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 for March 2023
as presented to the Safety Culture Committee
Communication and hand-off often are cited as frequent causes of safety events. The Joint Commission made hand-off communication a National Patient Safety Goal several years ago.
A typical teaching hospital may experience more than 4,000 hand-offs every day, and the numerous risk points during this process make patients vulnerable.
Hand-offs are a necessary part of patient care and cannot be avoided. We continue to investigate and look for opportunities to improve our hand-off communication across all areas.
To increase hand-off communication with Anesthesia, the nursing team caring for patients at the Clear Lake Campus identified the opportunity for Anesthesia to develop a workgroup to standardize its OR and ICU hand-off process.
Nursing will be taking similar actions in an effort to ensure hand-off occurs between the nursing staff during patient transport to and from different units and at shift change.
Familiarity with medications across all areas can be challenging between different units. OB medications are not frequently administered in the adult ICU setting. An OB skills fair was held to assist ICU staff to become familiar with OB medications and processes. There are also Elsevier modules that can assist all staff when unfamiliar with specific processes related to specialty areas. The ICU staff completed the OB modules to become familiar with their practices.
EPIC is the electronic medical record that we use, which helps us to see orders, notes and updates in real time and read all clearly. Yet challenges can still occur, and knowing where to find specific documentation by the varied team members during stressful situations can cause delays and miscommunication. Not all staff were aware of where to find the medications administered during surgery on the Anesthesia record. Education was provided to all nursing staff on all units of how to view the Anesthesia medications on the MAR.
We continue to monitor and report all hospital-acquired pressure ulcers that reach Stage 3, 4 and unstageable. Hospital-acquired means the ulcers were not identified on admission as present on admission. It is then presumed they occurred while in the hospital or were hospital-acquired.
These are also reported to the state as Preventable Adverse Events (PAE) and then are reported to the Centers for Medicare and Medicaid (CMS).
All of the actions that have been discussed in previous issues are reviewed to see if we have implemented all past action items.
New actions identified included reimplementation of POCR rounds to all units. Reporting of pressure ulcers or the risk of developing will be included for each patient as they are reviewed in the POCR rounds.
SICU is working to implement ICU liberation, which includes early mobilization. Aspects of the POCR discussions will be imbedded with the ICU liberation rounds as they are implemented.
Patients often refuse or ask to have their PT/OT postponed while they are inpatients. If a patient refuses three or more OT/PT interventions during a two-week period, PT and OT will contact the MD team to apprise them of the refusals and see if alternative actions are needed.
Most units continue to work on getting the HAIKU apps added to their charge nurse phones to be able to upload pictures of any pressure areas during an admission. Some campuses have identified certain days of the week to upload weekly pictures, i.e. Wound Care Wednesday has been adopted at the Angleton Danbury campus.
A re-evaluation of the Braden Skin Tool for ICU will go to the Pressure Ulcer Committee for review and discussion.
When patients have nutritional supplements ordered, such as Ensure, documentation is inconsistent at times. A work group with nursing and dietary is developing a process to identify the location of where Ensure and tube feedings should be documented. A new I&O flowsheet was presented to the Best Practice Council in February with a go-live date pending.
When specimens are ordered and obtained, it is crucial that they reach the appropriate lab to be processed. Did you know that we have courier services that pick up and transport labs for many clinics and campuses across our system? Some of them have multiple stops and transfers to be able to reach our Galveston lab services.
Updates to previous processes developed to ensure we get all specimens delivered include a change to the policy: one packing list per bag of specimens, unless there are multiple specimen bags for the same patient. In that case, enter the number of bags in the packing list comment box, number copies of packing list and corresponding bags 1 of 2, 2 of 2, etc.
To ensure that no items are missing from one location to another: A new policy was implemented with education to staff to ensure all packing list items are received and escalation to leadership when specimens are not received.
AP staff will monitor the expected list daily and escalate to leadership when not received.
Lab also made a physical change to their garbage cans, replacing cans with foot activated flip-top garbage cans. This will be a system-wide change for our labs.
A new courier specimen-tracking sheet was developed. Staff are required to count the total bags of specimens per pickup location. The new form versions require lab staff to count the total number of bags by temperature (ambient, refrigerated, frozen).
Workplace violence
Workplace violence has increased across all campuses and across many health care organizations these past few years. UTMB monitors workplace violence incidents on an ongoing basis. Reporting of such events can be completed through RL Datix under several different areas: Safety & Security, UTMB Employee Event and under the Professional Conduct section.
UTMB takes our employees’ safety as a high priority and investigates each event carefully. They are reviewed by the Quality & Safety department, managers, safety committee and our campus police.
The Joint Commission defines workplace violence as “an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written or physical aggression; threatening, intimidating, harassing or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients or visitors.
Please make sure you report any events that occur as you care for patients so they can be investigated fully and we can ensure the workplace is as safe as possible for all daily!
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
12 of the 29 citations have met compliance to date.
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—CLC 100% March, JS 100% March
Completion of Suicide Risk screen on admission—97%
Physician documentation of Immediate Post-Op notes prior to moving to next level of care—96.15%
Pain medication administration including pain assessment prior to medication administration and according to orders—CLC 96%, JS 83%
Pharmacy employees following hand hygiene prior to donning gloves in compounding areas—95%
Plan of care not individualized—96%
Maternal hypertensive drills— three months 100%
Visible bioburden & no evidence of wetting agent—trending down for each campus. Peel Pack—100%
Journey to Zero
Reductions in the number of events from Q2 to Q3 with the Journey to Zero Initiatives: March 2023
The committee sunset Specimen Rejection and replaced it with C-Diff Infections
CLABSI events: total of eight events for Q4; four events for March
CAUTI events: total of 16 events for Q4; 0 events for March
C diff (CDI): eight events for March
Fall events increased slightly in March with 42 events
Hypoglycemic events also had a slight increase with a total of 45 events in March
WBIT had two events for Q4 and 0 events in March
Blood Culture Contamination stayed the same with 54 events in March, same as in February