January
Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee
chaired by Joseph Hopkins, associate chief of staff
Patient
Admitting - Virtually all patients are being registered by an admitting
representative within 15 minutes of arrival at the triage desk. Patient
Admitting Services registered 11,379 patients between Nov. 29 and Dec.
31, 2004. Of that total, 11,377 (99.98 percent) were registered within
15 minutes of arrival. Two patients waited between 16 and 30 minutes.
DVT/PE
Pilot Study:
Results:
Phase 1, conducted Nov./Dec. 2004
--
67 percent of patients were assessed for DVT/PE [deep vein
thrombosis/pulmonary embolism] during their pre-op clinic appointments
--
Pre-op patients were adequately prophylaxed according to ACCP
guidelines.
Phase 2, under way
--
DVT/PE order set in POE (physician order entry) for post-op and medicine
patients.
-- Pre-op assessments for DVT/PE continue.
--
Providers will reassess patients post-operatively.
The study was led by David Spain, chief of trauma surgery.
PCA/FMEA
Performance Improvement Team
A single PCA (patient controlled analgesia) pump, from Alaris Medical
Systems Inc., was selected in December for use throughout the hospital
to maximize patient safety.
Pumps will be available in-house for training to begin by March.
Using a single system is expected to contribute to patient safety.
Monitoring will continue after implementation of the house-wide pump.
QIPSC recommended that patient education include the signs and symptoms
associated with the use of PCA.
PCA
by Proxy Sentinel Event Alert
An inter-hospital sentinel alert was issued by the Joint Commission
(JCAHO) following incidents elsewhere in other organizations of "PCA
by Proxy" - the triggering of PCA doses by family members.
SHC has a policy that addresses patient education, including
information that only patients should activate PCA.
Physicians should caution family members NOT to punch the PCA
button.
JCAHO
Lab Survey - Point of Care Testing
SHC will undergo a Lab Joint Commission survey in March, April
or May specifically focused on Point of Care Testing (POCT).
To ensure compliance and survey readiness, mock surveys were
scheduled starting in January. Mock surveys will be led by the lab and
supported by the Quality Improvement and Patient Safety Department.
Anesthesia
Awareness Policy
Policy outlines the responsibility and process requiring assessment
of patients who may be at risk for anesthesia, including the need to
provide information/education pre-operatively to patients identified
to be at risk. -- The Sentinel Events policy has been revised and renamed
the Reviewable Events policy. The policy now includes all reviewable
events but has been streamlined so staff may more easily understand
when sentinel events occur.
Recommendation: Reviewable Events that relate to the federal
Agency for Healthcare Research and Quality (AHRQ) indicators be given
special priority in the review process.
Transplantation
- A recent policy requiring that that two individuals must separately
document each transplant candidate's blood type has been implemented
with 100 percent compliance..
