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 November through December
as presented to the Safety Culture Committee
In an effort to prevent pressure ulcer injuries, the following actions have been implemented
Inconsistent care planning and documentation of skin assessment
- Reinforcement of pressure injury education to the nursing staff on the unit where the patient was cared for. Education consisted of preventive interventions such as dressings and routine position changes to eliminate pressure to bony prominences over a prolonged period of time.
- Ensure that staff are completing and documenting daily care planning and skin assessment in the medical record
It was found there was no consistent tool to assist frontline nursing staff with identification of high-risk patients who may be developing pressure injuries
- Work with Nursing Pressure Injury Taskforce Committee to develop a watch list for patients that are most at risk of developing pressure injuries
- Include examples of preventive measures such as nutrition deficit or mobility and others that can be addressed in care plans, etc.
Evaluation of how we can eliminate/minimize airway compromise post-surgery for patients with wired jaws
- Implement a new humidifier to decrease mucous in patients with potential airway issues and educate nursing staff on new equipment
- Consider admission to ICU setting for patients who may have difficulty clearing their airway with suctioning
- Review of escalation process when assistance is needed to ensure all are aware of escalation protocols
- Escalation to include provider notification as appropriate
- Develop and implement order sets specific to surgical patients with wired jaws to include suctioning protocols
- Discontinue narcotic orders once the patient is admitted outside the ICU setting
Ongoing monitoring of the quality initiatives related to the Joint Commission
identified from the survey held this past summer
Actions that have been at 100% compliance for the past four months
(these can go back to routine monitoring as before the JC survey)
- Use of lint-free cloth with TV ultrasound probes
- 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 NICU were checked daily and were without any out-of-range notices
- Completion of all pre-sedation assessment requirements prior to moderate sedation
- No spiking of IV bags greater than one hour prior to use
- Cleaning of microwaves completed routinely
- All but three of the environmental issues identified are now compliant and will return to routine monitoring
Areas that could cause harm that we continue to monitor
but where we are seeing increased compliance with our policies
- Titration of RASS according to orders Pitocin titration to orders
- Completion of 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
- Pharmacy employees following hand hygiene prior to donning gloves in compounding areas
- Completion of discharge instructions for all patients who had moderate sedation
- Glucometers not clean
- Plan of care not individualized
Reductions in the number of events
from Q2 to Q3 with the Journey to Zero Initiatives
- CLABSI events decreased from 12 in Q2 to 9 in Q3
- SSI events decreased from 12 in Q2 to 6 in Q3
- Fall events decreased from 116 in Q2 to 99 in Q3
- Hypoglycemic events had a small decrease in Q2 from 116 to 114 in Q3
- WBIT events decreased from 8 in Q2 to 3 in Q3
- Specimen rejection also had a decrease from 4,792 in Q2 to 4,697 in Q3
- Blood culture contamination had a nice decrease from Q2 at 348 to 230 in Q3
- Unplanned readmissions also had a big decline in the number of events from 676 in Q2 to 414 in Q3