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 January through February 2023
as presented to the Safety Culture Committee
In an effort to prevent pressure ulcer injuries, the following actions have been implemented this past several months:
Assess the AORN standards for protective items in the OR such as relief padding and the need for additional padding.
Evaluate the need for protocols for prophylactic dressing according to the risk scale.
Evaluate understanding of positioning to promote safety for different surgical cases.
Assess documentation of Braden scale prior to OR and documentation of protective items used during the procedure.
Identify difficulty in viewing EPIC orders for dietary supplements. Worked with EPIC to improve nursing view of supplement orders.
Barrier cream documentation not consistently found, with recommendations to request EPIC to include more appropriate options in the wound/LDA flowsheet.
Reinforce that media (pictures of pressure ulcers or wounds) be obtained and uploaded to the patient’s medical record on admission and any changes as well as at discharge. Some campuses have identified specific days to obtain and upload pictures weekly, i.e., “Wound Care Wednesday.”
Evaluation of mattresses and replace as they approach five-year life span
Evaluation of current airway management in neonates in the nursery
Evaluation and implementation of education plan for all RTs who rotate through the nurseries.
Conduct monthly educational offerings for all who staff in nurseries.
Create and implement checklists for RT staff in setting up equipment such as SiPAP and circuit changes and changing from CPAP to HHFNC.
Develop training by RT for providers and nursing staff on basic troubleshooting of respiratory equipment.
Implement process for RNs to check flow settings through nasal prongs and include in routine assessments.
Prevention of burns in the OR
Evaluation of Bovie extenders and insulation of equipment prior to use.
OR staff discussions and education on all shifts on how to visually inspect instrumentation prior to use.
Individually package these until a disposable option can be identified and procured.
DKA management when Prednisone is used prophylactically for iodine allergies
Review and modify current order sets to include modifications for diabetic patients requiring steroids for iodine allergies in procedures requiring contrast.
Review current processes of transporting lab specimens from campus to campus or from clinics to lab to minimize delays and missing specimens
Review current transport process for transporting specimens to ensure all specimens get removed from coolers and from one vehicle to the next.
Implement an improved process to include signatures and counts by couriers when transferring samples.
Evaluate possibility of obtaining automatic tracking system for coolers.
Evaluate and implement communication process of notifying all involved staff when samples are out of stability parameters.
In an effort to prevent patient falls resulting in injuries, the following actions have been implemented this past several months:
When patients have had a previous fall with previous admissions, an EPIC request has been submitted to add a banner alert to indicate patient has a history of previous in-hospital fall.
Evaluate the number of Sara Steadies available on campuses and units and order additional equipment to have available for use on units.
Designation of specific location for Sara Steadies to be placed when not in use so all staff can easily locate for use.
Visual observation by managers and delegated staff to ensure appropriate fall precautions are in place routinely, with just-in-time training when not found.
Evaluation of previous fall cases and current patients at risk (five/week) for falling to ensure fall scores are documented accurately.
Post findings of case descriptions of falls in breakrooms to heighten staff awareness of recent falls to include pre-fall score and post-fall scores.
Share and discuss fall scoring with Emergency Department staff during staff meetings, brainstorm with staff on how to improve patient fall history and include in documentation.
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
End tidal CO2 monitoring during sedation
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—JS: 93 percent
Completion of Suicide Risk screen on admission—97 percent
Physician documentation of Immediate Post-Op notes prior to moving to next level of care—data pending
Pain medication administration including pain assessment prior to medication administration and according to orders—CLC: 81 percent; JS—83 percent
Pharmacy employees following hand hygiene prior to donning gloves in compounding areas—86 percent
Glucometers not clean—two months at 100 percent
Plan of care not individualized—93 percent
Maternal hypertensive drills—three months at 100%
Visible bioburden and no evidence of wetting agent—Goal: 0 to 0.102 percent
Reductions in the number of events from Quarter 2 to Quarter 3
with the Journey to Zero Initiatives: January 2023
CLABSI events decreased from 12 in Quarter 2 to nine in Quarter 3—January: seven events
SSI events decreased from 12 in Quarter 2 to six in Quarter 3—December: three 3 events
Fall events decreased from 116 in Quarter 2 to 99 in Quarter 3—January: 43 events
Hypoglycemic events had a small decrease in Quarter 2 from 116 to 114 in Quarter 3; January increased with 57 events (several multiple events in three different patients)
WBIT events decreased from eight in Quarter 2 to three in Quarter 3—January: 0 events
Specimen Rejection also had a decrease from 4,792 in Quarter 2 to 4,697 in Quarter 3— January: slight increase with 1,604 events
Blood Culture Contamination had a nice decrease from Quarter 2 at 348 to 230 in Quarter 3—January: 66 events
Unplanned Readmissions also had a big decline in the number of events from 676 in Quarter 2 to 414 in Quarter 3—December: 193 events