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 2022
as presented to the Safety Culture Committee
In an effort to prevent pressure ulcer injuries, these are the NEW actions that have been implemented this past month:
When patients are in the OR more than six hours, these interventions will be implemented:
Assess the standards for protective items in place for patients in the OR such as relief padding, additional padding, positioning and proper documentation as well as documentation of Braden Risk & Skin Assessment.
Email OR managers to review and clarify standards. Education in place for periop positioning and padding in with preventative measures.
Currently there is no protocol for prophylactic dressings or risk scale in the OR.
Dietician not always involved in changing nutritional needs for patient
Explore the physician and dietician partnership as it relates to the nutritional decisions of the patients at high risk of PU development
Inconsistent documentation from nurses and nurse stopped continuous tube feed several days prior to doctor discontinuing order
Review and educate nursing staff on documenting I/O’s, clarifying and following nutrition orders and placing notes if unable to follow order
Identification of airway compromise for infants in CLC Neonatal ICU and evaluation of respiratory equipment:
RTs have NICU competencies, but many RTs may not have confidence in NICU assignments
Develop education plan and begin having monthly training for RTs.
No standardized checklist for setup and changes to SiPap machine to assist RTs in the process
Develop checklist for RTs to set up SiPap, circuit changes and change from CPAP to HHHFNC
RNs not familiar with checking respiratory equipment
Set up training session lead by an RT to train all providers and nurses on basic troubleshooting of respiratory equipment
RTs at CLC operate on “skeleton crew,” which makes it difficult for mentoring opportunities
Evaluate RT staffing
Additional FTEs have been approved and positions are posted
Nobody checked flow through nasal prongs as it is not a standard thing to check
RNs to begin checking flow through nasal prongs with regular RN assessments
Ongoing monitoring of the quality initiatives related to the Joint Commission
identified from the survey held this past summer
NEW Actions that have been at 100% compliance for the past four months
—these can go back to routine monitoring as before the JC survey (eight last month):
Clean biohazardous containers in the dirty utility rooms
Employee files in pharmacy included annual competency for proper garbing and hand hygiene
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 include:
Titration of RASS according to orders
Pitocin titration to orders
Completion of Suicide Risk screen on admission (96%-98% compliance past several months)
Visible bioburden and no evidence of wetting agents on instruments and instrument trays
Physician documentation of Immediate Post-Op notes prior to moving to next level of care (91% compliance last month)
Pain medication administration including pain assessment prior to medication administration and according to orders (73-77% compliance across campuses)
Pharmacy employees following hand hygiene prior to donning gloves in compounding areas (93.3% compliance last month)
Completion of discharge instructions for all patients who had moderate sedation (three months 100% compliance)
Glucometers not clean
Plan of care not individualized
Fingernail enhancement compliance (one month at 100%)
Reductions in the number of events from Q2 to Q3 with the Journey to Zero Initiatives
CLABSI events decreased from 12 in Q2 to nine in Q3 —two in December
SSI events decreased from 12 to in Q2 to six 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 eight in Q2 to 3 in Q3—two in December
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 3,48 to 230 in Q3— 99 in December
Unplanned Readmissions also had a big decline in the number of events from 676 in Q2 to 414 in Q3