Patient falls
The Joint Commission considers patient falls with injury among the top 10 sentinel events reported by hospitals. Elderly or frail patients and patients with physiological changes due to a medical condition, medications, surgery, procedures or diagnostic testing can be at risk for falls.
All falls with injury at UTMB are investigated for cause.
Contributing factors to falls with injury include current disease processes, such as sepsis, altered mental status, polypharmacy and history of falls and will be included in the nursing assessment to identify those patients at risk for falls.
Nursing regularly assesses all patients for risk of falls and provides established interventions as needed.
A review of falls with injury for May identified additional interventions. All actions discussed in previous falls with injury are reviewed to see if we have implemented all past action items.
Nursing will collaborate with the video monitoring staff to ensure that the correct type of notification is used (calls vs STAT alarms) to alert of patient movement or noncompliance that may lead to a fall; additionally, education regarding the telesitter algorithm if a patient refused a bed alarm will be reviewed with nursing and PCTs.
Focus group to discuss fall prevention agreement with key stakeholders.
Nursing identified additional interventions, including the use of a chair alarm for wheelchair-bound patients and earlier intervention using PT/OT consults to assess patient mobility.
Obstetrical care
Obstetrical care is currently provided at Galveston, ADC and CLC campuses. Patients with high-risk pregnancies often require a higher level of care.
Actions identified in the care of high-risk pregnancy patient:
In-house provider guidelines updated as well as handoff from provider to provider.
Anesthesia assistance with arterial lines in Labor & Delivery areas.
Exploration of transport services to decrease transfer process timelines.
Pre-procedure verification
The Joint Commission Universal Protocol provides guidance for health care professionals and consists of a pre-procedure verification process, marking the procedure site and performing a time-out to prevent wrong site, wrong procedure or wrong surgery for invasive procedures.
IT/EPIC team will work with providers to provide access to EPIC Care Link.
All referrals received through the CERM will be transcribed using the copy/paste option in EPIC.
All referrals to UTMB will provide background information related to the reason for referral request.
Diabetes care
Diabetic ketoacidosis is considered a Preventable Adverse Event reportable to Texas. A review and investigation of patients presenting with DKA is done by a multidisciplinary group.
Actions identified from previous DKA investigations are ongoing.
New actions identified:
POCR discussion for any patients with multiple out-of-range glucose readings and dietary needs.
Workflow process to improve communication between pharmacist and providers regarding changes in insulin, providing recommendations.
Hospital-acquired pressure ulcers
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 as present on admission. It is then presumed they occurred while in the hospital. These are also reported to the state as Preventable Adverse Events and then are reported to the Centers for Medicare and Medicaid.
All actions discussed in previous issues are reviewed to see if we have implemented all past action items.
New interventions identified include:
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 the Braden score.
Explore the physician and dietician partnership as it relates to nutritional decisions of the patients at high risk of pressure ulcer development.
Review and educate nursing staff on documenting and following nutrition orders and placing notes if unable to follow.
Employee safety
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.
An act or threat occurring at the workplace 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 assault; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.
Please make sure you report any events that occur 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—41%
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—92%
Pitocin titration to orders—CLC 100%, JS 93%
Completion of Suicide Risk screen on admission—99%
Physician documentation of Immediate Post-Op notes prior to moving to next level of care—new report format in progress
Pain medication administration including pain assessment prior to medication
Administration and according to orders—CLC 96%, JSA 3A/4A 83%
Pharmacy employees following hand hygiene prior to donning gloves in compounding areas—100%
Plan of care not individualized—100%
Maternal hypertensive drills—compliant
Visible bioburden & no evidence of wetting agent—compliance trending up for each campus.
Peel Pack—CLC 100%
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 Q4—April: five events
CAUTI events: total of 16 events for Q4—March: 0 events, April: one event
C diff (CDI): eight events for April
Fall events: 30 events for April
Hypoglycemic events also had a slight increase with a total of 29 events in April
WBIT events had two events for Q4 and 0 events in May (three-month trend of
no WBITs)!
Blood Culture Contamination at 46 events in April, down from February and March at 54 events.