway complications are unanticipated and can lead to harm and death, particularly in the ICU and ED. Therefore, the objectives of this initiative are the development of a pathway/protocol for a failed airway, organization of routine and difficult airway equipment in a cart, utilization of a checklist to be used as a staff resource and for quality assurance, and implementing a robust training designed for team success in both predictable and unpredictable airway situations. Commitment Description & Detail:
One of the main drivers of the Safer Airway initiative began as a short culture survey to staff members asking their perception of airway practices. The thought of having a well thought out pathway and an array of equipment at the bedside in an organized fashion just made sense from a patient safety , resource management, and staff efficiency point of view. In smaller facilities, like ours, anesthesia is often not present after hours, and that is a vulnerability to the facility. Safer Airway is not just about being prepared for the known difficult airway, but for the airway that was not perceived to be difficult.
Many facilities have adopted the use of direct laryngoscopy for intubations outside of the operating room. Using that technology as the anchor to the Safer Airway equipment list, Respiratory Therapists, Nurses, Hospitalists, and Emergency Department Physicians were trained on the newer technology, such as fiber optic bronchoscopes, and a wider selection of supraglottic airways. The Emergency Department was the first cart implemented in December of 2015, and a cart was added to the ICU in June 2016. Action Plan:
STEP 1: ADOPT A FAILED AIRWAY PATHWAY
*Ensure that your hospital or department has a simple, easy to use, team-based Failed Airway Pathway.
Step 2: Prepare Designated Airway Cart and Staff Driven Protocol
*Consolidate all basic and rescue equipment into one system or "cart."
*Arrange and label the drawers to support you system's Failed Airway Pathway.
*Standardize throughout your ED< ICU, and other out of OR airway management units to avoid potential pitfalls of separate systems.
STEP 3: CHECK IT!
*Utilize a checklist to assure preparedness, performance, and post intubation safety and CQI.
STEP 4: TEAM TRAINING AND IMPLEMENTATION
*Training is the best way to achieve staff buy in and engagement in the Safer Airway process.
*Hardwiring the following best practices for improved outcomes should be the goal of staff training:
PREPARATION
POSITIONING
PRE-OXYGENATION
PLANNING & PROTOCOL USE
PERFORMANCE
POST-INTUBATION MANAGEMENT
PREVENTION OF EXTUBATION
AIRWAY PROTECTION
Commitment Timeline:
Our project was fully implemented in June 2016 with Safer Airway carts located in the ED and ICU.
Heather Wright, RRT presented the Safer Airway Initiative in an open forum at the Maryland/DC Society for Respiratory Care Conference, September 2017.
The Safer Airway initiative was accepted to the Leading Practice Library maintained by The Joint Commission, February 2018.
Drew Fuller, MD and Heather Wright, RRT presented the Safer Airway Initiative as key speakers at the California Society for Respiratory Care Conference, May 2018
The website to review our Pathway and Checklists is www.saferairway.org
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| Cedars-Sinai |
California |
United States |
Reduction in Injury Falls View Commitment
Commitment
×
Cedars-Sinai
Reduction in Injury Falls
Contact Info
Name Linda Burnes Bolton, DrPH, RN, FAAN
Phone: 310-423-5191
Email: linda.burnesbolton@cshs.org
Position: System Chief Nurse Executive, Vice President, Nursing & Chief Nursing Officer
Organization Name: Cedars-Sinai
Organization Address:
8700 Beverly Boulevard Central LA , Los Angeles County
Los Angeles, 90048 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults Commitment Name:
Reduction in Injury Falls Commitment Start Date 01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Cedar Sinai’s Fall Bundle includes the fall risk assessment process, the use of visual cues and systems to alert staff to patients at high risk for falls while improving communication among staff regarding fall risk status, and individualized fall risk reduction plans. The Fall Bundle addresses safe patient transfers while getting out of the bed for toileting or other needs, the use of equipment such as low beds, and improving staff and patient education. We are adding a Fall Prevention patient/family video to as a strategy for patient education. Along with the bundle, hourly rounding and safety checks are key to decreasing patient falls. Commitment Timeline
The timeline for reducing the fall rate will be from January 1, 2017 – June 30, 2018
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Reduction of risk of death will be based on reduction in injurious falls. Reported in, “Falls among Adult Patients Hospitalized in the United States: Prevalence and Trends”, published in the Journal of Patient Safety by Bouldin, Andresen, et al., two in one thousand injurious falls resulted in death (0.2%). Medical-surgical units experienced a fall rate = 3.62/1,000 patient days and an injurious fall rate = 0.95/1,000 patient days.
The medical/surgical nursing units at Cedars-Sinai experienced an injurious fall rate of 0.17 per 1,000 patient days in Fiscal Year 2015 (baseline year for our commitment). While well below the national average, reducing the rate by 50% (to 0.085 per 1,000 patient days by FY2018) would cut the risk of death from a fall in hospital to 1 in 1,000 injurious falls.
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Reduction in Injury Falls – Update – 09.10.18 View Update
Commitment Update
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Cedars-Sinai
Reduction in Injury Falls – Update – 09.10.18
Contact Info
Name Linda Burnes Bolton, DrPH, RN, FAAN
Phone: 310-423-5191
Email: linda.burnesbolton@cshs.org
Position: System Chief Nurse Executive, Vice President, Nursing & Chief Nursing Officer
Organization Name: Cedars-Sinai
Commitment DetailsCommitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Cedar Sinai’s Fall Bundle includes the fall risk assessment process, the use of visual cues and systems to alert staff to patients at high risk for falls while improving communication among staff regarding fall risk status, and individualized fall risk reduction plans. The Fall Bundle addresses safe patient transfers while getting out of the bed for toileting or other needs, the use of equipment such as low beds, and improving staff and patient education. We are adding a Fall Prevention patient/family video to as a strategy for patient education. Along with the bundle, hourly rounding and safety checks are key to decreasing patient falls.
Commitment Update:
The Fall Prevention patient/family video was rolled out for all patients/families to view upon admission to the hospital. Cedars-Sinai activated a Falls Task Force in September 2017. Membership included, in addition to CS inpatient setting and staff, imaging, clinics, physician offices, our affiliate hospital and a preferred home health care provider). The task force developed recommendations for documentation and communication across levels of care, and clinical prevention services including) common risk assessment strategies, documentation of all falls with causal analyses, and injury prevention strategies across the continuum of care. The Falls Taskforce has undertaken two standardization efforts this year. First, a standardized electronic focus study approach for all falls with injury was developed using the patient’s electronic health record to gather details in the clinical context for all falls. This approach - creating an analyzable database - tracks and trends fall data for further informing preventative interventions.
Your commitment aligns with APSS
Challenge 14A - Falls and fall prevention in adults Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Cedars-Sinai strives for excellence in the prevention of falls. Over the past four (4) years, no patient at Cedars-Sinai has expired related to a fall with injury. Cedars-Sinai benchmarks its falls with injury data against large databases such as NDNQI and CALNOC. For example, from 2017-2018 the falls with injury on medical surgical units within the databases of NDNQI was 0.95 per 1000 patient days and for CALNOC 0.54 per 1000 patient days. However, at Cedars-Sinai, the rate of falls with injury is .19 per 1000 patient days. While we did not meet our aggressive pledged target of a 50% reduction (baseline 0.19/1000 patient days of falls with injury) to 0.085 falls with injury per 1000 patient days, we maintained our standard of excellence in prevention of falls with injury and have gained success in expanding our fall prevention program.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
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Lives Lost
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Lives Lost:
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Lives Spared Harm Target
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Actual Lives Spared Harm in last 12 months
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Lives Spared Harm Target for following calendar year
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Lives Saved Target
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Actual Lives Saved in last 12 months (might differ from initial target)
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Projected Target of Lives Saved for following calendar to try to finish commitment
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New Lives Lost (lives lost – actual lives saved)
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| Central Vermont Medical Center |
VT |
United States |
Antimicrobial Stewardship View Commitment
Commitment
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Central Vermont Medical Center
Antimicrobial Stewardship
Contact Info
Name Patrice Knapp
Phone: 802-371-5971
Email: patrice.knapp@cvmc.org
Position: Director of Quality Management
Organization Name: Central Vermont Medical Center
Organization Address:
130 Fisher Road
Berlin, 05641 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship
Commitment Name:
Antimicrobial Stewardship
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Reduce inappropriate use of antibiotics to specifically reduce CDI Commitment Description & Detail:
Annual antibiogram unique to our population and region for both acute and ambulatory settings
CDI nurse driven protocol
Action Plan:
Creation of annual antibiograms based on microbiology sensitivities
Creation of recommended antibiotic dose/duration for pediatric, adult and geriatric populations
Creation and implementation of a nurse driven CDI protocol for stool specimen testing (reduce # of ineligible stool samples)
Laundry vendor inspection Commitment Timeline:
September 2019
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CDI Reduction Initiative View Commitment
Commitment
×
Central Vermont Medical Center
CDI Reduction Initiative
Contact Info
Name Patrice Knapp
Phone: 802-371-5971
Email: patrice.knapp@cvmc.org
Position: Director of Quality Management
Organization Name: Central Vermont Medical Center
Organization Address:
130 Fisher Road
Berlin, 05641 United States
Participants:
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Erica Baker, Infection preventionist
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Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridioides difficile infection (CDI)
Commitment Name:
CDI Reduction Initiative
Commitment Start Date:01/03/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Reduce hospital acquired CDI Commitment Description & Detail:
Step 1: Ensure appropriate testing - instead of going right to PCR, stool leukocytes and antigen will be tested initially before proceeding to PCR testing. Results will be interpreted by the lab and decision support will be given to providers.
Step 2: Build C-diff protocol questions into the ordering process
Step 3: Educate C-diff protocol for MDs, Hospitalist group and nursing (RNs, LPNs)
Step 4: Integrate hand washing, Antibiotic Stewardship and environmental cleaning
Step 5: Analyze baseline against current data and benchmarks (NHSN) Action Plan:
Step 1: Ensure appropriate testing - instead of going right to PCR, stool leukocytes and antigen will be tested initially before proceeding to PCR testing. Results will be interpreted by the lab and decision support will be given to providers.
Step 2: Build C-diff protocol questions into the ordering process
Step 3: Educate C-diff protocol for MDs, Hospitalist group and nursing (RNs, LPNs)
Step 4: Integrate hand washing, Antibiotic Stewardship and environmental cleaning
Step 5: Analyze baseline against current data and benchmarks (NHSN Commitment Timeline:
Target completion date: October 30, 2018
Impact DetailsLives SavedLives Spared Total:
0.20249999999999998 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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| Centre Hospitalier de Melun-Senart |
Île-de-France |
France |
Reduction of ICU acquired infection and multi resistant bacteria transmission. The specific goal for catheter-related bloodstream infections is zero. View Commitment
Commitment
×
Centre Hospitalier de Melun-Senart
Reduction of ICU acquired infection and multi resistant bacteria transmission. The specific goal for catheter-related bloodstream infections is zero.
Contact Info
Name Cecile Lormail, RN, MSN, CNL
Phone: +33-1-6471 6660
Email: cecile.lormail@ch-melun.fr
Position: Head Nurse and Infection Prevention Coordinator
Organization Name: Centre Hospitalier de Melun-Senart
Organization Address:
20 Rue Marceline Leloup , Seine-et-Marne
Savigny-le-Temple, 77176 France
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) Commitment Name:
Reduction of ICU acquired infection and multi resistant bacteria transmission. The specific goal for catheter-related bloodstream infections is zero. Commitment Start Date 01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
The global action plan includes a nurse dedicated to hygiene and nosocomial infection prevention inside the ICU.
The pneumonia prevention plan will include the following 5 interventions:
• Selective oropharyngeal decontamination using chlorhexidine.
• Subglottic secretion drainage.
• Continuous endotracheal cuff pressure control.
• Broad spectrum antibiotics restriction (quinolones, cephalosporins, penems).
• Supervision and feedback on hygiene compliance for all ICU workers.
The prevention plan for Central Catheter-Related Bloodstream Infection is based on:
• Skin antisepsis using a chlorhexidine-based solution.
• Use of polyurethane or silicon catheters.
• Avoiding femoral catheters in obese patients.
• Ultrasound-guided aseptic techniques during catheter insertion, monitored by a dedicated nurse.
• Limiting parenteral nutrition to patients with enteral nutrition failure for more than 7 days.
• Changing catheters in case of fever or any sign of infection. Commitment Timeline
We aim to reduce our ventilator-associated pneumonia rate to <10/1000 days by the end of 2017, and our efforts to maintain zero catheter related bloodstream infections will be ongoing.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Compared to 1.5 per 1000 catheter days which is the median rate of central venous catheter related bloodstream infections in regional ICUs, a rate of zero infection rates may reduce the number of these infections from 6 to zero in our unit, avoiding 1 to 2 ICU deaths each year.
By reducing the ventilator associated pneumonia rate from 15 to <10 per 1000 days of mechanical ventilation, we can avoid 15 infections and 1 death. The impact of a reduction in ICU acquired infection might be very important in an era of increasing antibiotic resistance.
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| Centro Nacional de la Transfusión Sanguínea |
Ciudad de México |
Mexico |
Seguridad Transfusional View Commitment
Commitment
×
Centro Nacional de la Transfusión Sanguínea
Seguridad Transfusional
Contact Info
Name Julieta Rojo
Phone: 52 55 51192832
Email: julieta.rojo@salud.gob.mx
Position: directora general
Organization Name: Centro Nacional de la Transfusión Sanguínea
Organization Address:
195 Othon De Mendizabal , Zacatenco
Ciudad de México, 07360 Mexico
Participants:
-
Jose Luis Salazar Bailon, Hematólogo Pediatra
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient blood management Commitment Name:
Seguridad Transfusional How Many Hospitals Will This Commitment Represent? 1 Action Plan
Seguridad transfusional.
Si bien, el incrementar la seguridad transfusional en México del impulso de la donación altruista de repetición, también en este compromiso se abordan temas como las pruebas de escrutinio y la reciente introducción de las pruebas de biología molecular con el fin de incrementar la seguridad de las reservas sanguíneas. Por otro lado, resulta fundamental la función que el médico que indica la transfusión desempeña para fortalecer la cadena transfusional, la cual inicia con el tipo de donante (altruista o no) y culmina en la transfusión del componente sanguíneo al paciente. Toda esta cadena transfusional es susceptible de vigilar a través de un sistema de hemovigilancia, basado en las correctas acciones del Comité de medicina transfusional. De fructificar todos estos esfuerzos, se espera que en el futuro mediato se incremente la seguridad transfusional y se cierre la brecha que aún separa a México de los países industrializados en esta materia.
Commitment Timeline
Febrero- Abril 2018: recepción de informes que contemplen indicadores de medición del ejercicio de la transfusión en México
Mayo- Junio 2018: Análisis de resultados
Julio 2018: Emisión de informe de resultados
Julio 2018: Notificación a la autoridad sanitaria y de regulación de los resultados obtenidos
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| Centro Quirúrgico de Corta Estancia SERVICURA |
Ciudad de México |
Mexico |
Sistema de Notificación e Identificación de Incidentes de Seguridad View Commitment
Commitment
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Centro Quirúrgico de Corta Estancia SERVICURA
Sistema de Notificación e Identificación de Incidentes de Seguridad
Contact Info
Name Rafael Puppo
Phone: 528116602541
Email: rafael.puppo@hespanol.com
Position: Dr.
Organization Name: Centro Quirúrgico de Corta Estancia SERVICURA
Organization Address:
Eje 1 Poniente, 52 Avenida Cuauhtémoc , Doctores
Ciudad de México, 06720 Mexico
Participants:
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Sistema de Notificación e Identificación de Incidentes de Seguridad Commitment Details/h6>Commitment Summary:
SERVICURA es un centro quirúrgico de corta estancia, realizamos cirugía programada de bajo riesgo con un enfoque centrado en la seguridad del paciente. SERVICURA tiene 2 años implementando de manera formal diferentes sistemas de gestión de Calidad, logrando en el 2018 la certificación Hospitalaria por la instancia Mexicana de certificación (CSG) y en 2019 logra la acreditación internacional ante un organismo de acreditación internacional.
Durante estos años se a implementado un sistema de notificación de incidentes de seguridad, sin embargo a dos años de la Implementación inicial, los resultados respecto a la notificación voluntaria de incidentes a sido baja. esto secundario a diversas cosas entre las que destacan el miedo a una respuesta punitiva ante la notificación, Action Plan:
- Realizar la encuesta de clima de seguridad del paciente AHRQ especifica para centros quirúrgicos. (2019) Fecha tentativa: Agosto 2019
- Análisis de información obtenida para el diseño de estrategias. Fecha tentativa: Septiembre 2019
- Re-diseño del sistema de notificación de incidentes de seguridad (eventos adversos)
- Categorización y análisis de eventos adversos usando la taxonomía de la OMS.
- Habilitar en las coordinaciones medico-quirúrgica la competencia para hacer búsqueda intencionada de eventos adversos (metodologia global trigger tool IHI).
- Adoptar los principios de la cultura justa para el análisis de los incidentes de seguridad. Impact Details Lives Saved
Predicted Lives Spared Harm:
0.02 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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| Centro de Atención Integral de Salud Mental de Estancia Prolongada |
Jalisco |
Mexico |
Desafío 2A HAI: higiene de las manos View Commitment
Commitment
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Centro de Atención Integral de Salud Mental de Estancia Prolongada
Desafío 2A HAI: higiene de las manos
Contact Info
Name Jorge Estanislao Alvarez Barajas
Phone: 3330309900 ext 176
Email: estanislaoab@gmail.com
Position: Gestor de Calidad / Licenciado en enfermería
Organization Name: Centro de Atención Integral de Salud Mental de Estancia Prolongada
Organization Address:
1000 Avenida Zoquipan , Zoquipan
Zapopan, 45170 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
Desafío 2A HAI: higiene de las manos Commitment Start Date 01/01/1970 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Programa Manos Limpias
Medición Basal
Capacitación al 100% del personal para la higiene de manos
concientizacion de la adherencia de la higiene de manos
Entrega de insumos para la higiene de manos
Evaluación Commitment Timeline
01 febrero 2018 Medición basal
01 marzo 2018 inicio de la capacitación y entrega de insumos para el lavado
01 junio 2018 campaña de concientizacion de la adherencia de la higiene de manos
01 enero 2018 evaluación
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 170 Methodology for Determining Lives Saved:
la medición se realizará con las estadísticas de usuarios que acuden todos los días a recibir consulta y que son hospitalizados en la unidad
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Prog. operativo permanente para la limitación y prevención de infecciones asoc View Commitment
Commitment
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Centro de Atención Integral de Salud Mental de Estancia Prolongada
Prog. operativo permanente para la limitación y prevención de infecciones asoc
Contact Info
Name Erika León Plascencia
Phone: 01 (33) 3030-9950 ext. 150
Email: erika.leon.calidad@gmail.com
Position: Gestora de Calidad
Organization Name: Centro de Atención Integral de Salud Mental de Estancia Prolongada
Organization Address:
1000 Avenida Zoquipan , Zoquipan
Zapopan, 45170 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene
Commitment Name:
Prog. operativo permanente para la limitación y prevención de infecciones asoc
Commitment Start Date:11/05/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
El programa operativo permanente para la limitación y prevención de infecciones asociadas a la atención sanitaria y reducción a la resistencia de los antibióticos, es trascendental en la organización cuyas intervenciones, mejoran la calidad de la atención, ello lo definen las diferentes expresiones en los estudios presentados, un ejemplo claro es la referencia que se hace acerca de la disminución de tan solo el 0.1% de las infecciones nosocomiales, que genera disminución de los costes de forma sensible de los presupuestos, para ello una cultura de calidad es imprescindible, en toda organización.
La constante evolución en los procesos dinámicos para mejorar la calidad de la atención se observa en la documentación emanada desde el rector universal, la OMS; este establece que una cultura de calidad es sin lugar a dudas el mejor componente de una organización.
La creación de compromisos institucionales da prueba del deber en el proceso del quehacer por parte de los integrantes de la organización, la conformación de la subcomisión mixta de seguridad e higiene, una subunidad de calidad en enfermería, la sesión de estos mismo grupos en la búsqueda de soluciones eficientes, todo esto utilizando esquemas bien definidos dentro del programa.
En nuestro hospital este compromiso y la ejecución de las actividades a cumplir con este, se da de forma permanente con fechas de inicio y término, así como de promoción, capacitación, ejecución y evaluación de los elementos del proceso.
Conocedores de la gran importancia de impactar en la calidad de vida, la calidad de los servicios y la calidad de salud de nuestros usuarios, es que nos comprometemos a generar este proyecto de forma permanente.
Commitment Description & Detail:
Cuando la cultura de una organización se concientiza de la seguridad y se habla de los fallos y errores, la seguridad mejora, así lo refieren en el programa de siete pasos para la seguridad del paciente del sistema de salud del Reino Unido y no es de asombrarse que en la innovación de modelos de gestión de seguridad, éste, sea por sí solo, una guía a seguir. La seguridad del paciente en siete pasos. (agencia nacional para seguridad del paciente (npsa).sistema nacional de salud (nhs).Reino Unido)
El Consejo de Salubridad General propone en el año 2012 los estándares para la certificación de hospitales, ahí se establecen acciones contundentes para mejorar la seguridad del paciente como estrategia fundamental en la consecución de los objetivos primarios en la atención con calidad y seguridad del paciente.
Dentro de estas estrategias se plantean como primer punto las metas internacionales para la seguridad del paciente ya que estas identifican áreas de alto riesgo en los hospitales y describen soluciones basadas en evidencias y conocimientos de expertos. Dentro de las mismas la meta internacional número cinco, establece la necesidad de “reducir el riesgo de infecciones asociadas con la atención médica”. (consejo de salubridad general. Estándares para la certificación de hospitales 2012)
La higiene de las manos está posicionada como un punto de arranque natural para las unidades de atención a la salud que están realmente comprometidas en parar el persistente problema que representa la transmisión de infecciones dentro de la atención médica.
Por tanto, es de vital importancia establecer un programa permanente para la capacitación, implementación vigilancia y supervisión de una higiene de manos correcta, que permita garantizar la ausencia o disminución de infecciones asociadas a la atención sanitaria.
Action Plan:
La continua búsqueda de la excelencia en la atención con calidad de los usuarios, es un tema que cada día se ve y se escucha con más frecuencia y, en el entendido de que “sin seguridad no existe la calidad”, es que las grandes organizaciones nacionales e internacionales, tanto del ámbito de la salud, de la producción, técnica, etc. gubernamentales o no, organismos privados y públicos se han dado a la tarea, de establecer estándares para minimizar los errores en la atención con calidad total.
Esta tendencia aunque relativamente novedosa, no es nueva; es sabido que existen estudios desde las décadas de los 50’s y 60’s del siglo pasado que investigaron sobre las consecuencias de los eventos adversos en la atención de la salud, en Australia y Estados Unidos, pero no fue sino hasta 1999 que el instituto de medicina de ese país, publicara el libro “errar es humano: construir un sistema más seguro de salud”, donde señala que entre 44,000 hasta 98,000 muertes anuales se debían a errores prevenibles, cifras que superan las causadas por el SIDA, el CA. de mama o los accidentes automovilísticos. (to err is human, building a saber health system. Institute of medicine 2001)
Las incidencias pueden deberse al error del personal de salud, pero con frecuencia, estos se sustentan en una falta de procesos de atención aplicados en la institución, o debidos a una falta de actuación de las personas que integran los diferentes equipos que conforman el sistema de salud.
Lo más grave es que se dan estos eventos y, estos, deben ser una fuente de información que nos permita establecer directrices en el ámbito de una planeación efectiva y no dejarlos como eventos aislados.
Los adelantos en el ámbito de la seguridad, son sin lugar a dudas el elemento que mueve las acciones de este hospital psiquiátrico y, en pro de brindar una atención profundamente sensible y de calidad total, es que la revisión de los contenidos y los avances en la aplicación y cumplimiento de las acciones esenciales para la seguridad del paciente sean pues la base del cual se desprendan trabajos específicos para el mantenimiento de la salud con una disminución perceptible de los costes y correcta atención holística del paciente.
Se propone un trabajo en conjunto con la subcomisión de seguridad e higiene, en el tenor de ser coparticipes de una estrategia en la que estamos insertos todos, mediante juntas, reuniones establecimiento de calendarios de operacionalización.
Se presenta carta descriptiva para la capacitación y, que esta verse acerca de las acciones esenciales metas internacionales del paciente, con énfasis en la accione esencial de seguridad número cinco.
Se crean comisiones para la capacitación, información, vigilancia y a evaluación de la aplicación de la técnica correcta del lavado de manos con agua y jabón e higiene de manos con gel alcoholado. Esto significa que se establecerá un ejercicio bien diseñado en cuanto a estructura de organización y que éste abarque todos los elementos de la acción final que es la prevención y disminución de infecciones nosocomiales y la reducción a la resistencia de los antibióticos.
Las intervenciones seguras que de ellos se derivan, tienen la capacidad de producir un impacto positivo sobre la mortalidad, morbilidad, incapacidad y complicaciones en los usuarios, así como determinar la garantía de la calidad del cuidado.
Brindar cuidados seguros responde a un modo de actuación profesional, elemento esencial en la cultura de calidad que se estampa en los servicios de salud.
Nuestro objetivo será el de informar, enseñar, aplicar y crear estrategias junto al personal responsable y corresponsable, para a trabajar y conocer los avances e implementar medidas y tácticas, donde el 100% del personal conozca y ejecute las acciones tendientes a brindar una atención de calidad con seguridad, manifestado a través de una sensible expresión del compromiso personal e institucional.
Commitment Timeline:
Reunión con el grupo base presentación de programa 1 al 15 Agosto, 1 al 28 Febrero, 1 al 30 Junio
Establecimiento de metas, estrategias y compromisos 1 al 15 Agosto
Capacitación por cascada 16 al 31 Agosto, 1 al 15 Septiembre, 1 al 30 Noviembre,
Dispersión de información 1 al 31 Agosto, 1 al 28 Febrero
Vigilancia y retroalimentación 16 al 30 Septiembre, 1 al 31 Octubre, 1 al 30 Noviembre, 1 al 31 Enero, 1 al 28 Febrero, 1 al 31 Marzo, 1 al 30 Abril, 1 al 31 mayo, 1 al 30 Junio, 1 al 31 Julio.
Informe de avances y nuevas estrategias 1 al 31 de Diciembre, 16 al 31 mayo
Presentación de resultados 1 al 31 de Diciembre, 16 al 31 mayo
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| Chang Bing Show Chwan Memorial Hospital |
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Taiwan |
Take Care of the Psychiatric Patients View Commitment
Commitment
×
Chang Bing Show Chwan Memorial Hospital
Take Care of the Psychiatric Patients
Contact Info
Name wenchin lee
Phone: +886-4-7813888
Email: wenchinl@yahoo.com.tw
Position: Vice Superintendent
Organization Name: Chang Bing Show Chwan Memorial Hospital
Organization Address:
6 Lugong Road Changhua Binhai Industrial Zone , Changhua County, Lukang Township
, 505 Taiwan
Commitment DetailsCommitment Name:
Take Care of the Psychiatric Patients How Many Hospitals Will This Commitment Represent? 1 Action Plan
Access to acute psychiatric beds
Mental health
1. We provide a real-time electronic bed tracking system.
2. We have fixed staff to control the empty beds,
When working hours, the physician who need bed, he (she) would connect the staff.
When off hours, if the psychiatric patient visit emergency room, the ER doctor will visit first and connect
the on duty psychiatric doctor. Commitment Timeline
1. Announce to our members of hospital about the patient safety action plan.
2. Make a team work to accomplish the mission.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| Changhua Christian Hospital |
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Taiwan |
Airway Safety View Commitment
Commitment
×
Changhua Christian Hospital
Airway Safety
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Maw-Soan Soon, vice superintendent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management Commitment Name:
Airway Safety Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Improve Airway Safety
(1)Difficult Intubation Assessment; This will be assessed according to criteria related to throat, neck trauma, infection, surgery, obesity, or assessing history of difficult intubation.
(2)OSCE Training Program and Outcome, also known as Rapid Sequence intubation training and emergency cricothyrotomy
(3)Mobile Intubation Car with all Requirements for Difficult
(4)Intubation and Resuscitation Services; Anesthesia physicians will support difficult intubation and ENTs, thoracic surgery physicians will support emergency cricothyrotomy. Commitment Timeline
Improve Airway Safety- July 1st, 2017 ~ June 30th, 2018
Impact DetailsLives Lost in Last Calendar Year:2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Airway Safety – Update – 09.02.18 View Update
Commitment Update
×
Changhua Christian Hospital
Airway Safety – Update – 09.02.18
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment DetailsCommitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Improve Airway Safety
(1)Difficult Intubation Assessment; This will be assessed according to criteria related to throat, neck trauma, infection, surgery, obesity, or assessing history of difficult intubation.
(2)OSCE Training Program and Outcome, also known as Rapid Sequence intubation training and emergency cricothyrotomy
(3)Mobile Intubation Car with all Requirements for Difficult
(4)Intubation and Resuscitation Services; Anesthesia physicians will support difficult intubation and ENTs, thoracic surgery physicians will support emergency cricothyrotomy.
Commitment Update:
We organize OSCE committee to implement training program and audit operation process. Physician, intern and registered nurse include training program are above 90% certified rate. The successful rate of cricothyrotomy within 2 times improve from 79% to 87%.
Following airway safety guideline, keep patient more safety and efficiency.
Your commitment aligns with APSS
Challenge 8A - Safer airway management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) #8A:SAFER AIRWAY MANAGEMENT. The valuable lessons is we organize OSCE committee to implement training program and audit operation process.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2319 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
81 |
Lives Spared Harm Target for following calendar year
90 |
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
81 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2319 |
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Healthcare-associated Infections (HAIs) View Commitment
Commitment
×
Changhua Christian Hospital
Healthcare-associated Infections (HAIs)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Maw-Soan Soon, Vice superintendent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI) Commitment Name:
Healthcare-associated Infections (HAIs) Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Reduce Healthcare-associated Infections (HAIs):
(1) Health care–associated infection risks, rates, and trends are tracked quarterly by the infection committee.
(2)Processes are redesigned based on risk, rate, and trend data and information.
(3)Assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program. Commitment Timeline
Reduce Healthcare-associated Infections (HAIs)- July 1st, 2017 ~ June 30th, 2018
Impact DetailsLives Lost in Last Calendar Year:2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Healthcare-associated Infections (HAIs) – Update – 09.02.18 View Update
Commitment Update
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Changhua Christian Hospital
Healthcare-associated Infections (HAIs) – Update – 09.02.18
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment DetailsCommitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Reduce Healthcare-associated Infections (HAIs):
(1) Health care–associated infection risks, rates, and trends are tracked quarterly by the infection committee.
(2)Processes are redesigned based on risk, rate, and trend data and information.
(3)Assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program.
Commitment Update:
As urinary tract infection (UTI), we refer evidence to alter Foley size from 16 Fr. To 14Fr. for general drain urine condition to mitigate harm for urine tract. We also introduce bladder scan to detect urine volume in bladder and help physician to assess whether or not remove Foley. The UTI rate improves from 0.72% to 0.48%
Your commitment aligns with APSS
Challenge 2 - Healthcare-associated Infections (HAIs) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Sunnybrook Health Sciences Centre, Medical Directive for Early Removal of Urinary Catheter’s in Medical Ward Patients. 2015. We introduce some medical device to improve UTI.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2306 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
94 |
Lives Spared Harm Target for following calendar year
95 |
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
94 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2306 |
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Creating a Culture of Safety View Commitment
Commitment
×
Changhua Christian Hospital
Creating a Culture of Safety
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Maw-Soan Soon, Changhua Christian Hospital
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Creating a Culture of Safety Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Create a Culture of Safety:
(1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations
(2)Individuals are able to report errors or near misses without fear of reprimand or punishment;
(3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
(4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns. Commitment Timeline
Create a Culture of Safety- July 1st, 2017 ~ June 30th, 2018
Impact DetailsLives Lost in Last Calendar Year:2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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Creating a Culture of Safety – Update – 09.02.18 View Update
Commitment Update
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Changhua Christian Hospital
Creating a Culture of Safety – Update – 09.02.18
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment DetailsCommitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Create a Culture of Safety:
(1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations
(2)Individuals are able to report errors or near misses without fear of reprimand or punishment;
(3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
(4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.
Commitment Update:
We refer evidence Patient Safety Culture Improvement Tool to implement the following activity
1.Team Work – Collaborative disciplines
2.Patient Safety Leader Education and Training
3. Patient Safety Leader Performance Evaluation
4.Workload Management
5.Fatigue Management
6.Incident Sharing and Leaning
7.Incident Disclosure
8.Safety Risk Analysis System
We conduct patient safety culture survey and improve from 67.9% to 74.1%.
Your commitment aligns with APSS
Challenge 1 - Culture of safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from the Actionable Patient Safety Solution (APSS) #1:CULTURE OF SAFETY. We conduct patient safety culture survey and improve from 67.9% to 74.1%.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2308 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
92 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
92 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
|
|
New Lives Lost (lives lost – actual lives saved)
2308 |
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Hand-off Communications View Commitment
Commitment
×
Changhua Christian Hospital
Hand-off Communications
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Maw-Soan Soon, Vice superintedent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off communications Commitment Name:
Hand-off Communications Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Promote Hand-off Communications
(1) Standardized critical content is communicated between health care practitioners during handovers of patient care.
(2) Standardized forms, tools, or methods support a consistent and complete handover process
(3) Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented. Commitment Timeline
Promote Hand-off Communications- July 1st, 2017 ~ June 30th, 2018
Impact DetailsLives Lost in Last Calendar Year:2400 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000
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Hand-off Communications – Update – 09.02.18 View Update
Commitment Update
×
Changhua Christian Hospital
Hand-off Communications – Update – 09.02.18
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment DetailsCommitment Start Date: 07/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Promote Hand-off Communications
(1) Standardized critical content is communicated between health care practitioners during handovers of patient care.
(2) Standardized forms, tools, or methods support a consistent and complete handover process
(3) Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented.
Commitment Update:
We introduce ISBAR skill as standardized critical content is communicated between health care practitioners during handovers of patient care and implement “ticket-to-ride” handover sheet as standardized forms, tools, or methods support a consistent and complete handover process. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.
Your commitment aligns with APSS
Challenge 6 - Hand-off communications Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution APSS #6:
HAND-OFF COMMUNICATIONS. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2400 |
Lives Lost
2400 |
Lives Lost:
2308 |
Lives Spared Harm Target
90 |
Actual Lives Spared Harm in last 12 months
92 |
Lives Spared Harm Target for following calendar year
|
Lives Saved Target
90 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
90 |
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New Lives Lost (lives lost – actual lives saved)
2308 |
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Failure to detect critical congenital heart disease (CCHD) View Commitment
Commitment
×
Changhua Christian Hospital
Failure to detect critical congenital heart disease (CCHD)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Rei-Cheng Yang, superintendent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 7B - Detecting critical congenital heart disease (CCHD) in newborns Commitment Name:
Failure to detect critical congenital heart disease (CCHD) Commitment Start Date 10/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
● Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices,including awareness, accountability, and action.
● Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system.
● Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap
● Set a goal date to implement the plan to address the gap with measurable quality indicators.
● Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders.
● Clinical/safety leadership endorse the plan and drive implementation across all providers and systems.
● Conduct data collection and analysis to be used for implementation and assessment of outcomes Commitment Timeline
Failure to detect critical congenital heart disease (CCHD): Oct. 1st, 2017 ~ Sept. 30th, 2018
Impact DetailsLives Lost in Last Calendar Year:48 How many lives do you expect to spare from harm in the next calendar year 4 How many lives do you expect to save in the next calendar year 4 Methodology for Determining Lives Saved:
Based on Actionable Patient Safety Solution (APSS) for #7B: FAILURE TO DETECT CRITICAL CONGENITAL HEART DISEASE (CCHD) IN NEWBORNS
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Failure to detect critical congenital heart disease (CCHD) – Update – 09.02.18 View Update
Commitment Update
×
Changhua Christian Hospital
Failure to detect critical congenital heart disease (CCHD) – Update – 09.02.18
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: deputy Quality and Safety director
Organization Name: Changhua Christian Hospital
Commitment DetailsCommitment Start Date: 10/01/2017 How many hospitals are represented in this commitment?
Action Plan:
● Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices,including awareness, accountability, and action.
● Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system.
● Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap
● Set a goal date to implement the plan to address the gap with measurable quality indicators.
● Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders.
● Clinical/safety leadership endorse the plan and drive implementation across all providers and systems.
● Conduct data collection and analysis to be used for implementation and assessment of outcomes
Commitment Update:
In the “Failure to Detect CCHD” program, we have established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents. In addition, education and training for physicians and nursing staff in the baby room have been established. Everyone is familiar with this screening activity. Hence this screening has already started in mid-August.
Your commitment aligns with APSS
Challenge 7B - Detecting critical congenital heart disease (CCHD) in newborns Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) for #7B:FAILURE TO DETECT CRITICAL CONGENITAL HEART DISEASE (CCHD) IN NEWBORNS. The valuable lessons is established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
48 |
Lives Lost
48 |
Lives Lost:
45 |
Lives Spared Harm Target
4 |
Actual Lives Spared Harm in last 12 months
3 |
Lives Spared Harm Target for following calendar year
4 |
Lives Saved Target
4 |
Actual Lives Saved in last 12 months (might differ from initial target)
3 |
Projected Target of Lives Saved for following calendar to try to finish commitment
4 |
|
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New Lives Lost (lives lost – actual lives saved)
45 |
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Severe Hypoglycemia View Commitment
Commitment
×
Changhua Christian Hospital
Severe Hypoglycemia
Contact Info
Name Samuel Chang
Phone: +886-4-7238595 ext. 8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3C - Severe hypoglycemia Commitment Name:
Severe Hypoglycemia Commitment Details/h6>Commitment Summary:
1. Create insulin order sets that can be modified to reduce risks of hypoglycemia
2. Coordinate glucose monitoring, automate insulin dose calculations, insulin administration, and meal delivery during changes of shift and times of patient transfer
3. Continuously monitor the incidence of SH in the hospital
4. Use the results of this monitoring in staff education as a part of Continuous Quality Improvement (CQI)
5. Raise institutional awareness of issues through a system that compares hospital and nursing units based on performance quality scorecards Action Plan:
We will create SH information system to help us to detect SH, coordinate and monitor insulin administration, then conduct CQI program. Impact Details Lives Saved
Tell us about your baseline level of harm:
2 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
According to SH annually incident reports and prevent harm to 0.
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Central Line-associated Blood Stream Infections (CLABSI) View Commitment
Commitment
×
Changhua Christian Hospital
Central Line-associated Blood Stream Infections (CLABSI)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Central Line-associated Blood Stream Infections (CLABSI) Commitment Details/h6>Commitment Summary:
Our goal is to reduce central line-associated bloodstream infections Action Plan:
1. Implementation of CVC Bundle includes hand hygiene, maximum sterile face protection, 2% CHG skin disinfection, avoidance of femoral vein selection, daily assessment of retention neecessity.
2. CVC daily care assessment project: Perform hand hygiene before care, check the effective date of dressing, check whether there are red, swelling, heat, pain, etc. in the placement site, disinfect the skin before changing the dressing, disinfection of the pipeline, reduce unnecessary CVC use.
3. In view of the importance of medical quality and patient safety, the hospital established a clinical skills training center in 2006. Ultrasound-guided CVC implantation training courses are provided at the center.
4. The name of medical staff who implant CVCs is recorded for surveillance the infection rate attributing to individual personnel.
5. CVC Bundle awareness and compliance from monthly surveillance by unit auditor.
6. Calculate the infection density of CLABSI monthly. The threshold is three times of standard deviations above last year's average or above the average of last year for consecutive three months. If the infection density breaches the threshold, PDCA improvement is required. Impact Details Lives Saved
Lives Spared Total:
2.904499999999998 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
3
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Patient Safety Curriculum View Commitment
Commitment
×
Changhua Christian Hospital
Patient Safety Curriculum
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 17 - Patient Safety Curriculum How Many Hospitals Will This Commitment Represent?
1 Does your hospital, college or health professional program currently have explicit and meaningful patient safety education embedded into the curriculum?
Yes If you selected “Yes”, please indicate how long your organization/program has been working on embedding patient safety into your curriculum?
2-3 years Commitment Name:
Patient Safety Curriculum Curriculum QuestionsDoes your organization/program currently use simulation to teach patient safety?
Yes If you selected “Yes”, please check what types of simulators you are using to access and evaluate clinical skills.
- High-fidelity simulators
- Objective Structured Clinical Examination (OSCE)
What types of resources does your organization/program use to teach patient safety?
- Patient Videos & Stories
- Clinical cases
- Local experience
- Online resources
- Didactic resources
- Reading material
- Reflection
- Other
Other:
Simulation What types of teaching methods does your organization/program use to teach patient safety?
- Reflections
- Small group discussions
- Didactic presentations
- Learning in the clinical environment
- Self-directed learning
- Other
Other:
Learning Please indicate which domains you commit to incorporating into your curriculum.
- Error Science
- System Science
- Human Factors
- Technology
- Teamwork & Communication
- Leadership & Leading Change
- Culture of Safety
- Patient-Oriented Safe Care
Please indicate what type of learner you plan to teach the patient safety curriculum.
- Medical Student
- Resident
- Attending Physician
- Nursing Student
- Nurse
- Pharmacy Student
- Pharmacist
- Other
Other:
administrative and logistic staff For the learners you listed above, please indicate the stage of education you are teaching. Ex: First year resident, nursing student years 1 and 2.
- Year 1
- Year 2
- Year 3
- Year 5
- Year 6
What is the entry skill level of your learners as reflected in our curriculum? [Please indicate all that apply]
- Novice
- Advanced Beginner
- Competent
- Proficient
- Expert
Commitment Details/h6>Commitment Summary:
Re-develop quality and patient safety training programs and training curriculum blueprints based on APSS Patient Safety Courses
According to this plan and training blueprint:
1. Promote the cultivation of patient safety course teachers and implement the design and teaching of various courses.
2. Training of qualified personnel to guide quality improvement and patient safety implementation and management continuity improvement of quality improvement activities.
3. Review patient safety courses in the Specialist Training Program for Resident Physicians, medical professional advance training programs ( career development plans) and make appropriate adjustments if necessary.
4. Continue to implement the hospital-wide staff quality and patient safety training courses for all staff to complete 2 hours per year.
5. Integrates students and trainees into the hospital’s “Medical Quality and Patient Safety” program, and gives a one hour course in their orientation. Action Plan:
Based on the PSMF’s Executive Summary Checklist, We plan to teach the patient safety curriculum to all type of learners. (All staffs and students are included in this training program). Staffs include medical staff, Nursing staff, other health care practitioners and administration staff.
First, we re-develop quality and patient safety training programs and training curriculum blueprints based on APSS Patient Safety Curriculum.
Blue Print (Core Curriculum)
Medical Staff Nursing Staff Other Health Care Practitioners Administration
Senior Executive Foundational Domains Courses: C→E
Linking Domains Courses: C→E
Aspirational Domains Courses: C→E
Supervisor/HQPs* Foundational Domains Courses: C→P
Linking Domains Courses: C→P
Aspirational Domains Courses: C→P
Senior Staff Maintains:
Foundational Domains Courses: C
Linking Domains Courses: C
Aspirational Domains Courses: C
New Staff/
PGY1, PGY2 Foundational Domains Courses: N→C
Linking Domains Courses: N→C
Aspirational Domains Courses: N→C N→AB
Students N N N x
HQPs: Health care Quality Professionals
Foundational Domains Courses: Error Science, System Science, Technology, Human Factors
Linking Domains Courses: Teamwork/ Communication, Leadership/Leading Change
Aspirational Domains Courses: Culture of Safety, Patient Oriented Safe Care
N: novice (N) is able to “recognize” recently gained knowledge
AB: advanced beginner (AB) can “articulate” what has been learned
C: competent (C) individual can do this but also “values” the applicability of the learning reflecting an attitudinal development.
P: proficient (P) individual “models” valued knowledge and behaviors for others.
expert (E) advances from modeling to actively teaching the knowledge, skills, attitudes, and behaviors they exemplify.
Second, Impletement quality and patient safety training programs:
1. Conducting various teacher-training courses under the Patient Safety Education Program.
2. Training of qualified personnel to guide quality improvement and patient safety implementation and management continuity improvement of quality improvement activities.
3. Review patient safety courses in the Specialist Training Program for Resident Physicians, medical professional advance training programs ( career development plans) and make appropriate adjustments if necessary.
4. Continue to implement the hospital-wide staff quality and patient safety training courses for all staff to complete 2 hours per year.
5. Integrates students and trainees into the hospital’s “Medical Quality and Patient Safety” program, and gives a one hour course in their orientation.
Third, Assessing training effectiveness:
Assess the training effectiveness of learners at all levels through using multiple learning assessment tools.
Finally, Study and revise training curriculum.
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Person and Family Engagement View Commitment
Commitment
×
Changhua Christian Hospital
Person and Family Engagement
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Person and Family Engagement Commitment Details/h6>Commitment Summary:
Patient and family engagement is not a new initiative.
It is part of what we are already doing to improve quality and safety! Action Plan:
On one level, patient and family engagement means providing day-to-day care experiences that engage patients and family members as members of the health care team. For example, in our hospital, we provide opportunities for patients and family members to be involved in their care by working together with staff, clinicians, and leaders to improve policies, processes, programs, facility design, and education for hospital staff, clinicians and trainees in the health professions. Impact Details Lives Saved
Methodology for Determining Lives Saved:
According to annually incident reports and prevent harm to 0.
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Nasogastric Tube (NGT) Placement and Verification View Commitment
Commitment
×
Changhua Christian Hospital
Nasogastric Tube (NGT) Placement and Verification
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric tube (NGT) placement and verification How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Nasogastric Tube (NGT) Placement and Verification Commitment Details/h6>Commitment Summary:
(1) Radio-opaque NTG is available, but not reimbursed by national health insurance.
(2) We use pH testing or chest x ray in high-risk patients and use conventional auscultation in low-risk patients. Action Plan:
(1) We will explain the benefit of radio-opaque NTG and promote the use of radio-opaque NTG.
(2) After well introducing and good training of pH testing, the use of pH testing may be extended to low-risk group but need further discussion. Impact Details Lives Saved
Tell us about your baseline level of harm:
9 Lives Saved:
9 Methodology for Determining Lives Saved:
According to NG annually incident reports and prevent harm to 0.
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Falls and Fall Prevention View Commitment
Commitment
×
Changhua Christian Hospital
Falls and Fall Prevention
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Vice Superintendent
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Falls and Fall Prevention Commitment Details/h6>Commitment Summary:
1. Collect fall and injury data to improve the performance of your fall prevention and protection from injury program: Consider tracking and collecting inpatient fall data and outcomes post-discharge to monitor the frequency and cost of morbidity and mortality.
2. Share this data with patients and families. Action Plan:
1. Phone interview to follow up the status of the patient especially with fall-related injury after discharge from hospital, including consultation and referral to related medical services and social resources, such as Post Acute Care (PAC), Longterm care 2.0.
2. While group education, we will provide and share the data and case studies of falls to strengthen the awareness of fall prevention for patient and their care-givers. Impact Details Lives Saved
Lives Spared Total:
0.09659649999999993 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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Venous Thromboembolism (VTE) View Commitment
Commitment
×
Changhua Christian Hospital
Venous Thromboembolism (VTE)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous thromboembolism (VTE) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Venous Thromboembolism (VTE) Commitment Details/h6>Commitment Summary:
We can establish the policies about the education for family, the records of patients with venous thromboembolism in electrical chart, and the learning of VTE-related knowledge. Action Plan:
First, we can review the VTE prophylaxis guidelines, VTE risk assessment tool, and other VTE-related knowledge in the morning meeting. We will find the best policy from the previous studies. Then make the policies which we can do. We will also educate the family the basic knowledge about how to prevent and manage the VTE. Impact Details Lives Saved
Lives Spared Total:
3.4111999999999982 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
4
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Reducing Unnecessary Cesarean Sections (C-Sections) View Commitment
Commitment
×
Changhua Christian Hospital
Reducing Unnecessary Cesarean Sections (C-Sections)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 11C - Reducing unnecessary cesarean sections (c-sections) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Reducing Unnecessary Cesarean Sections (C-Sections) Commitment Details/h6>Commitment Summary:
Reducing unnecessary cesarean section by medical staff education and patient shared decision making to prevent further complication caused by the section. Action Plan:
1. Evidence based clinical practice: Improve and update the knowledge of medical staffs by monthly obstetric meeting to spread the knowledge pearl of the latest medical evidence of delivery method, techniques and induction of labor.
2. Patient education and outpatient department staff education: pros and cons of cesarean section and vaginal delivery. Shared-decision making sheet allow the patients and family to understand that cesarean section is the alternative strategy if vaginal delivery is not applicable.
3. Monthly audit about primary and repeat cesarean rate and the indications of sections. Prevent and education about unnecessary induction of labor and induction of labor at early term. Impact Details Lives Saved
Tell us about your baseline level of harm:
15 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
10 Lives Saved:
5 Lives Spared Harm:
5 Methodology for Determining Lives Saved:
1. WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections ISBN 978-92-4-155033-8
2. Cesarean delivery among women with prolonged labor induction.
J Perinat Med. 2016 Oct 1;44(7):759-766. doi: 10.1515/jpm-2014-0357.
From 2018/01 to 2018/12, we calculated our “Lives saved” from all term pregnancy with primiparous delivered vaginally.
“Lives spared harm” was calculated under the following: term pregnancy with primiparous delivered vaginally under labor induction.
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Severe Hypertension in Pregnancy and Postpartum View Commitment
Commitment
×
Changhua Christian Hospital
Severe Hypertension in Pregnancy and Postpartum
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 11B - Severe hypertension in pregnancy and postpartum How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Severe Hypertension in Pregnancy and Postpartum Commitment Details/h6>Commitment Summary:
Pregnant women with hypertension can be treated safely in our hospital. Methods of prevention and treatment policy are enforced in our obstetric unit to provide high quality medical care. Action Plan:
1. Evidence based clinical practice: Improve and update the knowledge of medical staffs by monthly obstetric meeting to spread the knowledge pearl of the latest medical evidence of hypertension in pregnancy.
2. Routine blood pressure check in every antenatal visit.
3. Patient education and outpatient department staff education: accurate and importance of blood pressure measurement. Education the complication to patients and their family to let them understand the importance of medication compliance (Aspirin, or including labetalol) and lifestyle change. Inform the patients about warning signs, including headache, upper abdominal pain, visual disturbance, etc and when they should visit emergency obstetric unit.
4. Admission assessment and informed consent. Impact Details Lives Saved
Tell us about your baseline level of harm:
15 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
10 Lives Saved:
5 Lives Spared Harm:
5 Methodology for Determining Lives Saved:
1. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia Obstetrics & Gynecology: January 2019 - Volume 133 - Issue 1 - p e1-e25
2. Contribution of hypertension to severe maternal morbidity Am J Obstet Gynecol. 2018 Oct;219(4):405.e1-405.e7. doi: 10.1016/j.ajog.2018.07.002. Epub 2018 Jul 27.
3. Hypertensive Disorders and Severe Obstetric Morbidity in the United States ACOG VOL. 113, NO. 6, JUNE 2009
4. Maternal deaths from hypertensive disorders: lessons learnt Acta Obstetricia et Gynecologica Scandinavica 97 (2018) 976–987
5. Contribution of hypertension to severe maternal morbidity. American journal of obstetrics and gynecology. Hitti, Jane & Sienas, Laura & Walker, Suzan & Benedetti, Thomas & Easterling, Thomas. (2018).. 219. 10.1016/j.ajog.2018.07.002.
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Patient Blood Management View Commitment
Commitment
×
Changhua Christian Hospital
Patient Blood Management
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient blood management How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Patient Blood Management Commitment Details/h6>Commitment Summary:
Ensure accountability
Establish PBM protocols Action Plan:
(1) Establish a Patient Blood Management Committee and appoint an MD to be responsible and accountable for leading this group
(2) Develop a Patient Blood Management education program for any staff involved with blood transfusions
(3) Set a single unit transfusion policy for non-bleeding patients
(4) Minimize transfusion with proper anemia treatment tailored to the cause of the anemia
(5) Use interdisciplinary and conservative blood management practices, including: (a)Minimize the amount blood drawn (b)Minimize discarded dead space blood volumes Impact Details Lives Saved
Methodology for Determining Lives Saved:
Patient Blood Management London Congress 2015
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Postpartum Hemorrhage (PPH) View Commitment
Commitment
×
Changhua Christian Hospital
Postpartum Hemorrhage (PPH)
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 11A - Postpartum hemorrhage (PPH) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Postpartum Hemorrhage (PPH) Commitment Details/h6>Commitment Summary:
We will improve maternal survival rate of women with postpartum hemorrhage by staff education and teamwork training. Action Plan:
1. Evidence based clinical practice: Improve and update the knowledge of medical staffs by monthly obstetric meeting to spread the knowledge pearl of the latest medical evidence of postpartum hemorrhage.
2. Scheduled simulation training: Same as ACLS, we arrange simulation training to allow our medical staffs keep in mind that emergency might occur to any pregnant women and make them be experienced with all the procedures.
3. Training of new staffs, including medical students: for every trainees in obstetrical department, we let them practice actionable steps by groups to let them have the basic knowledge of postpartum hemorrhage.
4. Admission assessment and informed consent: every patient admitted to obstetric ward will receive assessment of risks of postpartum hemorrhage and also education about that postpartum hemorrhage could happen to any pregnancy women and the medical methods we might practice. Impact Details Lives Saved
Tell us about your baseline level of harm:
15 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
10 Lives Spared Harm:
5 Methodology for Determining Lives Saved:
1. https://apps.who.int/iris/bitstream/handle/10665/75411/9789241548502_eng.pdf;jsessionid=9457F82C402555E586241E2CB364B016?sequence=1
2. Machado LS. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3(8):358–361. doi:10.4297/najms.2011.358
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Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest View Commitment
Commitment
×
Changhua Christian Hospital
Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic prevention and resuscitation of in-hospital cardiac arrest How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest Commitment Details/h6>Commitment Summary:
1. Ensure sufficient efficacy of Resuscitation Outcomes Workgroup
2. Regular data collection, analysis and improvement Action Plan:
1. Optimize hospital information system for data collection and analysis
2. Provide efferent data to healthcare providers monthly, to enhance their personal sense of ownership and accountability
3. Establish warming system to early recognize patients who are at risk of cardiac arrest
4. Apply education program to improve staff CPR capability
5. Monitor and improve performance of CPR Impact Details Lives Saved
Predicted Lives Spared Harm:
60.95000000000005 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
61
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Unplanned Extubation View Commitment
Commitment
×
Changhua Christian Hospital
Unplanned Extubation
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned extubation How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Unplanned Extubation Commitment Details/h6>Commitment Summary:
Neonatal, Pediatric, and Anethesiology representation (expertise) is vital
The action plans of UE are partially established. However, educational programs and root cause analysis are incomplete. Action Plan:
1. To complete our airway safety team, including EMS, neonatal, pediatric and anesthesiology departments.
2. To establish a more comprehensive educational program, using patient stories as materials for staff training.
3. To perform root cause analysis for the UEs resulting in clinically significant complication periodically. Impact Details Lives Saved
Lives Spared Total:
0.6216000000000014 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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Antimicrobial Stewardship View Commitment
Commitment
×
Changhua Christian Hospital
Antimicrobial Stewardship
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Antimicrobial Stewardship Commitment Details/h6>Commitment Summary:
The audit and feedback system for infectious disease professionals from Medicine is not efficient and well. In the next calendar year, we plan to create and develop a more efficient process to eliminate antimicrobial stewardship in our hospital. Action Plan:
Create a more efficient prospective audit and feedback system of antibiotics use through CPOE. Impact Details Lives Saved
Methodology for Determining Lives Saved:
ASP program in our hospital has been implemented for over 4 years, antibiotic related error rate is low and all are near-miss without harm
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Early Detection and Treatment of Sepsis for High-income Countries View Commitment
Commitment
×
Changhua Christian Hospital
Early Detection and Treatment of Sepsis for High-income Countries
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 9A - Early detection and treatment of sepsis for high-income countries How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Early Detection and Treatment of Sepsis for High-income Countries Commitment Details/h6>Commitment Summary:
1. Create sepsis workgroup
2. Establish monitoring indicators for sepsis Action Plan:
1. Design a workflow for screening and managing SIRS/sepsis/septic shock
2. Optimize hospital information system for data collection and analysis
3. Regular review and improve the problems
4. Create instant indicator dashboards for primary healthcare providers
5. Use case stories to inspire change in staffs Impact Details Lives Saved
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Medication Errors View Commitment
Commitment
×
Changhua Christian Hospital
Medication Errors
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication errors How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Medication Errors Commitment Details/h6>Commitment Summary:
˙ CPOE Drug dosing solutions: now we have already established system for IV pump and IV infusion rate prescribing, but not all IV medications are included in this system
˙ Pharmacist dispensing: LASA medications dispensing errors
˙ IV pump administration: wrong infusion rate set-up by nurse
˙ Controlled drug administration: Schedule 1~2 controlled drugs are stocked in nurse stations. Wrong preparation and administration were still occurred even with two nurses double check Action Plan:
(1) Develop smart IV Pump system
1. CPOE: Use standard prescription that contain standard concentration solutions, preparation method, infusion time, automatic calculation infusion rate.
2. Intelligent smart IV pump technology: the infusion rare in CPOE can be transmitted to IV pump through Wifi, to ensure the consistence of Rx and pump setting. Nurses only have to recheck the setting in pump, which can reduce the potential pump manual setting errors.
3. Taking chemotherapy drugs as a priority, and then focus on high alert medications.
(2) Use smart cell indicator system in dispensing drawer for pharmacists: this system is developed by our hospital in 2018, and is used in emergency and inpatient pharmacy since 2019. Through this system, pharmacist can scan the barcode from Rx, then the corresponding cell in the drawer can be lighted up to indicate the correct medication for pharmacists. We hope implement this system in more pharmacy dispensing sites such as outpatient pharmacy, pediatric pharmacy, to avoid the dispensing errors.
(3) Use smart controlled drug management system in all nursing stations which stocked with schedule 1-2 controlled medications: this system can replace the traditional key lock and paper work. We can use electronic lock system and data recording system to help nurses preparing controlled medications in stations. System can avoid the potential medication errors. Impact Details Lives Saved
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Monitoring for Opioid-induced Respiratory Depression View Commitment
Commitment
×
Changhua Christian Hospital
Monitoring for Opioid-induced Respiratory Depression
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8455
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for opioid-induced respiratory depression How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Monitoring for Opioid-induced Respiratory Depression Commitment Details/h6>Commitment Summary:
Continuous monitoring for opioid-induced respiratory depression with pulse oximeter regarding in-hospital patients with opioid infusion intravenously has been performed for one year in our hospital. However, patients in ward with oral opioid were monitored only every 8 hours as ward routine. While opioid-induced respiratory depression could still happen to patient with oral opioid. Action Plan:
1. All in-hospital patients with intravenous and subcutaneous opioid infusion, and oral opioid plus intravenous sedative agents, will be monitored continuously with pulse oximeter.
2. The data obtained from bedside pulse oximeter will be transmitted to HIS and shown in TPR sheet in the electronic medical chart every 2 hours. Meanwhile, the data will be transmitted to the central nurse station.
3. When the patient’s SpO2 fall below 90%, the alarm of pulse oximeter will be triggered and the in-charged nurse will be notified via wireless pager.
4. For patients who receive only single dose of opioid, the in-charged nurse will return to the patient 30 minutes after the medication given, to re-evaluate the pain score and SpO2 will be checked with pulse oximeter at the same time.
5. Educate all staff, patients, family members and care-givers on the common contributing factors leading to opioid-induced respiratory depression and side effects of opioids and sedatives.
6. Review the action plan from time to time in the regular meeting of Pain Management Committee, and revise as needed. Impact Details Lives Saved
Methodology for Determining Lives Saved:
The study by Taenzer et al., which published in January 2010, reported that rescue events decreased from 3.4 to 1.2 per 1,000 patient discharges after implementation of the system, which included continuous pulse oximetry monitor and notification sent to in-charged nurse via pager. For our hospital, continuous monitoring with pulse oximeter regarding in-hospital patients with opioid infusion intravenously, but not all surgical patients, has been performed for recent one year. To our knowledge, there is no case of opioid-induced respiratory depression that leads to cardiac or respiratory arrest.
Reference:
1. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010; 112:282-7. Doi: 10.1097/ALN.0b013e3181ca7a9b.
2. Sun Z, Sessler DI, Dalton JE, Devereaux PJ, Shahinyan A, Naylor AJ, Hutcherson MT, Finnegan PS, Tandon V, Darvish-Kazem S, et al. Postoperative hypoxemia is common and persistent: a prospective blinded observational study. Anesth Analg. 2015;121: 709–715. doi:10.1213/ANE.0000000000000836.
3. Khanna KA. Respiratory depression on the wards: why better monitoring may be the answer? Anesthesiol Open J. 2017;2:9–11. doi:10.17140/AOJ-2-109.
4. Gary M. Oderda, Anthony J. Senagore, Kellie Morland, Sheikh Usman Iqbal, Marla Kugel, Sizhu Liu & Ashraf S. Habib (2019): Opioid-related respiratory and gastrointestinal adverse events in patients with acute postoperative pain: prevalence, predictors, and burden, Journal of Pain & Palliative Care Pharmacotherapy, DOI: 10.1080/15360288.2019.1668902
5. Ochroch EA, Russell MW, Hanson WC III, Devine GA, Cucchiara AJ, Weiner MG, Schwartz SJ. The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor. Anesth Analg 2006;102:868–75
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Air Embolism View Commitment
Commitment
×
Changhua Christian Hospital
Air Embolism
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 12B - Air embolism How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Air Embolism Commitment Details/h6>Commitment Summary:
From above checklist, lack of audit and analysis AE to improve outcome and introduce patient and family engagement. Action Plan:
Measure quality indicators related to AE to determine the best way to close your institution’s performance gap
Complete an in-depth chart review for in-hospital AE events to find areas for improvement and address these areas
Utilize patient stories – in written and video form – to identify gaps and inspire change in your staff Impact Details Lives Saved
Tell us about your baseline level of harm:
210 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
190 Lives Spared Harm:
20 Methodology for Determining Lives Saved:
According to AE annually incident reports and prevent harm to 0.
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Post-Operative Delirium in Older Adults View Commitment
Commitment
×
Changhua Christian Hospital
Post-Operative Delirium in Older Adults
Contact Info
Name Samuel Chang
Phone: +886 4 7238595#8449
Email: 60452@cch.org.tw
Position: Healthcare Quality Management Department Deputy Director
Organization Name: Changhua Christian Hospital
Organization Address:
, Changhua County, Changhua City
, 500 Taiwan
Participants:
-
Lin, Ching-hsiung, Vice Superintendent
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 18 - Post-operative delirium in older adults How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Post-Operative Delirium in Older Adults Commitment Details/h6>Commitment Summary:
Post-operative Delirium in Older Adults solution doesn’t systematically implement in our hospital. Action Plan:
Establish a Cognition Care Oversight Committee which oversees pre-hospital and admission screening programs, multidisciplinary care programs and perioperative assessment and care strategies. The committee chair will select an appropriately experienced clinician and committee will report through safety and quality care pathways. Impact Details Lives Saved
Tell us about your baseline level of harm:
190 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
170 Lives Spared Harm:
20 Methodology for Determining Lives Saved:
According to Post-operative Delirium in Older Adults annually incident reports and prevent harm to 0.
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| Chapman University School of Pharmacy |
California |
United States |
Chapman University School of Pharmacy, Patient Safety Curriculum View Commitment
Commitment
×
Chapman University School of Pharmacy
Chapman University School of Pharmacy, Patient Safety Curriculum
Contact Info
Name Ronald
Phone: 714-516-5486
Email: rpjordan@chapman.edu
Position: Dean
Organization Name: Chapman University School of Pharmacy
Organization Address:
9401 Jeronimo Road Irvine Industrial Complex-East , Orange County
Irvine, 92618 United States
Participants:
-
Jerika Lam
-
Enrique Seoane-Vazquez
-
Coco Yang
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 17 - Patient Safety Curriculum Does your hospital, college or health professional program currently have explicit and meaningful patient safety education embedded into the curriculum?
Yes If you selected “Yes”, please indicate how long your organization/program has been working on embedding patient safety into your curriculum?
Less than 1 year Commitment Name:
Chapman University School of Pharmacy, Patient Safety Curriculum Curriculum QuestionsDoes your organization/program currently use simulation to teach patient safety?
Yes If you selected “Yes”, please check what types of simulators you are using to access and evaluate clinical skills.
- Roleplaying utilizing all learners
- Computer-based systems
- Standardized patients (use of trained patient actors)
- High-fidelity simulators
- Objective Structured Clinical Examination (OSCE)
- Integrated simulators
What types of resources does your organization/program use to teach patient safety?
- Patient Videos & Stories
- Clinical cases
- Local experience
- Online resources
- Didactic resources
- Reading material
- Reflection
What types of teaching methods does your organization/program use to teach patient safety?
- Reflections
- Small group discussions
- Didactic presentations
- Learning in the clinical environment
- Self-directed learning
Please indicate which domains you commit to incorporating into your curriculum.
- Human Factors
- Teamwork & Communication
- Culture of Safety
- Patient-Oriented Safe Care
Please indicate what type of learner you plan to teach the patient safety curriculum.
- Resident
- Attending Physician
For the learners you listed above, please indicate the stage of education you are teaching. Ex: First year resident, nursing student years 1 and 2.
- Year 1
- Year 2
- Year 3
- Year 4
- Year 5
What is the entry skill level of your learners as reflected in our curriculum? [Please indicate all that apply]
- Novice
- Advanced Beginner
- Competent
- Proficient
- Expert
Commitment Details/h6>Commitment Summary:
The World Health Organization defines patient safety as the prevention of errors and adverse effects to patients associated with health care. Medication errors are the third leading cause of death in the United States. Pharmacists are the guardians against drug misadventures and medications that could cause patient harm. Medications are also patient’s most frequently encountered form of medical therapy. Pharmacists are the most frequently encountered and accessible care giver in health care as a result. There is a pharmacy and pharmacists within five miles of every American citizen. Pharmacists are in our community and are underutilized resources that can be leveraged to keep patients safe in health care. To decrease morbidity and mortality associated with adverse health care events and medication errors, we have identified pharmacy students as a target group to introduce the full range of concepts in the patient safety curriculum and the PSMF actionable Patient Safety Solutions. Beginning with the first year of their professional education, patient safety concepts, the patients voice, and the concept of preventable harm and death are introduced with the goal of building on this foundation throughout their education and training that will lead to the development of entry-level practitioners with a broad knowledge base and skills that can be used to improve patient safety. Not the least of which a safety-oriented culture and practice orientation. The key stakeholders that will be involved in our commitment to develop and implement patient safety initiatives include CUSP faculty, our schools’ staff, clinicians, and health care systems partners. Our school’s five-year strategic plan calls for specific activity and investment in patient safety research, education and practice. These graduates will be part of the future workforce of health care professionals steeped in patient safety, focused on improving patient outcomes, and elimination of preventable error harm and mortality. They will be high performing team players capable of meeting the demands of the complex environments at their respective practices.
Action Plan:
3. Human Factors: This domain is very important to address since it resonates with the textbook “To Err Is Human” where almost all of the medical and medication errors stem from human factors. In order to deliver safe care to patients, our students need to know and understand how people perform under different circumstances and the different types of human-to-human interactions such as communication, teamwork and organizational culture. Our curriculum will incorporate examples from the aviation, military and manufacturing sectors to reinforce how teamwork and human factors are essential to improve their services and ensure their success. Students will learn how human factors can be used to reduce/prevent adverse events and medication errors, identify how and why systems break down, and understand why mistakes are made.
5. Teamwork & Communication: Teamwork and effective communication are pivotal in any successful organization. In terms of the patient safety curriculum, students will learn about the benefits of interprofessional teams and how they can improve patient care and reduce medical/medication errors. Students will learn that team members are comprised of health care practitioners, the patient and/or patient’s family, and other relevant ancillary members. Furthermore, the students will learn that effective health care teams are successful when they communicate with one another, engage in shared decision-making, and practice professional responsibilities to optimize patient outcomes and care.
7. Culture of Safety: In order to ensure safety when providing medication therapy management and comprehensive health services to patients, we plan to incorporate non-punitive safety culture principles and real-life case scenarios that will emphasize the appropriate, effective reporting mechanisms to help prevent and correct system failures and human errors rather than seeking individual or institutional culpability. As part of the process of educating pharmacy students about a blame-free culture, they will learn how to (1) work collaboratively in interprofessional health care teams, (2) recognize and/or identify unsafe situations and practices, (3) take preventive action to avoid unnecessary risks, and (4) implement the culture of safety at their experiential rotations and in their future workplaces.
8. Patient-Oriented Safe Care: This domain will be implemented in our curriculum by underscoring the importance of appropriate, effective communication through core courses and extracurricular activities. Examples of the activities will include real-life exercises of communication hand-offs, clearly defined roles and responsibilities within an interprofessional health care team, and active engagement with patients to understand their needs and respect their expectations and fears.
--
3. Human Factors
• Implement in Objective Structured Clinical Examinations (OSCEs) and Interprofessional Education (IPEs), Pharmacist Care Skills Labs (PCL)
• Simulations
• Didactic courses
5. Teamwork & Communication
• Continue to reinforce in the Health Care Communication and PCL courses
• Implement this in OSCEs and IPEs
• Explore opportunities to have students practice these skills in IPPE and APPE settings
• Extracurricular and co-curricular activities with other professional students
7. Culture of Safety
• Weave this concept in pre-existing courses via TBL activity, lecture, and case studies
• Emphasize in OSCEs and IPEs
• Emphasize in IPPEs and APPEs
8. Patient-Oriented Safe Care
• Continue to reinforce in the Health Care Communication and PCL courses
• Emphasize in OSCEs and IPEs
• Explore opportunities to have students practice these skills in IPPE and APPE settings
• Extracurricular and co-curricular activities
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| Cheng Ching General Hospital Chung Kang Branch |
Taichung City |
Taiwan |
Decrease the Rate of Ventilator Associated Pneumonia in ICU View Commitment
Commitment
×
Cheng Ching General Hospital Chung Kang Branch
Decrease the Rate of Ventilator Associated Pneumonia in ICU
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Organization Address:
, Xitun District
, 407 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-associated pneumonia (VAP) Commitment Name:
Decrease the Rate of Ventilator Associated Pneumonia in ICU How Many Hospitals Will This Commitment Represent? 1 Action Plan
Measure adherence to VAP prevention practices and consider monitoring compliance:
(1)Hand hygiene.
(2)Daily sedation vacation/interruption and assessment of readiness to wean.
(3)Regular antiseptic oral care.
(4)Semi-recumbent position of all eligible patients.
Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention of VAP Commitment Timeline
Start from 2017
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Decrease the Rate of Ventilator Associated Pneumonia in ICU – Update – 12.14.18 View Update
Commitment Update
×
Cheng Ching General Hospital Chung Kang Branch
Decrease the Rate of Ventilator Associated Pneumonia in ICU – Update – 12.14.18
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Commitment DetailsCommitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Measure adherence to VAP prevention practices and consider monitoring compliance:
(1)Hand hygiene.
(2)Daily sedation vacation/interruption and assessment of readiness to wean.
(3)Regular antiseptic oral care.
(4)Semi-recumbent position of all eligible patients.
Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention of VAP
Commitment Update:
All activities were implemented currently.
We will continue to work hard every day to protect patients from errors, injuries.
Your commitment aligns with APSS
Challenge 2D - Ventilator-associated pneumonia (VAP) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We learn how to avoid and prevent the event of Ventilator Associated Pneumonia by using the APSS plan.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
12 |
Lives Lost:
12 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
0 |
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New Lives Lost (lives lost – actual lives saved)
12 |
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Implementation of a Difficult Airway Team in Our Hospital View Commitment
Commitment
×
Cheng Ching General Hospital Chung Kang Branch
Implementation of a Difficult Airway Team in Our Hospital
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Organization Address:
, Xitun District
, 407 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer airway management Commitment Name:
Implementation of a Difficult Airway Team in Our Hospital How Many Hospitals Will This Commitment Represent? 1 Action Plan
Establishment of the members of the team;
Perform literature review and elaborate protocol;
Perform structural changes;
Investment in training and education;
Review of results and improvements. Commitment Timeline
Start from 2017
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Implementation of a Difficult Airway Team in Our Hospital – Update – 12.14.18 View Update
Commitment Update
×
Cheng Ching General Hospital Chung Kang Branch
Implementation of a Difficult Airway Team in Our Hospital – Update – 12.14.18
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Commitment DetailsCommitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Establishment of the members of the team;
Perform literature review and elaborate protocol;
Perform structural changes;
Investment in training and education;
Review of results and improvements.
Commitment Update:
All activities were implemented currently.
We will continue to work hard every day to protect patients from errors, injuries.
Your commitment aligns with APSS
Challenge 8A - Safer airway management Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We learn how to avoid and prevent the event of Difficult Airway by using the APSS plan.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
0 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Improve Prevention of Severe Hypoglycemia View Commitment
Commitment
×
Cheng Ching General Hospital Chung Kang Branch
Improve Prevention of Severe Hypoglycemia
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Organization Address:
, Xitun District
, 407 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3C - Severe hypoglycemia Commitment Name:
Improve Prevention of Severe Hypoglycemia How Many Hospitals Will This Commitment Represent? 1 Action Plan
Set up the system of warning of hypoglycemia, while the data of blood sugar became lower than normal, and will automatically send a massage to attending doctor and telephone to the duty doctor by the Clinical laboratory technologist Commitment Timeline
Start from 2017
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Improve Prevention of Severe Hypoglycemia – Update – 12.14.18 View Update
Commitment Update
×
Cheng Ching General Hospital Chung Kang Branch
Improve Prevention of Severe Hypoglycemia – Update – 12.14.18
Contact Info
Name Liang-Po Hsieh
Phone: +886-4-24632000 # 32527
Email: lphsieh624@gmail.com
Position: Vice Superintendent
Organization Name: Cheng Ching General Hospital Chung Kang Branch
Commitment DetailsCommitment Start Date: 01/01/2017 How many hospitals are represented in this commitment?
Action Plan:
Set up the system of warning of hypoglycemia, while the data of blood sugar became lower than normal, and will automatically send a massage to attending doctor and telephone to the duty doctor by the Clinical laboratory technologist
Commitment Update:
All activities were implemented currently.
We will continue to work hard every day to protect patients from errors, injuries.
Your commitment aligns with APSS
Challenge 3C - Severe hypoglycemia Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We learn how to avoid and prevent the event of Severe Hypoglycemia by using the APSS plan.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
0 |
Projected Target of Lives Saved for following calendar to try to finish commitment
0 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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| Chi Mei Medical Center, YungKang, Tainan, Taiwan |
Tainan City |
Taiwan |
Creating a Culture of Safety View Commitment
Commitment
×
Chi Mei Medical Center, YungKang, Tainan, Taiwan
Creating a Culture of Safety
Contact Info
Name Che-Kim Tan
Phone: +886-6-2812811 ext 52955
Email: chekim.tan@gmail.com
Position: Deputy Director, Center for Quality Management
Organization Name: Chi Mei Medical Center, YungKang, Tainan, Taiwan
Organization Address:
901號 Zhonghua Road , Yongkang District
, 710 Taiwan
Participants:
-
Hung-Jung Lin, Vice Superintendent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Creating a Culture of Safety How Many Hospitals Will This Commitment Represent? 1 Action Plan
1. Continuously implementation of Team Resource Management
2. Care for the care providers and care for the patients campaign
3. Cultivate a positive attitude towards patient safety
4. Hospital-wide implementation of Shared Decision Making
5. Encourage hospital staff to participate in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan, goal of participation rate 80% of the staff. Commitment Timeline
Dec 2017 Increase of 5-points in the Patient Safety domain in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan.
Dec 2018 Increase of another 5-points in the Patient Safety domain in the annual Patient Safety Culture survey conducted by the Joint Commission of Taiwan.
Impact DetailsLives Lost in Last Calendar Year:1400 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
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Hand-off Communications View Commitment
Commitment
×
Chi Mei Medical Center, YungKang, Tainan, Taiwan
Hand-off Communications
Contact Info
Name Che-Kim Tan
Phone: +886-6-2812811 ext 52955
Email: chekim.tan@gmail.com
Position: Deputy Director
Organization Name: Chi Mei Medical Center, YungKang, Tainan, Taiwan
Organization Address:
901號 Zhonghua Road , Yongkang District
, 710 Taiwan
Participants:
-
Hung-Jung Lin, Vice Superintendent
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off communications Commitment Name:
Hand-off Communications How Many Hospitals Will This Commitment Represent? 1 Action Plan
We have established several computerized hand-off systems for physicians among wards, ER and ICU. We have have different hand-off systems for different healthcare professionals.
We tried to integrated all the different hand-off systems into a "multidisciplinary communication platform" Commitment Timeline
June 2017 - complete the "multidisciplinary communication platform" and fine tuning the platform from the feedback of users.
Dec 2017 - establish a complete hand-off system between OR and ward/ICU, between examination room and ward/ICU/ER
Impact DetailsLives Lost in Last Calendar Year:1400 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
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| Chia-Yi Hospital, Taiwan |
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Taiwan |
Challenge 2 – Healthcare-associated Infections (HAIs) View Commitment
Commitment
×
Chia-Yi Hospital, Taiwan
Challenge 2 – Healthcare-associated Infections (HAIs)
Contact Info
Name Hsi-Yen Pai
Phone: +886 5 2319090 ext1192
Email: andersonhyp@gmail.com
Position: acting superintendent
Organization Name: Chia-Yi Hospital, Taiwan
Organization Address:
312號 Beigang Road , Chiayi City, West District
, 60096 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI) Commitment Name:
Challenge 2 – Healthcare-associated Infections (HAIs) Commitment Start Date 07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Dr. Hsi-Yen Pai, on behalf of Chia-Yi Hospital in Taiwan would like to make a commitment to OX2020 for actionable patient safety solutions program..
Chia-Yi Hospital had focused on hospital-acquired infections, especially in hand hygiene, bundle care for tubing and infection control/prevention. We also took patient blood management program, including proper indication and use of blood products.
We performed teamwork for patient safety and strived to be perfect in 2020.We commit that patient safety is our promise and priority. Commitment Timeline
Commitment Start Date:1, July, 2017
Commitment End Date:31, December, 2019
Impact DetailsLives Lost in Last Calendar Year:290 How many lives do you expect to spare from harm in the next calendar year 90 How many lives do you expect to save in the next calendar year 90 Methodology for Determining Lives Saved:
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| Chiang Mai University Hospital |
เชียงใหม่ |
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Marking the Operative Site View Commitment
Commitment
×
Chiang Mai University Hospital
Marking the Operative Site
Contact Info
Name Suraphong Lorsomradee
Phone: 66861972167
Email: slorsomr@yahoo.com
Position: Associate Professor
Organization Name: Chiang Mai University Hospital
Organization Address:
7-11 ถนน สุเทพ
, 50200
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Marking the Operative Site Commitment Start Date 10/10/2016 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Including the initiative within hospital policy Commitment Timeline
One year
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Annual report of how many case reductions of wrong site operation
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| Chiayi Branch, Taichung Veterans General Hospital |
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Taiwan |
To Reduce Sepsis Mortality View Commitment
Commitment
×
Chiayi Branch, Taichung Veterans General Hospital
To Reduce Sepsis Mortality
Contact Info
Name HUANG,MIN-WEI
Phone: 886-5-235-9630
Email: Hminwei@gmail.com
Position: Vice-Dean
Organization Name: Chiayi Branch, Taichung Veterans General Hospital
Organization Address:
600號 Section 2, Shixian Road , Chiayi City, West District
, 600 Taiwan
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 9A - Early detection and treatment of sepsis for high-income countries Commitment Name:
To Reduce Sepsis Mortality How Many Hospitals Will This Commitment Represent? 1 Action Plan
1.Form multidisciplinary team with members from Clinical Quality, Infectious disease, Medical informatics, Pharmacology, Nursing, Intensive care units, Emergency department with the support from the leadership.
2.Criteria of initiating a rapid response team and subsequent sepsis management team formation would then defined.
3.Technology to connect automated vital signs devices with the hospital Information system to be completed and tested.
4.Monitoring dashboard for sepsis patients would be built providing information for the sepsis management team and subsequent data analysis.
5.Physicians would be educated about the detection of early sepsis, management strategy and use of new tools in information systems.
6.Systems would be constantly reviewed and improved before and after implementation.
7.Data analysis would be performed regularly by combining data from dashboard, EMR and the data warehouse in the hospital.
Commitment Timeline
2018/05/01-2019/04/30
Impact DetailsLives Lost in Last Calendar Year:300 How many lives do you expect to spare from harm in the next calendar year 10 How many lives do you expect to save in the next calendar year 5 Methodology for Determining Lives Saved:
We will take several bundle care to save lives. Examples include the sepsis bundle, Central vein catheter bundle, Foley care bundle, and ventilator weaning bundle.
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| Children’s Hospitals’ Solutions for Patient Safety |
Ohio |
United States |
Eliminating Serious Harm in Children’s Hospitals View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric adverse drug events
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals
Commitment Summary:
The Children’s Hospitals’ Solutions for Patient Safety National Children’s Network represents the most herculean effort to date by the country’s children’s hospitals to create a universally safe and healing environment for all children who are in our care. We are working together to eliminate serious harm across children's hospitals in the United States. Commitment Description & Detail:
With the creation of the SPS National Children’s Network – funded in part by the federal Partnership for Patients initiative and the Cardinal Health Foundation - leaders from 81 children’s hospitals across the United States have stepped forward and committed to clear, shared network goals of harm reduction by December 31, 2014.
40 percent reduction in hospital-acquired conditions (HACs)
20 percent reduction in readmissions
25 percent reduction in serious safety events (SSEs)
A Journey Toward Zero Harm
The 80+ Children’s Hospitals’ Solutions for Patient Safety (SPS) Network hospitals are driven by the
shared goal to urgently reduce and then eliminate serious harm for the children being cared for in our
facilities. To guide this work, SPS network hospitals have come together around the following tenants.
Leadership Matters
Executive leadership is a critical aspect of successful improvement in pediatric patient safety. The
network has designed efforts to inspire and continuously develop the safety leadership skills of the
executives who lead our network hospitals.
Our mission motivates all that we do
We must act with urgency and discipline, focusing on outcomes through a combination of high-reliability concepts and quality improvement science methods. We learn through testing and partnering with families and front-line staff.
Network hospitals must commit to building a “culture of safety". Hospitals within the network are employing the cultural transformation strategies of other high reliability industries to significantly reduce harm in their institutions. This emphasis on creating a culture of safety within pediatric institutions is a unique aspect of SPS’s approach.
Network hospitals will NOT compete on safety
Instead, the SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone.
“All Teach, All Learn”
SPS network hospitals must humbly share and gratefully learn from others. Accomplishing our goals requires focus on the detailed processes and cultural elements that lead to safer hospitals, guidance and support for hospital teams as they build the capacity for change and facilitating relationships within the network to broaden and accelerate learning. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline:
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
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Eliminating Serious Harm in Children’s Hospitals – CAUTI – Update – 12.03.16 View Update
Commitment Update
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CAUTI – Update – 12.03.16
Contact Info
Name Anne Lyren, MD, MSc, Associate Professor of Pediatrics and Bioethics, Strategic Advisor of Quality and Safety
Phone: 216-844-3669
Email: Anne.Lyren@UHhospitals.org
Position: Clinical Director, Children's Hospitals' Solutions for Patient Safety, Associate Professor of Pediatrics & Bioethics, Case Western Reserve University School of Medicine, Strategic Advisor of Quality and Safety, UH Rainbow Babies & Children's Hospital
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Commitment DetailsCommitment Update:
As of August 2016, the Solutions for Patient Safety has decreased hospital-acquired harm in all areas the network has tackled, including a 79% reduction in serious falls, 63% reduction in adverse drug events, 47% reduction in catheter-associated urinary tract infections, and a 31% reduction in surgical site infections. SPS estimates that the network has prevented harm to over 6800 children and saved over $120,000,000 in healthcare costs.At the same time, the network has grown from the original 8 Ohio children's hospitals to over 110 children's hospitals across the United States and Canada, all of whom are teaching and learning together.
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Eliminating Serious Harm in Children’s Hospitals – SSI View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – SSI
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical site infections (SSI) Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – SSI Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – CAUTI View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CAUTI
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI) Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – CAUTI Commitment Start Date 12/03/2016 How Many Hospitals Will This Commitment Represent? 96 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – Obstetrical Adverse Events View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Obstetrical Adverse Events
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Obstetrical Adverse Events Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – Readmissions View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Readmissions
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Readmissions Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – Falls View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Falls
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Falls Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – VAP View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – VAP
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-associated pneumonia (VAP) Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – VAP Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – Pressure Ulcers View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – Pressure Ulcers
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – Pressure Ulcers Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Eliminating Serious Harm in Children’s Hospitals – CLABSI View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Eliminating Serious Harm in Children’s Hospitals – CLABSI
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Clinical Director, SPS and VP Safety, Associate Professor of Pediatrics, Cincinnati Children's Hospital Medical Center
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) Commitment Name:
Eliminating Serious Harm in Children’s Hospitals – CLABSI Commitment Start Date 12/03/2016 Action Plan
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children’s hospitals in the United States.
*Creation of operational definitions for 9 HACs plus Readmissions for pediatrics
*Creation of recommended Prevention Bundles and eventually SPS Prevention Bundles for 9 HACs plus Readmissions for pediatrics Commitment Timeline
Our current goals are through 2014, however, our network is a permanent network and will continue on our journey to zero for many years to come.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Reduce Network Employee/Staff Days Away, Restricted, or Transferred (DART) by 25% View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
Reduce Network Employee/Staff Days Away, Restricted, or Transferred (DART) by 25%
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Strategic Advisor
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
-
Missy Shepherd, Executive Director
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Employee/Staff Safety How Many Hospitals Will This Commitment Represent?
140 Commitment Name:
Reduce Network Employee/Staff Days Away, Restricted, or Transferred (DART) by 25% Commitment Details/h6>Commitment Summary:
The commitment addresses employees/staff seriously hurt in the workplace that requires the worker to take time off from their job or be transferred to another job or doing lighter (restricted) duties as defined with OSHAs definition of the DART. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children's hospitals in the United States and Canada. Impact Details Lives Saved
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By December 31, 2021, 80% of SPS hospitals will achieve performance targets in Pressure Injuries: 0.04 PIs per 1,000 patient days View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
By December 31, 2021, 80% of SPS hospitals will achieve performance targets in Pressure Injuries: 0.04 PIs per 1,000 patient days
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Strategic Advisor
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
-
Missy Shepherd, Executive Director
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Pressure Injuries How Many Hospitals Will This Commitment Represent?
140 Commitment Name:
By December 31, 2021, 80% of SPS hospitals will achieve performance targets in Pressure Injuries: 0.04 PIs per 1,000 patient days Commitment Details/h6>Commitment Summary:
In 2011, approximately 43 children were harmed each month as a result of PI across the Phase I SPS hospitals (n=33). The PI team formed in May of 2012 to develop strategies consistent with high reliability concepts to reduce harm caused by PI, and released the first recommended bundle to the network. In 2013, Phase II hospitals (n=55) joined the network and the number of children harmed per month increased to 65. Today, SPS has 140+ hospitals aimed at reducing harm from pressure injuries. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children's hospitals in the United States and Canada. Impact Details Lives Saved
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By December 31, 2021, 80% of SPS hospitals will achieve the following performance target: Unplanned Extubations: 0.95 UEs per 100 vent days View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
By December 31, 2021, 80% of SPS hospitals will achieve the following performance target: Unplanned Extubations: 0.95 UEs per 100 vent days
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Strategic Advisor
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
-
Missy Shepherd, Executive Director
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Unplanned Extubations How Many Hospitals Will This Commitment Represent?
140 Commitment Name:
By December 31, 2021, 80% of SPS hospitals will achieve the following performance target: Unplanned Extubations: 0.95 UEs per 100 vent days Commitment Details/h6>Commitment Summary:
A pediatric unplanned extubation (UE) is the inadvertent dislodgement of an endotracheal tube in a pediatric patient setting. Historically, many providers have considered unplanned extubations an expected consequence of care delivery in children’s hospitals because of various difficult challenges, including sedation of a child, length of the neonatal/pediatric airway and inability to predict extubation readiness. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children's hospitals in the United States and Canada. Impact Details Lives Saved
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By Dec. 31, 2021, 80% of SPS hospitals will achieve the following performance target: Central Line-Associated Blood Stream Infections (CLABSI): 1.07 infections per 1,000 central line days View Commitment
Commitment
×
Children’s Hospitals’ Solutions for Patient Safety
By Dec. 31, 2021, 80% of SPS hospitals will achieve the following performance target: Central Line-Associated Blood Stream Infections (CLABSI): 1.07 infections per 1,000 central line days
Contact Info
Name Stephen Muething
Phone: (513) 636-2068
Email: stephen.muething@cchmc.org
Position: Strategic Advisor
Organization Name: Children’s Hospitals’ Solutions for Patient Safety
Organization Address:
3333 Burnet Avenue , Hamilton County
Cincinnati, 45229 United States
Participants:
-
Missy Shepherd, Executive Director
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) How Many Hospitals Will This Commitment Represent?
140 Commitment Name:
By Dec. 31, 2021, 80% of SPS hospitals will achieve the following performance target: Central Line-Associated Blood Stream Infections (CLABSI): 1.07 infections per 1,000 central line days Commitment Details/h6>Commitment Summary:
In 2011, approximately 97 children were harmed each month as a result of CLABSI across the Phase I SPS hospitals (n=33). The CLABSI team formed in May of 2012 to develop strategies consistent with high reliability concepts to reduce harm caused by CLABSI, and released the first recommended bundle to the network. In 2013, Phase II hospitals (n=55) joined the network and the number of children harmed per month increased to 159. Today, SPS has 140+ hospitals aimed at reducing harm to hospitalized children as a result of CLABSI. Action Plan:
To achieve these goals, CEOs, hospital boards of trustees and clinical leaders are aligning their organizational goals with the network harm reduction goals in a way that is transforming the safety and quality of care delivered in children's hospitals in the United States & Canada. Impact Details Lives Saved
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| Christiana Care Health System |
Delaware |
United States |
Christiana Care Early Warning Score (CEWS) View Commitment
Commitment
×
Christiana Care Health System
Christiana Care Early Warning Score (CEWS)
Contact Info
Name Eric V. Jackson, Jr., MD, MBA
Phone: 302-733-1534
Email: EJackson@ChristianaCare.org
Position: Director, Health Care Delivery Science; Associate Director, Value Institute
Organization Name: Christiana Care Health System
Organization Address:
4755 Ogletown-Stanton Road , New Castle County
Newark, 19713 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for opioid-induced respiratory depression Commitment Name:
Christiana Care Early Warning Score (CEWS) Commitment Start Date 07/01/2016 How Many Hospitals Will This Commitment Represent? 2 Action Plan
1. Build a consensus on the appropriate metrics for CEWS clinical implementation.
2. Identify targets for each metric.
3. Identify sponsors and champions.
4. Promote implementation goals through education programs.
5. Phased roll-out of CEWS visualization and decision support functionality. Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
CEWS is currently under construction. Our intention is to help Christiana Care Health System’s staff identify high-risk patients before their conditions deteriorates. Total number of individuals that will be impacted is to be determined.
CEWS is a physiologic scoring system for adult patients. This scoring system was developed using EHR data from December 2015 to present in 26 CH and WH units. The algorithm calculates a new numeric CEWS value anytime the physiological measures or Nurse Screening Assessment (NSA) components are entered into the EHR system. The minimum possible CEWS value is 0; this represents the optimal acuity score. The maximum CEWS value is 27; this represents the maximum failure of all vitals measurements and failure of all NSA components. We used an iterative data collection and analysis approach while piloting the algorithm in selected units without visualization.
Descriptive Statistics are as follows:
-From December 1, 2015 to April 30, 2016, the data included 22,007 patients; 28,283 visits; 1,478,020 CEWS observations and 347,601 completed NSA forms.
-1,743 events (RRT, Code Blue, and inpatient mortality) occurred with at least one CEWS measurement within 24 hours prior to the event. There were 1,481 RRTs; 123 Code Blues and 139 in-hospital mortality events.
-Events occur in roughly 5% of visits. There are on average 1.4 events per patient-day in the considered units.
-Between December 1, 2015 and June 30, 2016, nurses completed over 350,000 NSAs.
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| Chung Shan Medical University Hospital |
Taichung City |
Taiwan |
Medication Errors View Commitment
Commitment
×
Chung Shan Medical University Hospital
Medication Errors
Contact Info
Name Yu, Chia Hui
Phone: +886-4-24739595
Email: cshe642@csh.org.tw
Position: Director
Organization Name: Chung Shan Medical University Hospital
Organization Address:
501 Zhongshan Road , West District
, 403 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication errors Commitment Name:
Medication Errors Commitment Start Date 01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
1. To implement the reporting system of Medication Errors and Adverse Drug Reaction continuously
2. To apply the automatic checking mechanism to monitor the physicians’ prescriptions
3. To establish a comparison system between NIH Phamacloud and the medication in CSMUH
4. To improve pediatrics’ medication safety
5. To enhance the control of using antibiotics Commitment Timeline
1. Reporting system provides real-time information of medication errors and adverse drug reaction. After following up and accessing, we can design preventive measures to improve relating operation procedures and fix the faults of the equipment, and avoid the re-occurrence due to negligence.
2. The automatic checking mechanism had been designed in our Health information system to monitor the physicians’ prescriptions, and to explore the medication errors and Adverse Drug Reactions.By implementing the automatic checking mechanism of Health information system in CSMUH, the error rate of physicians’ prescriptions was decreased from 0.046% in 2016 to 0.07% in 2017.
3. In order to improve patients’ medication safety, we will compare the patients’ medication history from NIH Phamacloud with the medication in CSHMUH by using ATC7 code system, to identify if there are duplicate Medications or drug interaction events. The comparison system is expected before the end of 2017.
4. We will improve pediatrics’ medication safety, by reviewing the adverse reaction events in children and providing adequate trainings.
5. The monitor system of antibiotics usage and antibiotic resistance surveillance system are under construction in CSMUH. The systems are expected before the end of year 2017.
Impact DetailsLives Lost in Last Calendar Year:449 How many lives do you expect to spare from harm in the next calendar year 244 How many lives do you expect to save in the next calendar year 10 Methodology for Determining Lives Saved:
The calculation for lives spared from harm is as follows:
700*9.2%= 64
700: The number of cases of annual medical error at Chung Shan Medical University Hospital.
9.2%: The rate of harm caused by medical error from Taiwan Patient Safety Reporting System
Reporting System:
453*39.88%=180
453: The number of cases of the adverse drug reactions reporting during the last calendar year at Chung Shan Medical University Hospital
39.88%: The rate of harm or death caused by adverse drug reactions from Taiwan National Adverse Drug Reactions Reporting System
64+180=244
The calculation for lives saved in the next calendar year is as follows:
453*2.23%=10
453: cases of the adverse drug reactions reporting during the last calendar year at Chung Shan Medical University Hospital
2.23%: the mortality rate from Taiwan National Adverse Drug Reactions Reporting System
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| City International Hospital |
Hồ Chí Minh |
Vietnam |
Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR) View Commitment
Commitment
×
City International Hospital
Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR)
Contact Info
Name Sheilla Mercado
Phone: +841263178106
Email: mercado_sheilla@cih.com.vn
Position: Nurse Manager - Quality Unit
Organization Name: City International Hospital
Organization Address:
3 Đường Số 17A
, 700000 Vietnam
Participants:
-
Dr. Le Quoc Su, CEO-CIH
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Thai Thi Kim Nga, Director of Nursing - CIH
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off communications Commitment Name:
Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR) Commitment Start Date 10/01/2016 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR)
To familiarize the staff with SBAR. It is challenging to ensure standard of care in transition from the department to the other (for example form OT or ICU to inpatient ward or from the current team to the other). As result, patients with more critical condition may expose to both medical and non-medical risks such as medications, laboratory tests, and protocols delayed.
Commitment will focus on the ward hand-off communication (Nurses to Nurses/ shift) and (Night shift Doctors to Day shift Doctors)
We want to maintain the existing prevention of pressure ulcer plan and fall prevention which are effective at the moment. And to ensure 95% medications and key clinical protocols to be done on time. Those will be submitted to Quality Management to include in the Quality Indicators monthly. Commitment Timeline
1 year
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 431 Methodology for Determining Lives Saved:
same as above
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Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR) – Update – 12.22.18 View Update
Commitment Update
×
City International Hospital
Hand-Off Communications: Hospital Unit Shift Change (APSS #6; 2g Appendix C using SBAR) – Update – 12.22.18
Contact Info
Name Sheilla Mercado
Phone: +840763178106
Email: mercado_sheilla@cih.com.vn
Position: Nurse Manager - Quality Management Department
Organization Name: City International Hospital
Commitment DetailsCommitment Start Date: 10/01/2016 How many hospitals are represented in this commitment?
Action Plan:
Hand-Off Communications: Using SBAR 2017-2018 Oct.
To familiarize the staff with SBAR.
It is challenging to ensure standard of care in transition from the department to the other department.
Commitment will focus on the ward hand-off communication between Nurses to Nurses handover per ward transfer.
Commitment Update:
COMMITMENT REPORT:
CIH commits to Patient Safety Movement Foundation in prevention of HAI-VAP in ICU and Hand-Off Communications.
For hand-off communications, we focused more on the “step-up hand-off” using SBAR from A&E to different wards, wards to ICU or NICU to ensure 95% of medications and key clinical protocols are done on time and no vital information’s are forgotten during the transfer of patient.
Take note that the patient files were reviewed randomly on a monthly basis. With a total of 386 patient files reviewed from Oct. 1, 2017 to September 30, 2018 from A&E to different wards, Medical or Surgical Wards to ICU, Paediatrics or Nursery to NICU.
Total of 703 patient files randomly reviewed. The total patient files reviewed for SBAR to different wards were 386.
The total patient files reviewed with SBAR was 381 which 99% compliance rate.
ESTIMATED LIVES SAVED: 386
Your commitment aligns with APSS
Challenge 6 - Hand-off communications Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
The Nurses learned the importance of good communication (SBAR) to prevent mistakes.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-386 |
Lives Spared Harm Target
386 |
Actual Lives Spared Harm in last 12 months
386 |
Lives Spared Harm Target for following calendar year
386 |
Lives Saved Target
386 |
Actual Lives Saved in last 12 months (might differ from initial target)
386 |
Projected Target of Lives Saved for following calendar to try to finish commitment
386 |
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New Lives Lost (lives lost – actual lives saved)
-386 |
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Prevention of Hospital Acquired Infections (Ventilator – Associated Pneumonia) View Commitment
Commitment
×
City International Hospital
Prevention of Hospital Acquired Infections (Ventilator – Associated Pneumonia)
Contact Info
Name Sheilla Mercado
Phone: 841263178106
Email: mercado_sheilla@cih.com.vn
Position: Nurse Manager - Quality Unit
Organization Name: City International Hospital
Organization Address:
3 Đường Số 17A
, 700000 Vietnam
Participants:
-
Dr. Le Quoc Su, CEO-CIH
-
Thai Thi Kim Nga, Director of Nursing - CIH
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2D - Ventilator-associated pneumonia (VAP) Commitment Name:
Prevention of Hospital Acquired Infections (Ventilator – Associated Pneumonia) Commitment Start Date 10/01/2016 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Prevention and Monitoring of HAI related to Ventilator-Associated Pneumonia. Ventilator-associated pneumonia (VAP) is defined as pneumonia in a patient intubated and ventilated at the time of or within 48 hours before the onset of the event. NOTE: There is no minimum period of time that the ventilator must be in place in order for the pneumonia to be considered ventilator-associated. The ventilator-associated pneumonia (VAP) rate is defined as the number of ventilator-associated pneumonias per 1,000 ventilator days Since we have a limited number of patients as of the moment, In this case, for a particular time period, we are interested in the total number of cases of ventilator-associated pneumonia in the ICU. For example, if in February there were 12 cases of VAP, the number of cases would be 12 for that month.
We want to be able to understand that number as a proportion of the total number of days that patients were on ventilators. Thus, if 25 patients were ventilated during the month and, for purposes of example, each was on mechanical ventilation for 3 days, the number of ventilator days would be 25 x 3 = 75 ventilator days for February. The Ventilator-Associated Pneumonia Rate per 1,000 Ventilator Days then would be 12/75 x 1,000 = 160.
Goal
Decrease the VAP rate per 1,000 ventilator days by 50 percent within 12 months.
(Reference from Institute for Healthcare Improvement …)
Maintain the existing prevention of pressure ulcer plan and fall prevention which are effective at the moment. And to ensure 95% medications and key clinical protocols to be done on time. Those will be submitted to Quality Management to include in the Quality Indicators monthly. Commitment Timeline
1 year
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year 7 Methodology for Determining Lives Saved:
same as above
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Prevention of Hospital Acquired Infections (Ventilator – Associated Pneumonia) – Update – 12.22.18 View Update
Commitment Update
×
City International Hospital
Prevention of Hospital Acquired Infections (Ventilator – Associated Pneumonia) – Update – 12.22.18
Contact Info
Name Sheilla Mercado
Phone: +840763178106
Email: mercado_sheilla@cih.com.vn
Position: Nurse Manager - Quality Unit
Organization Name: City International Hospital
Commitment DetailsCommitment Start Date: 10/01/2016 How many hospitals are represented in this commitment?
Action Plan:
Maintain the existing prevention of pressure ulcer plan and fall prevention which are effective at the moment. And to ensure 95% medications and key clinical protocols to be done on time. Those will be submitted to Quality Management to include in the Quality Indicators monthly.
Commitment Update:
HAI-VAP in ICU:
Update our commitment from October 1, 2017 to end of September 2018. The total number of patient in ICU with ventilator is 23
From the total of 23 patients on ventilator, out 9 were discharged home due to severe conditions.
ESTIMATED LIVES SAVED: 14
Your commitment aligns with APSS
Challenge 2D - Ventilator-associated pneumonia (VAP) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We have zero rates of HAI-VAP in ICU.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
9 |
Lives Lost:
0 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
14 |
Lives Spared Harm Target for following calendar year
0 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
14 |
Projected Target of Lives Saved for following calendar to try to finish commitment
20 |
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New Lives Lost (lives lost – actual lives saved)
-14 |
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| Cleveland Clinic |
Ohio |
United States |
A Value-Based Approach to Induction of Labor View Commitment
Commitment
×
Cleveland Clinic
A Value-Based Approach to Induction of Labor
Contact Info
Name Sharon Sutherland
Phone: (216) 445-2460
Email: suthers1@ccf.org
Position: Population Health and Quality Improvement Officer, OB/GYN and Women's Health
Organization Name: Cleveland Clinic
Organization Address:
9500 Euclid Avenue
Cleveland, 44195 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Commitment Name:
A Value-Based Approach to Induction of Labor How Many Hospitals Will This Commitment Represent? 6 Action Plan
The health system developed a paper scheduling form and a matching tool in the electronic medical record to communicate key clinical information between the obstetric provider's office and the maternity unit when scheduling induction of labor. All obstetric providers in Wave 1 hospitals are encouraged to utilize the scheduling tool to support proper utilization of induction of labor.
Milestone 1: Participating hospitals will review all requests for induction of labor to assure appropriateness prior to scheduling. Hospital leadership will contact the obstetric provider to discuss any cases in which induction of labor is indicated at an earlier date than requested or when postponement is recommended.
Milestone 2: Hospitals will report clinical compliance by obstetric provider semi-annually and this will be shared with providers, their employers, and hospital leadership.
Milestone 3: Information will be collected about maternal and newborn outcomes as well as ongoing review of clinical evidence that will inform periodic revision of the Care Path guide.
Milestone 4: Based on the experience of the six participating hospitals, an Induction of Labor Toolkit will be developed to share with other organizations. Commitment Timeline
Quarter 1, 2016:
Wave 1 Hospitals:
Review current state of induction of labor and maternal and newborn outcomes and share with participating hospitals and providers on a quarterly basis.
Support development of Clinical Compliance report for performance management by employers and hospitals to be reported on a periodic basis.
Wave 2 Hospital:
Engage leadership to review Care Path Guide for Induction of Labor, existing paper and electronic tools, and to develop a clinical workgroup to map a process for use in their hospital.
Identify a Physician Champion to work with project management team.
Query existing data for this hospital to determine baseline utilization rates for induction of labor and related maternal and neonatal outcomes.
Quarter 2, 2016: Wave 2 Hospital
Support workgroup in mapping process for rollout of the resources relating to Induction of Labor and to create a local process for review of Induction of Labor requests.
Support education of providers, childbirth educators, nurses and hospital leadership about this project and perceived impact on outcomes for mothers and newborns.
Quarter 3, 2016: Wave 2 Hospital
Support workgroup in rollout of project and initiation of local process for review of Induction of Labor requests.
Review impact of review process on number of requests for induction of labor, and outcomes of for mothers and newborns.
Quarter 4, 2016: Wave 2 Hospital
Support Physician Champion in initial report on results from review process and to elicit feedback from providers and nurses.
Develop Year 1 report for Wave 1 and Wave 2 hospitals.
Develop materials for Induction of Labor Toolkit.
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
Maternal mortality is a rare event however has been on the rise nationally in the last two decades due to chronic health conditions and obstetric complications. Based on current U.S. statistics, there is one maternal death for every 7,700 cesarean births. The national rate of cesarean birth is about 33%, with 1.4 million cesarean births annually. It is likely that there are about 177 cesarean-related maternal deaths annually. Based on 2013 health system date, the baseline rate of cesarean birth (31.6%) and the projected volume of births in 2016, there would be 4200 cesarean births expected in the health system in 2016 without reduction of induction of labor. Based on the projected impact of the project, approximately 547 cesarean births will be averted in 2016. If Induction of Labor optimization is undertaken across the U.S., a modest 13% reduction in rate of cesarean birth (from 33% to 28.7%) could potentially prevent 20 maternal deaths annually.
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| Clinica CER |
Querétaro |
Mexico |
Reduce Infection and Venous Thrombosis View Commitment
Commitment
×
Clinica CER
Reduce Infection and Venous Thrombosis
Contact Info
Name Carlos Martin Guerrero Patino
Phone: 442250845
Email: cg621102@gmail.com
Position: Director
Organization Name: Clinica CER
Organization Address:
Avenida Constituyentes No. 15 , Centro
Santiago de Querétaro, 76000 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
Reduce Infection and Venous Thrombosis Commitment Start Date 02/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Action Plan 1
Schedule briefings with operational staff during shift links.
Post posters and leaflets to make the project known.
Ask the area heads to extend the project information.
Schedule educational sessions in order to indoctrinate the operative staff.
Carry out hand hygiene assessments using a checklist to check the impact of educational sessions.
Take direct observation of the 5 moments of hand hygiene and quantify them in the hospital areas.
In case it is necessary to restructure the educational sessions based on the results of the evaluations and study of direct observation.
Employ John Kotter's Change Management Model (1. Create sense of urgency 2. Form a coalition 3. Create vision for change 4. Communicate vision 5. Remove obstacles 6. Ensure short-term achievements 7. Build On change 8. Anchor change to hospital culture).
Sensitize operational staff through a permanent hand hygiene campaign.
Generate indicators of structure, process and result that help us measure the impact and at the same time allow us to generate new improvement strategies.
Action Plan 2
To identify patients at high risk of developing venous thrombosis in the emergency and hospitalization area.
Use of early heparinization
Prophylactic dietary hygienic measures. Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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Venous Thrombosis View Commitment
Commitment
×
Clinica CER
Venous Thrombosis
Contact Info
Name Carlos Martin Guerrero Patino
Phone: 442250845
Email: cg621102@gmail.com
Position: Director
Organization Name: Clinica CER
Organization Address:
Avenida Constituyentes No. 15 , Centro
Santiago de Querétaro, 76000 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 12 - Embolic events Commitment Name:
Venous Thrombosis Commitment Start Date 02/01/2017 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Action Plan 2
To identify patients at high risk of developing venous thrombosis in the emergency and hospitalization area.
Use of early heparinization
Prophylactic dietary hygienic measures. Commitment Timeline
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| Cloudnine Hospital |
Karnataka |
India |
Patient safety through technology View Commitment
Commitment
×
Cloudnine Hospital
Patient safety through technology
Contact Info
Name Dr Kishore Kumar
Phone: (806) 673-2259
Email: drkishore@cloudninecare.com
Position: Chairman, Senior Consultant Neonatologist and Pediatrician
Organization Name: Cloudnine Hospital
Organization Address:
115 HAL Old Airport Road
Bengaluru, 560075 India
Participants:
-
Dr P C Nayana Prabha, Pediatrician & Neonatologist
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Dr Nandini Nagar, Pediatrician
-
Dr lakshmy Menon, Consultant Pediatrician & Neonatologist
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Technology Commitment Name:
Patient safety through technology How Many Hospitals Will This Commitment Represent? 16 Action Plan
1) Use of Masimo pulse oximetry throughout all Cloudnine hospitals
2) Mandatory screening of all babies born in Cloudnine Hospital using Masimo
3) Use of Masimo SET in ER to reduce ICU outcome rates
4) Using Masimo in ICU to improve patient safety with regards to false alarm and missed true alarm Commitment Timeline
It will continue till Masimo Technology is in the hospital
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
258
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| Coscami S.A. de C.V. |
Querétaro |
Mexico |
Optimización de la seguridad obstetrica View Commitment
Commitment
×
Coscami S.A. de C.V.
Optimización de la seguridad obstetrica
Contact Info
Name Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
176 Avenida Río Moctezuma , San Cayetano
San Juan del Río, 76807 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 11A - Postpartum hemorrhage (PPH) Commitment Name:
Optimización de la seguridad obstetrica How Many Hospitals Will This Commitment Represent? 1 Action Plan
Difusión entre los integrantes del Centro Médico Coscami las aplicaciones de la optimización de la seguridad obstétrica. Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact DetailsLives Lost in Last Calendar Year:3 How many lives do you expect to spare from harm in the next calendar year 80 How many lives do you expect to save in the next calendar year 12 Methodology for Determining Lives Saved:
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Compromiso de la persona y familia View Commitment
Commitment
×
Coscami S.A. de C.V.
Compromiso de la persona y familia
Contact Info
Name Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
176 Avenida Río Moctezuma , San Cayetano
San Juan del Río, 76807 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement Commitment Name:
Compromiso de la persona y familia How Many Hospitals Will This Commitment Represent? 1 Action Plan
Agendar sesiones informativas con los miembros de Espartanos Grupo Médico.
Publicar carteles y tripticos que den a conocer el proyecto.
Calendarizar sesiones educativas con el fin de capacitar al personal de salud.
Emplear el modelo de gestión de John Kotter (1. Crear sentido de urgencia. 2 Formar una coalición. 3 Crear visión para el cambio. 4 Comunicar la visión. 5 Eliminar los obstáculos. 6 Asegurarse de logros a corto plazo. 7 Construir sobre el cambio. 8 Anclar el cambio a la cultura del hospital).
Generar indicadores de estructura , proceso y resultado que nos ayuden a medir el impacto y a la vez nos permitan generar nuevas estrategias de mejora.
Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact DetailsLives Lost in Last Calendar Year:3 How many lives do you expect to spare from harm in the next calendar year 80 How many lives do you expect to save in the next calendar year 80 Methodology for Determining Lives Saved:
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Prevención de caídas View Commitment
Commitment
×
Coscami S.A. de C.V.
Prevención de caídas
Contact Info
Name Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
176 Avenida Río Moctezuma , San Cayetano
San Juan del Río, 76807 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults Commitment Name:
Prevención de caídas How Many Hospitals Will This Commitment Represent? 1 Action Plan
Agendar sesiones informativas con los miembros de Espartanos Grupo Médico.
Publicar carteles y tripticos que den a conocer el proyecto.
Calendarizar sesiones educativas con el fin de capacitar al personal de salud.
Emplear el modelo de gestión de John Kotter (1. Crear sentido de urgencia. 2 Formar una coalición. 3 Crear visión para el cambio. 4 Comunicar la visión. 5 Eliminar los obstáculos. 6 Asegurarse de logros a corto plazo. 7 Construir sobre el cambio. 8 Anclar el cambio a la cultura del hospital).
Generar indicadores de estructura , proceso y resultado que nos ayuden a medir el impacto y a la vez nos permitan generar nuevas estrategias de mejora.
Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact DetailsLives Lost in Last Calendar Year:3 How many lives do you expect to spare from harm in the next calendar year 80 How many lives do you expect to save in the next calendar year 80 Methodology for Determining Lives Saved:
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Creación de cultura de seguridad View Commitment
Commitment
×
Coscami S.A. de C.V.
Creación de cultura de seguridad
Contact Info
Name Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
176 Avenida Río Moctezuma , San Cayetano
San Juan del Río, 76807 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Creación de cultura de seguridad How Many Hospitals Will This Commitment Represent? 1 Action Plan
Difundir entre todos los integrantes de Centro Médico Coscami las aplicaciones de crear una cultura deseguridad, Infecciones asociadas a la atención sanitaria, optimización de la seguridad obstétrica, prevención de caídas y compromiso de la persona y familia.
Agendar sesiones informativas con los miembros de Centro Médico Coscami.
Publicar carteles y tripticos que den a conocer el proyecto.
Calendarizar sesiones educativas con el fin de capacitar a todo el personal de salud.
En caso de se necesario, reestructurar las sesiones educativas, basadas en los resultados de las evaluaciones y estudio de las 6 Metas Internacionales de Seguridad del Paciente.
Emplear modelo de gestión del cambio de Jhon Kotter (1. Crear sentido de urgencia. 2 Formar una coalición. 3 Crear visión para el cambio. 4 Comunicar la visión. 5 Eliminar los obstáculos. 6 Asegurarse de logros a corto plazo. 7 Construir sobre el cambio. 8 Anclar el cambio a la cultura del hospital).
Generar indicadores de estructura , proceso y resultado que nos ayuden a medir el impacto y a la vez nos permitan generar nuevas estrategias de mejora.
Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact DetailsLives Lost in Last Calendar Year:3 How many lives do you expect to spare from harm in the next calendar year 12 How many lives do you expect to save in the next calendar year 80 Methodology for Determining Lives Saved:
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Infecciones Asociadas a la atención Sanitaria View Commitment
Commitment
×
Coscami S.A. de C.V.
Infecciones Asociadas a la atención Sanitaria
Contact Info
Name Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
176 Avenida Río Moctezuma , San Cayetano
San Juan del Río, 76807 Mexico
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene Commitment Name:
Infecciones Asociadas a la atención Sanitaria How Many Hospitals Will This Commitment Represent? 1 Action Plan
Difusión entre todos los integrantes de Centro Médico Coscami las aplicaciones para las infecciones asociadas a la atención sanitaria. Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact DetailsLives Lost in Last Calendar Year:3 How many lives do you expect to spare from harm in the next calendar year 12 How many lives do you expect to save in the next calendar year 80 Methodology for Determining Lives Saved:
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| Da-Li Jen Ai Hospital |
Taichung City |
Taiwan |
Patient Safety Culture in order to Raise Healthcare Quality View Commitment
Commitment
×
Da-Li Jen Ai Hospital
Patient Safety Culture in order to Raise Healthcare Quality
Contact Info
Name linlin lee
Phone: +886-4-24819900 ext 12402
Email: jah0061@mail.jah.org.tw
Position: deputy director of Nursing Department
Organization Name: Da-Li Jen Ai Hospital
Organization Address:
483號 Dongrong Road , Dali District
, 412 Taiwan
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety Commitment Name:
Patient Safety Culture in order to Raise Healthcare Quality How Many Hospitals Will This Commitment Represent? 2 Action Plan
1. Activating the functions of “Patient Safety Committee”: The superintendent will lead and invite attending physicians of all disciplines to join the committee to implement healthcare quality and patient safety plans.
2. Forming a “multidisciplinary healthcare team”: Physicians of all disciplines, nurses, patients and their relatives are invited to join the team to promote shared decision making while actively supplying information concerning patient safety.
3. Calls to “mobilize all hospital employees on patient safety issues”: Each employee is required to attend patient safety on job training and related activities on annual basis in order to integrate the knowledge, skills and attitudes into daily routine.
4. Promoting “Safety Risk Management”: Headed by the superintendent and vice superintendents to oversee hospital-wide safety and quality. An in-depth standard operation procedures inspection on clinical units and gathering information regarding patient safety from inpatients or their relatives.
5. “Patient Safety Incident Management”: Providing incentives for staff members to report incidents while analyzing their root causes and presenting with feasible solutions. In the meantime, offering psychological assistance and emtional support to staff members who are involved in medical malpractice thereby cultivating positive patient safety culture. Commitment Timeline
Launch all five strategies from 01/01/2017
2017/07/01 reinforce on "multidisciplinary healthcare team"
2017/10/01 establish "Patient Safety Week" and related activities
Review and evaluate the results in the end of 2017.
Impact DetailsLives Lost in Last Calendar Year:22 How many lives do you expect to spare from harm in the next calendar year 4 How many lives do you expect to save in the next calendar year 4 Methodology for Determining Lives Saved:
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Patient Safety Culture in order to Raise Healthcare Quality – Update – 08.27.18 View Update
Commitment Update
×
Da-Li Jen Ai Hospital
Patient Safety Culture in order to Raise Healthcare Quality – Update – 08.27.18
Contact Info
Name Linlin Lee
Phone: +886-4-24819900 ext 12402
Email: jah0061@mail.jah.org.tw
Position: Deputy Director of Nursing Department
Organization Name: Da-Li Jen Ai Hospital
Commitment DetailsCommitment Start Date: 08/01/2017 How many hospitals are represented in this commitment?
Action Plan:
1. Activating the functions of “Patient Safety Committee”: The superintendent will lead and invite attending physicians of all disciplines to join the committee to implement healthcare quality and patient safety plans.
2. Forming a “multidisciplinary healthcare team”: Physicians of all disciplines, nurses, patients and their relatives are invited to join the team to promote shared decision making while actively supplying information concerning patient safety.
3. Calls to “mobilize all hospital employees on patient safety issues”: Each employee is required to attend patient safety on job training and related activities on annual basis in order to integrate the knowledge, skills and attitudes into daily routine.
4. Promoting “Safety Risk Management”: Headed by the superintendent and vice superintendents to oversee hospital-wide safety and quality. An in-depth standard operation procedures inspection on clinical units and gathering information regarding patient safety from inpatients or their relatives.
5. “Patient Safety Incident Management”: Providing incentives for staff members to report incidents while analyzing their root causes and presenting with feasible solutions. In the meantime, offering psychological assistance and emotional support to staff members who are involved in medical malpractice thereby cultivating positive patient safety culture.
Commitment Update:
Jen Ai Hospital held series activities of "Communication between Patients and Hospital" , known as "Patient Safety Week", from 2017/10/15 to 2017/10/21. The details are below:
Series 1: "Communication between Patients and Hospital" wall: Several posters were displayed on the wall of lobby, counters, and elevators.
Series 2: Multimedia propaganda: Patient Safety slogan and knowledge were shown on the LED screen on the top of front door, the TV wall on the lobby, and the manuscript in outpatient department.
Series 3: Public speech: Two Speeches were held in the lobby: "Communication between Patients and Hospital" and "Prevention from Tumbling"
Series 4: "Answering": This activity encouraged patient to actually join and clearly know the whole process of medication, letting them to speak for themselves
Series 5: Essay writing. Patient Safety related essay form the public were encouraged, collected, and shared.
Series 6: Patient Safety Survey: A online survey for the employee were used to evaluate the attitude to Patient Safety, in order to promote the Culture of Safety.
Your commitment aligns with APSS
Challenge 1 - Culture of safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
The Patient Safety week was a success. Both our employee and the public joined the activities and enjoyed it. The communication between patient and hospital is promoted. Patient gain the autonomous making medical decision, providing a good partnership between patient and hospital.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
22 |
Lives Lost
17 |
Lives Lost:
9 |
Lives Spared Harm Target
4 |
Actual Lives Spared Harm in last 12 months
8 |
Lives Spared Harm Target for following calendar year
8 |
Lives Saved Target
4 |
Actual Lives Saved in last 12 months (might differ from initial target)
8 |
Projected Target of Lives Saved for following calendar to try to finish commitment
8 |
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New Lives Lost (lives lost – actual lives saved)
9 |
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| Dartmouth-Hitchcock |
New Hampshire |
United States |
Ideal Rescue System Design and Development View Commitment
Commitment
×
Dartmouth-Hitchcock
Ideal Rescue System Design and Development
Contact Info
Name Susan McGrath
Phone: 603-715-4204
Email: susan.p.mcgrath@hitchcock.org
Position: Director of R&D Patient Safety Learning Laboratory
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
George Blike, Chief Quality and Value Officer
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for opioid-induced respiratory depression Commitment Name:
Ideal Rescue System Design and Development Commitment Start Date 01/01/2018 How Many Hospitals Will This Commitment Represent? 1 Action Plan
Failure to Rescue is a significant driver of inpatient mortality. Dartmouth-Hitchcock is committed to reducing overall hospital mortality by identifying, designing and implementing systems to support early detection of patient deterioration and intervention. Over the next 3 years the organization will systematically identify and evaluate gaps in our rescue system and design, prototype and deploy interventions, including: patient state assessment tools to assist in appropriate patient placement and clinical resource allocation;
patient state assessment tools to improve early recognition of deterioration at the bedside
; and communication systems to improve shared mental models across clinical teams to promote prompt intervention and rescue activation when patient deterioration is detected. Commitment Timeline
Year 1: design and prototype general care patient state assessment tools and communication system; identify and design approaches to improve shared mental models and handovers; identify patient placement and resource allocation system opportunities
.
Year 2: deploy general care setting patient state assessment and communication system; design multi-care level patient state assessment and communication system; implement shared mental model and handover improvements; design and prototype patient placement and resource allocation tools.
Year 3: Complete individual tool/training development and assessment; perform system-wide integration and validation across care settings.
Impact DetailsLives Lost in Last Calendar Year:60 How many lives do you expect to spare from harm in the next calendar year 20 How many lives do you expect to save in the next calendar year 15 Methodology for Determining Lives Saved:
PSI 4 metrics were used, with a goal of reducing these deaths by 25% per year over 2 years after implementation of improvements begins.
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Hand Hygiene View Commitment
Commitment
×
Dartmouth-Hitchcock
Hand Hygiene
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Hand Hygiene Commitment Details/h6>Commitment Summary:
There is opportunity to improve reliability with hand cleaning Action Plan:
Focus on personal accountability by providing person-specific hand cleaning data
Focus on psychological safety to improve the culture of "reminding"
Add HH software to remaining inpatient units Impact Details Lives Saved
Tell us about your baseline level of harm:
43 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
32 Lives Spared Harm:
11 Methodology for Determining Lives Saved:
Lacking an evidenced-based method to determine lives saved, we used our current CDI infections, which are in part, environmentally transmitted (43). Our target improvement is 25% (32).
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Culture of Safety View Commitment
Commitment
×
Dartmouth-Hitchcock
Culture of Safety
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Culture of Safety Commitment Details/h6>Commitment Summary:
There is an opportunity to reduce serious safety events by continuing efforts to improve reliability in the systems and processes used to deliver and support patient care. Action Plan:
Explore the opportunity to hold additional executives accountable for performance through bonus-based compensation programs.
Fully transition the Leadership Methods course into mandatory "Leading at Dartmouth" course required for all manager levels.
Continue "Error Prevention Training" for all new employees and follow-up with existing employees who haven't taken the course
Add the "Root Cause" and "Peer Review" modules to 'OWLS"
Expand focus on just culture Impact Details Lives Saved
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CDI View Commitment
Commitment
×
Dartmouth-Hitchcock
CDI
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridioides difficile infection (CDI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
CDI Commitment Details/h6>Commitment Summary:
There is an opportunity to further reduce CDI Action Plan:
Focus on environmental enhanced cleaning by optimizing use of Bioquell and piloting use of UV lights
Improve HH by all employees
Continue efforts that support antimicrobial stewardship Impact Details Lives Saved
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SSI View Commitment
Commitment
×
Dartmouth-Hitchcock
SSI
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical site infections (SSI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
SSI Commitment Details/h6>Commitment Summary:
There is an opportunity to reduce surgical site infections, specifically colorectal and hysterectomy Action Plan:
Improve reliability of use of the colorectal surgical prevention bundle
Adopt similar prevention bundle for hysterectomy
Implement CHG pre-op bathing for patients who did not complete pre-op bathing at home
Improve documentation of PATOS and assure coverage with correct antibiotic post-operatively Impact Details Lives Saved
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Pediatric ADEs View Commitment
Commitment
×
Dartmouth-Hitchcock
Pediatric ADEs
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric adverse drug events How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Pediatric ADEs Commitment Details/h6>Commitment Summary:
Continue improvement of medication safety to reduce pADEs Action Plan:
Redesign and build the drug library for pediatric large volume infusions with the updated patient safety features for intermittent infusions that are available with the new Spectrum IQ Infusion Pump Impact Details Lives Saved
Tell us about your baseline level of harm:
2 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
1 Lives Spared Harm:
1 Methodology for Determining Lives Saved:
As proxy will follow our pediatric category F and higher medication errors (2) with a 50% target reduction.
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Antimicrobial Stewardship View Commitment
Commitment
×
Dartmouth-Hitchcock
Antimicrobial Stewardship
Contact Info
Name Lori Key
Phone: 650-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Antimicrobial Stewardship Commitment Details/h6>Commitment Summary:
Further improve anti-microbial stewardship Action Plan:
Institute updated antimicrobial stewardship education to all clinicians.
Strengthen patient education materials
Improve prescriber-level antibiotic usage reports Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
As proxy will follow our SSER and SSE count (11); we have targeted reduction of less than 10 (~10%).
Analyze and follow up on outlier prescribers of antibiotics
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CAUTI View Commitment
Commitment
×
Dartmouth-Hitchcock
CAUTI
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
CAUTI Commitment Details/h6>Commitment Summary:
There is opportunity to further reduce catheter-associated urinary tract infections Action Plan:
Improve reliability of the care associated with urinary catheters: insertion and maintenance bundles, restricting utilization based on evidenced-based standards, limiting urine culturing to evidence-based standards. Impact Details Lives Saved
Lives Spared Total:
0.3909999999999999 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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CLABSI View Commitment
Commitment
×
Dartmouth-Hitchcock
CLABSI
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
CLABSI Commitment Details/h6>Commitment Summary:
Opportunity exists to further reduce central line infections. Action Plan:
Continued efforts by focusing on bundle reliability when performing insertion and maintenance of lines; special focus on blood culture technique and reducing line access. Also implementing a provider mandatory insertion competency. Impact Details Lives Saved
Lives Spared Total:
0.97125 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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Safety Education View Commitment
Commitment
×
Dartmouth-Hitchcock
Safety Education
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 17 - Patient Safety Curriculum How Many Hospitals Will This Commitment Represent?
1 Does your hospital, college or health professional program currently have explicit and meaningful patient safety education embedded into the curriculum?
Yes If you selected “Yes”, please indicate how long your organization/program has been working on embedding patient safety into your curriculum?
2-3 years Commitment Name:
Safety Education Curriculum QuestionsDoes your organization/program currently use simulation to teach patient safety?
Yes If you selected “Yes”, please check what types of simulators you are using to access and evaluate clinical skills.
- Roleplaying utilizing all learners
- Computer-based systems
- Standardized patients (use of trained patient actors)
- High-fidelity simulators
What types of resources does your organization/program use to teach patient safety?
- Patient Videos & Stories
- Clinical cases
- Local experience
- Didactic resources
- Reading material
- Reflection
What types of teaching methods does your organization/program use to teach patient safety?
- Reflections
- Small group discussions
- Didactic presentations
- Learning in the clinical environment
- Self-directed learning
Please indicate which domains you commit to incorporating into your curriculum.
- Error Science
- System Science
- Human Factors
- Technology
- Teamwork & Communication
- Leadership & Leading Change
- Culture of Safety
- Patient-Oriented Safe Care
Please indicate what type of learner you plan to teach the patient safety curriculum.
- Medical Student
- Resident
- Attending Physician
- Nursing Student
- Nurse
- Pharmacy Student
- Pharmacist
For the learners you listed above, please indicate the stage of education you are teaching. Ex: First year resident, nursing student years 1 and 2.
- Year 1
- Year 2
- Year 3
- Year 4
- Year 5
- Year 6
What is the entry skill level of your learners as reflected in our curriculum? [Please indicate all that apply]
- Novice
- Advanced Beginner
- Competent
Commitment Details/h6>Commitment Summary:
We have an entry level "Error Prevention Training" but have committed to annual safety training for all staff and need to expand our curriculum. Action Plan:
Review the Patient Safety Movement curriculum and identify if/how this will help with ongoing safety training.
Continue to pursue other web-based educational resources
Finalize proposal for annual safety training and present back to MEC who has already endorsed this concept
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Person and Family Engagement View Commitment
Commitment
×
Dartmouth-Hitchcock
Person and Family Engagement
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and family engagement How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Person and Family Engagement Commitment Details/h6>Commitment Summary:
There is an opportunity to continue to build engagement with patients and families Action Plan:
Focus will be on several patient initiatives including "back to basics," timely discharge, improving physician and nurse communication. Additional focus on staff engagement based on areas of opportunity identified in the most recent employee engagement survey. Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
As proxy will follow our SSER and SSE count (11); we have targeted reduction of less than 10 (~10%).
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Medication Standards View Commitment
Commitment
×
Dartmouth-Hitchcock
Medication Standards
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3E - Standardize and safeguard medicine administration How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Medication Standards Commitment Details/h6>Commitment Summary:
There is an opportunity to improve medication management in remote service locations and in down-time situations Action Plan:
Implement fully integrated smart pumps with the EHR
Investigate opportunity to utilize other mobile medication IS applications to reach more remote locations Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Saved:
1 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
As a proxy, will use SSER and SSE (11) with reduction goal of under 9 (~10%)
Will also use preventable medication errors, F and higher. Currently 2/2276944 dispenses.
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Glycemic Control View Commitment
Commitment
×
Dartmouth-Hitchcock
Glycemic Control
Contact Info
Name Lori Key
Phone: 6-3-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3C - Severe hypoglycemia How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Glycemic Control Commitment Details/h6>Commitment Summary:
Further reduce episodes of severe out of range glucose events Action Plan:
Implement the Glucomander software in the CVCC then to other high-risk units Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Saved:
1 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
We will use a proxy measure of our SSER and SSE. The above represents 11 SSEs with a goal of under 10. (~10 % reduction goal).
Our current % of all blood glucose values (POC and lab) less than 70 for adult inpatients receiving insulin is 1.0%
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Medication ADE View Commitment
Commitment
×
Dartmouth-Hitchcock
Medication ADE
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication errors How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Medication ADE Commitment Details/h6>Commitment Summary:
Reduce avoidable medication errors by implementing/supporting all safe medication administration practices Action Plan:
Will convert to fully integrated medication infusion pumps.
Will continue to refine CPOE tools
Will pilot Glucomander to improve administration of insulin Impact Details Lives Saved
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NGT/Small Bore Feeding Tubes View Commitment
Commitment
×
Dartmouth-Hitchcock
NGT/Small Bore Feeding Tubes
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric tube (NGT) placement and verification How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
NGT/Small Bore Feeding Tubes Commitment Details/h6>Commitment Summary:
We have an opportunity to measure harm based on misplacement of NGT/small bore feeding tubes Action Plan:
Design a electronic report to capture number of NGT/small bore feeding tubes Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Saved:
1 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
As a proxy measure we will follow our SSER and count of SSEs.
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IPASS View Commitment
Commitment
×
Dartmouth-Hitchcock
IPASS
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off communications How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
IPASS Commitment Details/h6>Commitment Summary:
Reduce serious safety events associated with hand-offs Action Plan:
Adopt I-PASS as a standardized shift hand-off process for all clinical disciplines. Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Saved:
1 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
As a proxy measure we will follow our SSER and count of SSEs.
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Postpartum Hemorrhage View Commitment
Commitment
×
Dartmouth-Hitchcock
Postpartum Hemorrhage
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 11A - Postpartum hemorrhage (PPH) How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Postpartum Hemorrhage Commitment Details/h6>Commitment Summary:
There is an opportunity to continuously improve detection and response to maternal hemorrhage Action Plan:
Maintain current maternal hemorrhage management action plan including RCA analysis for opportunities to improve current system/procedures Impact Details Lives Saved
Tell us about your baseline level of harm:
11 Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
9 Lives Spared Harm:
2 Methodology for Determining Lives Saved:
We will use the proxy of SSER and SSE (currently 11) with target to decrease to less than 10. Current rate of SMM among hemorrhage cases is 5.56%
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Newborn CCHD View Commitment
Commitment
×
Dartmouth-Hitchcock
Newborn CCHD
Contact Info
Name Lori Key
Phone: 603-653-1063
Email: lori.b.key@hitchcock.org
Position: Associate Chief Quality Officer
Organization Name: Dartmouth-Hitchcock
Organization Address:
1 Medical Center Drive , Grafton County
Lebanon, 03766 United States
Participants:
-
Susan McGrath, Director Pt. Surveillance R&D
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 7B - Detecting critical congenital heart disease (CCHD) in newborns How Many Hospitals Will This Commitment Represent?
1 Commitment Name:
Newborn CCHD Commitment Details/h6>Commitment Summary:
There is an opportunity to improve reliability of CCHD screening Action Plan:
Investigate additional options for surveillance of CCHD
Choose a proven technology that can accurately monitor and read through during motion and low perfusion Impact Details Lives Saved
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| Del Sol Medical Center |
Texas |
United States |
Transfusion Reduction Initiative View Commitment
Commitment
×
Del Sol Medical Center
Transfusion Reduction Initiative
Contact Info
Name Bradford Ray
Phone: (915) 595-9224
Email: Bradford.Ray@hcahealthcare.com
Position: Director Patient Blood Management
Organization Name: Del Sol Medical Center
Organization Address:
10301 Gateway Boulevard West
El Paso, 79925 United States
Participants:
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient blood management Commitment Name:
Transfusion Reduction Initiative How Many Hospitals Will This Commitment Represent? 1 Action Plan
Continue to have CME/CEU talks on new medical devices and pharmaceutical therapies to reduce transfusion. Milestones:
1. Anemia Management and Pre-Surgical Assessment Center
2. New medical devices
3. Latest clinical journals & SABM conferences
Del Sol Medical Center will also be a participant on the panel in which I will discuss our transfusion reduction strategy for Del Sol Medical Center and for the West Central division of HCA and our results. On average, we have held steady at a 40% reduction in RBC utilization for the last 10 months. Commitment Timeline
ongoing
Impact DetailsLives Lost in Last Calendar Year: 0 How many lives do you expect to spare from harm in the next calendar year: 0 How many lives do you expect to save in the next calendar year: 0 Methodology for Determining Lives Saved:
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| Dignity Health |
California |
United States |
Improving Hand Hygiene View Commitment
Commitment
×
Dignity Health
Improving Hand Hygiene
Contact Info
Name Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand hygiene
Commitment Name:
Improving Hand Hygiene
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Hand hygiene compliance continues to fluctuate across healthcare settings due to lack of accountability, buy-in, and true understanding of patient impact when hand hygiene is not done. In addition, patient impact is not immediately realized as the adverse event of poor hand hygiene may appear several days later and thus making it difficult in tying the adverse event to one particular moment in time. Commitment Description & Detail:
Dignity Health will work at the system level to develop the expectation of hand hygiene compliance by collaborating with multiple stakeholders and producing standardized tools for system wide implementation. Action Plan:
Dignity Health plans to address the problem by the following actions:
- Standardizing a hand hygiene policy across the system
- Evaluate the capability of obtaining electronic monitoring systems for all facilities
- Revamp how hand hygiene data is presented to staff (e.g., tie it to a patient story)
- Work with senior leadership to enhance accountability (e.g., integrate hand hygiene compliance in performance reviews) Commitment Timeline:
within 12 months of start date
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Elimination of CAUTI View Commitment
Commitment
×
Dignity Health
Elimination of CAUTI
Contact Info
Name Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated urinary tract infections (CAUTI)
Commitment Name:
Elimination of CAUTI
How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Catheter Associated Urinary Tract Infections (CAUTI) account for 75% of urinary tract infections (UTI) within a healthcare setting. In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients. Over utilization of Foley catheters and inappropriate urine culture testing has been well documented in the literature. Foley catheters are seen as a convenient and efficient device for both healthcare provider and patient as it doesn't require frequent pad changes or ambulation to the bathroom thus maintaining a Foley catheter is seen as a benefit to the front line staff and patients on occasion. Also, The lack of clinical assessment for true UTI is leading to excessive urine cultures that are in return causing inappropriate antibiotic use due to false positive culture results. Commitment Description & Detail:
Dignity Health plans on addressing this concern by standardizing implementation strategies across the system, increasing accountability by placing this measure as part of the board approved annual goals, and working with a multi-disciplinary team (e.g., Lab, Nursing, Supply Chain, etc.) to approach CAUTI prevention from all angles. Action Plan:
Dignity Health will perform the following:
- Produce a gap analysis on all evidence based practices and require all facilities to review and implement action plans as necessary
- Create distinct and unique strategies for CAUTI prevention and designate nursing executives as the lead for implementation strategy
- Work with laboratory to produce a standardized urine reflex protocol to limit inappropriate testing and antibiotic treatment
- Provide a standardized list of alternatives to Foley catheters to all facilities and require staff education on their use Commitment Timeline:
12 months from start date
Impact DetailsLives SavedLives Spared Total:
0.7624500000000003 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
1
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Antimicrobial Stewardship View Commitment
Commitment
×
Dignity Health
Antimicrobial Stewardship
Contact Info
Name Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial stewardship
Commitment Name:
Antimicrobial Stewardship
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Antimicrobial use has been noted to be over prescribed and has led to increased resistance and unwarranted patient exposure to side effects. The CDC and WHO have vast efforts in reducing the inappropriate use of antimicrobials and our efforts align with these agencies. Commitment Description & Detail:
Dignity Health as established a system approach to support antimicrobial stewardship. We have developed a system steering committee to lead the efforts to reduce the over use of antimicrobials that include leadership support, standardization in the EHR, standard protocols, and a strategic plan to continue a system focus. Action Plan:
• System P & T support
• System White Paper
• Restrictions for fluoroquinolones – quality metric
• Required indications
• 48hr time out
• Therapeutic interchanges
• IV to PO interchange
• System Database to track Days of Therapy
• Quarterly monitoring for adherence to CDC Core Elements
• NHSN AU/ AR data submission
Commitment Timeline:
These strategies will be completed and new efforts started....this will be an on -going process
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Improving the Prevention of Severe Hypoglycemia View Commitment
Commitment
×
Dignity Health
Improving the Prevention of Severe Hypoglycemia
Contact Info
Name Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 3C - Severe hypoglycemia
Commitment Name:
Improving the Prevention of Severe Hypoglycemia
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Severe hypoglycemia can be life threatening and often is associated with increased morbidity, mortality and length of stay in the hospital. The inappropriate management of blood glucose in the hospital can result in severe hypoglycemia and is often avoidable. Commitment Description & Detail:
Dignity Health has focused on reducing severe hypoglycemia for the past five years. The approach has been, amongst many efforts, a full scale education to the standardized basal bolus order sets as well mealtime coordination of insulin. Practice variations have been identified that have contributed to low blood glucose. Those variations were addressed at facility levels but shared on monthly calls that focus on the management of blood glucose. The use of toolkits and frequent data sharing has also facilitated our improvement Action Plan:
• Standardized Basal Bolus order set
• Standard approach to meal time coordination of insulin
• Education to all clinicians
• Standard Hypoglycemia protocol
• Monthly submission of results
• Monthly analysis of all outliers
• Monthly webinar with current results
• Monthly discussion of best practices
• Glycemicare Module integrated into the EHR
• Monthly upload to eQUIPs and analysis of aggregate data Commitment Timeline:
This is an on going focus for our organization
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Elimination of CLABSI View Commitment
Commitment
×
Dignity Health
Elimination of CLABSI
Contact Info
Name Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood-stream infections (CLABSI)
Commitment Name:
Elimination of CLABSI
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Central Line Associated Blood Stream Infections (CLABSI) are serious infections typically causing an increased length of stay and increased cost. In addition, it is estimated that CLABSI accounts for an average mortality rate of 18% . Central lines are seen as a medical necessity but also as a device that provides convenience to healthcare providers and patients on occasion. Given this reality, over utilization of central lines are well documented in literature as well as inappropriate collection technique of blood cultures drawn from these lines which eventually leads to inappropriate antibiotic administration and potential bacterial resistance formation. Commitment Description & Detail:
Dignity Health plans to address CLABSIs by standardizing policies and protocols across the organization to ensure appropriate selection, maintenance, and removal is done consistently across all hospital settings. In addition, work with internal and external partners (e.g., supply chain, contracted dialysis companies) to ensure product selection and external policies and procedures align with current evidenced based practice. Action Plan:
Dignity Health will take the following steps:
- Standardize vascular access policies across all facilities
- Establish uniform education across the organization on proper insertion, maintenance, and discontinuation of lines
- Implement technology across the system to reduce false positive blood cultures in collaboration with laboratory leadership
- Work with hospitalist to critically review line necessity on a daily basis
Commitment Timeline:
12 months from start date
Impact DetailsLives SavedLives Spared Total:
3.85725 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
4
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Eliminating C-diff Infections View Commitment
Commitment
×
Dignity Health
Eliminating C-diff Infections
Contact Info
Name Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridioides difficile infection (CDI)
Commitment Name:
Eliminating C-diff Infections
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Clostridium difficile (C-diff) has emerged as one of the most significant healthcare-associated infection in recent years surpassing central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), and surgical site infections (SSI). C-diff can survive on surfaces for extended periods of time and is commonly triggered by overuse of antibiotics outside the healthcare setting and within. Historically Dignity Health has struggled to reduce C-diff events given the multiple discipline involvement that is required to curb infection (e.g., Lab, Pharmacy, Physicians, Infection Prevention, EVS, Nursing). Commitment Description & Detail:
Dignity Health will create multiple system strategies in collaboration with the multi-disciplinary team to address all facets of C-diff prevention Action Plan:
Dignity Health will take the following actions:
- Create a gap analysis of evidence based practice and require facilities to complete within 30 days
- Produce a checklist of evidence based practice to eliminate C-diff infection for local facility adoption
- Educate nursing staff on clinical presentation of C-diff for early detection and isolation
- Standardized laboratory method of testing to limit false positives across the organization
- Require all C-diff cases to be reviewed by the local antimicrobial stewardship team
- Implement electronic health record clinical decision support for physicians in order to prevent false positives and unnecessary antibiotic administration
- Standardized quality assurance testing for environmental services across all facilities
Commitment Timeline:
12 months from start date
Impact DetailsLives SavedLives Spared Total:
6.156000000000003 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Spared Total:
7
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Sepsis Bundle Compliance View Commitment
Commitment
×
Dignity Health
Sepsis Bundle Compliance
Contact Info
Name Catherine Hesse
Phone: 9167652107
Email: whirlyk8@gmail.com
Position: System Director, Emergency Services
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 9 - Early detection and treatment of sepsis
Commitment Name:
Sepsis Bundle Compliance
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 36 Commitment Summary:
Sepsis is often poorly recognized in the Emergency Department upon arrival. It is in the top 10 causes of death in the United States. Early recognition and detection with rapid deployment of evidence based practices such the use of the Sep 1 bundle could save lives if employed more quickly. Commitment Description & Detail:
Dignity Health plans to improve Sepsis recognition within Emergency Services by educating care providers, nurses and physicians to better recognize the signs and symptoms of sepsis in infants, children and adults and take action more quickly. Training, visuals, review of cases with opportunity and education of the public are just a few ways we plan to improve Sepsis care within the Emergency Department. Action Plan:
1. Improve triage accuracy in Emergency Services.
2. Improve the early recognition of Sepsis in adults and children.
3. Place visuals in each emergency department that teach the Sepsis care bundle to practitioners to improve their knowledge.
4. Teach the public how to recognize and care for Sepsis and seek care when ill. Commitment Timeline:
12 month timeline with stepwise fashion of implemetation.
Gradual improvement over time with new Sep 1 guidelines anticpated.
Impact DetailsLives SavedPredicted Lives Spared Harm:
14 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
12
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System wide adoption of CANDOR – Communication and Early Resolution View Commitment
Commitment
×
Dignity Health
System wide adoption of CANDOR – Communication and Early Resolution
Contact Info
Name Barbara Pelletreau
Phone: 415-438-5567
Email: barbara.pelletreau@dignityhealth.org
Position: Senior Vice President, Patient Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of safety
Commitment Name:
System wide adoption of CANDOR – Communication and Early Resolution
How Many Hospitals Will This Commitment Represent? 35 Commitment Summary:
Dignity Health is committing to full adoption of CANDOR. By adopting CANDOR, Dignity Health is going beyond traditional \"disclosure\" to training teams to communicate immediately after a serious safety event with family and patient. Also, Dignity Health will formalize the care for the caregiver support programs for clinicians involved with serious safety events. Commitment Description & Detail:
Dignity Health will measure adoption of CANDOR with the following actions at each hospital: 1. Present to Hospital Board, Medical Executive Committee and Leadership 2. Train leadership and directors/managers, including physician leaders 3. Identify team members of the Patient Communication Team 4. Establish WeCare (care for the caregiver) program 5. Track CANDOR events through events reporting system 6. Partner with legal and risk services for CANDOR events 7. Adopt CANDOR practices (no bills to family/patient)
Action Plan:
Dignity Health will do the following to support 100% adoption: 1. Provide training 2. Include a CANDOR event in monthly Shared Learnings call 3. Track CANDOR events 4. Provide system wide policies to support CANDOR principles Commitment Timeline:
December 2020
Impact DetailsLives SavedPredicted Lives Spared Harm:
85 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
85
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Fall Prevention Program View Commitment
Commitment
×
Dignity Health
Fall Prevention Program
Contact Info
Name Margaret Swisher
Phone: (805) 482-1239
Email: margaret.swisher@dignityhealth.org
Position: Director, Regulatory Readiness
Organization Name: Dignity Health
Organization Address:
3400 Data Drive
Rancho Cordova, 95670 United States
Commitment DetailsWhat Patient Safety Challenge does your Commitment address?
Challenge 14A - Falls and fall prevention in adults
Commitment Name:
Fall Prevention Program
How Many Hospitals Will This Commitment Represent? 37 Commitment Summary:
Fall Reduction and Prevention Program Commitment Description & Detail:
Dignity Health has committed to a standardized Fall Reduction and Prevention Program. The Dignity Health Fall Team is interdisciplinary including system and facility leaders in nursing, therapy, patient safety, quality, IT, informatics, supply chain, outpatient, patient access, safe patient handling, educators, and fall team leaders from each facility and other partners based on identified issues. The team has revised the System-wide policy and electronic education plan that was developed for both clinical and non-clinical staff. Fall reduction and prevention is everyone's responsibility. The System Fall team identified the minimum membership for the local fall team to include: Safe Patient Handling (SPHM) and Fall Team (Co-chairs), Quality Director, Patient Safety Officer, Educators, Physical Therapy, Nursing Leadership with Representation From Each Unit, Bedside staff representation, Logistics/Transportation, CMO, Pharmacist, and CNEO (Executive Sponsor). Ad Hoc: Materials Management, Engineering, and other disciplines as needed. Each organiz |
