UTMB Health takes patient safety seriously. But the system can’t fix what it doesn’t know about, so staff reports are an important part of improving the patient experience. “Because You Reported” will let staff know what safety measures were taken in previous months based on staff reporting.
These are the Root Cause Analyses and actions from July through September as presented to the Safety Culture Committee.
To prevent patient falls, the following actions have been implemented over the past few months:
- Install shower dams that are ADA compliant in all inpatient rooms (ADC)
- Report when showers are not draining appropriately—complete jetting of floor drains (ADC)
- In procedure areas when patients have an assigned sitter, consider having the sitter stay where they can observe the patient at all times (all campuses)
- When securing patients to tables, all blankets and pillows will be removed prior to applying safety strap to patient (IR, Radiology)
- Apply two safety straps to altered patients (IR, Radiology)
- Review EPIC for option to document safety strap application as part of pre-procedural checklist (all campuses)
- Do not remove the footboard to accommodate patients who are tall—bed alarm does not function with the footboard removed. Remove headboard instead (all campuses)
- Consider using telesitter with high-risk fall patients (all campuses)
- Remember to use chair alarms for high-risk patients (all campuses)
- IT added the “chair alarm check box” under Daily Care in EPIC (all campuses)
- Consistently share when patient is high-risk for fall to each patient huddle/handoff (all campuses)
- Currently, no verbal handoff from dialysis to unit that patient complete and returning to unit–will discuss how to coordinate (all campuses)
- Missed PT/OT due to scheduled daily procedures–reschedule PT/OT to ensure therapy as able (all campuses)
- Verbally notify physician team when any service notices changes in mobility (all campuses)
Iatrogenic Pneumothorax and follow-up chest X-ray
- Faculty-to-faculty handoff from Anesthesia to ICU faculty (all campuses)
- Anesthesia to amend checklist to ensure CXR completed prior to leaving (all campuses) OR
- Checking to see if BPA can be added to alert to complete CXR post placement (all campuses)
Emergent C-section, uterine rupture, possible placental abruption
- Earlier consideration for rupture or abruption diagnosis and earlier C-section with concern (all campuses)
Information provided by LaDonna Strait, director, Quality, Patient Safety & Process Improvement