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.
Root Cause Analyses and actions from October
as presented to the Safety Culture Committee
In an effort to prevent patient falls, the following actions have been implemented:
Dialysis team is discussing with inpatient units the possibility of incorporating a verbal hand-off prior to a patient being returned to his or her home unit.
PT/OT will evaluate patient dialysis schedules to arrange their PT/OT therapy around the time they are off the unit.
When PT/OT sees changes in a patient’s mobility they will communicate this to the medical team
Other quality initiatives related to the Joint Commission actions
from the survey held this past summer
Actions for which we were at 100% compliance:
Pre-sedation assessments completed prior to moderate sedation initiation
Fold-over sterile peel packs ready for use during surgery or procedures were without holes or openings
All consent forms have been modified to now include a designated space for date, all consents contained date, time and appropriate signatures
The breast milk refrigerators in the Neonatal Intensive Care Unit were checked daily and were without any out-of-range notices
Areas that could cause harm that we continue to monitor but are seeing increased compliance with our policies:
Titration of RASS according to orders
Pitocin titration according to orders
Completed Suicide Risk screen on admission
End tidal Co2 monitoring during moderate sedation cases
Physician documentation of Immediate Post-Op notes prior to moving to next level of care
Pain medication administration including pain assessment prior to medication administration and according to orders
We are seeing significant improvement in some of our Journey to Zero Initiatives, such as:
Improvement with specimen rejection
Actions implemented: December 2021 through May 2022 as high as 1,729/month; June through September 2022 decreased to an average of 1,555/month
Monthly raw data is shared with nurse managers for further drill down
Specimen collections observations conducted at all campus emergency departments and the John Sealy WIC units by lab
GEMBA walks conducted at Clear Lake Campus nursing units and Galveston lab
Knowledge gap assessment surveys distributed at Clear Lake Campus and adapted to all campuses reviewing all comments
Creation of Perfect 10 Specimen Rejection taskforce with weekly meetings to monitor progress
Training and education provided for specimen collectors outlining best practices
Shared “Stop Before You Stick” posters distributed to all campuses
Tip sheets distributed to all nursing
Added specimen rejection topics to the skills fairs at League City Campus and Angleton Danbury Campus
Developed a phlebotomy cart to help keep supplies organized
Reduction in pressure ulcer
Actions implemented: Pressure injury cases FY 2022 equal 26; FY 2023 YTD equal two cases (zero cases April through June, two in July, zero in August)
Strict two-hour turning schedule – identifying barriers to address increased compliance
Skin Care Champions and Wound Treatment Associate Training inflight on Sept. 1 with plans to graduate January 2023
Documentation of “present on admission” pressure injury education shared
Updated pressure injury risk assessment tool includes device-related injuries and new Braden for Pediatrics
Identification of knowledge deficits with resources developed and deployed – bed order sets, skincare resources and documentation of pressure injury staging (education)
Identification of high-risk patients
Skin and risk assessment by two staff for ICU admissions and patients admitted post-surgery