November 19, 2019

At Texas Children’s, we care for some of the country’s most critically ill patients, and delivering safe, quality care for our patients is the most important responsibility of each staff member and employee.

In Fiscal Year 2019, Texas Children’s reached several remarkable patient safety milestones, which demonstrate our continued commitment to cultivating a harm-free environment for our patients.

“The key to creating an environment of safe patient care is ensuring that our staff is equipped with the knowledge and tools they need to take preventive action,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “When analyzing our patient safety statistics over the last several years, we have seen a significant decrease in both serious patient safety events and preventable deaths across the system.”

Texas Children’s reached several patient safety milestones in FY19 including:

  • Decreased serious safety events (SSE) – A serious safety event is a deviation from standard practice or process that reaches the patient and causes moderate to severe harm or death. In FY13, there were 20 SSE’s compared to 5 SSE’s in FY19, resulting in a 75 percent decrease.
  • Reached Zero SSE deaths in FY19 – Since January 20, 2018, Texas Children’s reached 655 days with zero preventable pediatric deaths and zero maternal deaths since 2013.
  • Reduced Hospital Acquired Conditions (HAC) – Pressure injuries have significantly improved over time and we have seen a considerable drop in adverse drug events, catheter associated urinary tract infections and surgical site infections.
  • Immunization compliance – Since implementing new immunization requirement in 2019, the organization has reached a 99.3 percent compliance rate, which is important to patient safety.

As part of Texas Children’s continuing efforts to improve patient safety across the system, employees and medical staff participated in the Agency for Healthcare Research and Quality’s 2019 Hospital Survey on Patient Safety Culture that is administered by Texas Children’s every 18 to 24 months. The survey evaluates 13 dimensions of patient safety and measures the organization’s overall patient safety performance.

When comparing survey results from 2016, Texas Children’s – for the first time ever – showed statistically significant improvement in five major areas including feedback and communication about error, teamwork across individual units, management support for patient safety, staffing, and hand-offs and transitions.

Through the hospital’s systemwide patient safety and quality improvement efforts, employees and staff continue to apply proven safety behaviors in their every day work and are more comfortable speaking up when there is a potential safety concern. Shook says this along with other contributing factors – like reviewing monthly unit-based safety scoop reports and reaccessing current practices to identify areas of improvement where change is needed – have helped us create and sustain a culture of patient safety.

“Our recent patient safety milestones reflect the tremendous work and collaboration from multiple teams across the organization that have led us on a positive trajectory,” Shook said. “Our goal is to build upon these successes and continue to take proactive steps to eliminate preventable harm to our patients.”

September 16, 2019

More than 1 million patients are harmed each year in the United States because of medical errors. The most common, yet preventable types of medical errors are those involving patient misidentification.

Collecting blood specimen and other lab results from patients is more than just placing a label on a tube. It’s a complex, multi-step process that involves meticulously checking and re-checking to ensure that the specimen being collected, labeled, processed and handled matches the right patient, every time.

“We know that safe, quality care for every patient at Texas Children’s is the most important responsibility of each staff member and employee here,” said Texas Children’s Vice President Trudy Leidich. “While no hospital is completely immune to medical errors, Texas Children’s continues to take proactive steps to improve the positive patient identification process in order to eliminate preventable harm to our patients.”

In conjunction with World Patient Safety Day on September 17, Texas Children’s has launched a new campaign – Don’t Skip the Check: ID every patient, every time – to engage our employees system wide around PPID efforts and to ensure error prevention alertness and accountability are always top of mind.

“We have several teams anchored around specific PPID goals,” said Denise Tanner-Brown, Director of Patient Care Services at Texas Children’s Hospital West Campus. “They’ve helped us assess and refine our PPID processes and develop learning principles that translate into safe practice at the point of care.”

Since one of the top safety risks nationwide is misidentification, Texas Children’s PPID leaders took an introspective look at our organization to re-assess and identify our potential safety risks. As part of our PPID improvement efforts, the Quality and Safety teams reviewed safety scoops from March 2018 to February 2019, and found that mislabeled specimens was by far the greatest risk of preventable harm.

“Our review of near miss safety events were invaluable lessons for us,” said Nicole Crews, a nurse practitioner in Pathology and Transfusion Safety Officer for the PPID Leadership Team. “By comparing these data trends, we saw what areas we’ve improved upon and what areas need more reinforcement, which subsequently has helped us proactively address these issues and remove barriers to success.”

PPID education roll-out plan – what to expect

The PPID education roll-out initiative will be conducted in several phases across the organization for clinical staff as well as nonclinical employees who have direct encounters with patients and their families.

The training modules accessible via Health Stream include an overview of Texas Children’s PPID policies and processes during blood specimen collection, processing and blood product handling. The modules also include patient families’ stories about misidentification to underscore the important role each of us play in helping to cultivate a harm-free environment for our patients and families at Texas Children’s.

To further drive home this message, the PPID Leadership team collaborated with Marketing to produce electronic slides and screen savers with our call-to-action messaging – Don’t skip the check: ID every patient, every time – that will be used across our three hospital campuses to keep positive patient identification top of mind. Posters will also be placed in our patient units to serve as a visible reminder.

In addition to this, Texas Children’s PPID campaign also includes efforts to educate our patients and families about the importance of wearing ID bands at all times while in our care to ensure their safety.

“September 17 marks a cultural revolution at Texas Children’s Hospital,” said Associate Chief Nursing Officer Jackie Ward, and executive co-sponsor of the PPID Initiative. “We want to ensure every patient has a positive PPID experience and that we’re providing the right care to the right patient every time.”

April 9, 2019

At Texas Children’s, we care for some of the country’s most critically ill patients, and delivering safe, quality care for our patients is the most important responsibility of each staff member and employee.

As part of Texas Children’s continuing efforts to enhance patient safety across the system, employees and medical staff are encouraged to complete the Hospital Survey on Patient Safety Culture by April 22. The survey will be sent via email and will measure Texas Children’s overall patient safety performance.

“Our clinical and non-clinical staff play an important role in patient safety at Texas Children’s and their input matters,” said Katie Basta, assistant director of Quality and Patient Safety. “The more feedback we have, the better we can plan for the future by identifying gaps and taking action. The survey also tells us what areas we’re doing well in – which is equally important – so that we can hardwire good practices.”

The survey assesses 13 dimensions of patient safety including communication openness, teamwork within and across individual work areas, overall perceptions of patient safety, frequency of safety events reported, and implementation of solutions to cultivate a work environment that promotes patient safety.

“Texas Children’s employees and medical staff – regardless of their job title or position – are crucial in helping us cultivate a harm-free environment for our patients,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “The survey takes only a few minutes to complete and is one important way we can assess how well Texas Children’s is performing. The feedback received will guide our strategies for continual improvement.”

The survey is administered every18- 24 months per regulatory requirement by Joint Commission. The survey takes about 10 minutes or less to complete. All responses will remain anonymous.

If you have any questions, please contact Sharon Jacobson with Patient Safety at 832-824-1310.

March 12, 2019

As patient care manager in the Emergency Center (EC) at Texas Children’s Medical Center Campus, Tashia Bush oversees a dedicated team of nurses that treat more than 75,000 children every year.

Given the fast-paced, high-stress nature of an emergency care setting, there is one common goal that Bush and her team focus on daily – cultivating a safer environment for patients and staff in the EC.

“Every day is patient safety day in the EC,” Bush said. “The key to creating an environment of safe patient care is ensuring our staff is equipped with the knowledge and tools they need to take preventive action.”

Bush recently was recognized for her patient safety efforts in the EC when she became the January 2019 recipient of the Shamrock Award, which is awarded every month to a patient safety champion.

Texas Children’s Safety and Quality Leadership Group presents this award to a person or group who has done something extraordinary to enhance patient safety across the organization like taking immediate action to avert a potential safety concern, spearheading improvements to enhance patient safety and other above and beyond actions that make a positive impact on the safety of Texas Children’s patients.

Last year, Bush created the Safety Promotion Team comprised of EC staff, a quality improvement specialist and 10 safety coaches that meet every month to review current trends in the EC, identify opportunities for improvement, and develop action plans to address potential patient safety concerns.

To promote transparency, safety scoop report cards are sent to staff each month to keep them abreast of the number of serious safety events reported in the EC. By comparing data trends on a monthly basis, staff can see what areas they have improved upon and what areas need additional reinforcement. Staff members can then share their ideas for improvement with the Safety Promotion Team for consideration.

“Through our educational efforts, our EC staff has made great strides in patient safety,” Bush said. “We have seen a decrease in the number of falls and central line infections, and we have implemented new processes to improve positive patient identification and reduce the potential for medication errors.”

Similar to the Shamrock Award, Bush also created a new program in her unit called “Catch of the Month,” that recognizes staff for making “great catches” that averted potential safety concerns in the EC.

“There is no question our employees are making Texas Children’s safer,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “Since we launched the Shamrock program more than a year ago, there has been tremendous enthusiasm and the number of nominees has grown dramatically every month.”

The Shamrock Program is open to both clinical and non-clinical employees since everyone at Texas Children’s – regardless of their job title or position – plays an important role in cultivating a harm-free environment for our patients. Click here for a list of previous Shamrock Award winners.

For Bush, she says programs like this are a great morale booster and keeps patient safety top of mind.

“It is so important that we acknowledge our patient safety champions who play a critical role in the care of our patients,” Bush said. “Every time we let somebody know that they’ve done a great job, they are more apt to do more and become an inspiration for others to go the extra mile to keep our patients safe.”

Do you know someone who is deserving of the Shamrock Award? Click here to access the nomination form.

May 3, 2017

As a health care system, Texas Children’s believes that a critical component to offering outstanding clinical care is measuring the results of the care we deliver and doing our best to provide our patients and families with the safest environment possible.

“By tracking what we do, we learn about what happens to our patients, and we also learn about our performance as a health care delivery organization,” said Chief Safety Officer Dr. Joan Shook. “We know we can always do better and must continue to strive toward excellence in health care delivery.”

With that in mind, Texas Children’s has created a dedicated safety and outcomes website that parents can access directly from the Texas Children’s main landing page. The information on this page is organized into the following nationally recognized categories of quality measures:

  • Safe: Avoiding harm to patients from the care that is intended to help them.
  • Effective: Providing services based on scientific knowledge. This category also measures the outcomes of the care we provide.
  • Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.
  • Timely: Reducing wait times and harmful delays for both those who receive and those who give care.
  • Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy.

When possible, the website shows how Texas Children’s compares to other children’s hospitals in the United States in these categories. Where no good comparisons are available, the website illustrates how Texas Children’s compares to our own performance in the past, and how we measure up to our own goals.

Some of the topics and data reported include: hand-hygiene compliance, catheter associated blood stream infections, surgical site infections, death and complications within 30 days of surgery, patient experience, third next available appointment, patients leaving emergency care and transfer denials. Additional measures will be added over time.

For each measure, information is provided that lays out what parents can do to help Texas Children’s deliver the highest quality pediatric care. The website also includes links to our health system’s evidence-based guidelines. A distinctive feature of the website is an email address for readers who want to provide input on what additional information they would like to know and ways we can improve our website.

“We invite you to check out how we are doing and to share our outcomes with patients and their families,” Shook said. “We believe our patients and families deserve the most complete and accurate information possible about how we are doing as a health care system.”

Texas Children’s Pavilion for Women also has launched a safety and outcomes website. Click here for more information.

March 21, 2017

Imagine spending several months trying to find the pathogen responsible for a cluster of Burkholderia cepacia infections among critically ill, hospitalized patients. For infection preventionists, solving this mystery can be a daunting task but not impossible if you have the epidemiology skills and collaborative resources in your investigative toolbox.

When Texas Children’s had a small outbreak of B. cepacia infection last year, Texas Children’s Quality and Safety Director Elaine Whaley immediately sprang into action to identify the cause of the outbreak. Her extensive experience in infection prevention and control coupled with her professional networking skills helped her locate an infection preventionist at another pediatric hospital one-thousand miles away who had experienced a similar outbreak. Together, they identified the pathogen responsible for the B. cepacia outbreak in their respective hospitals.

Partnering with Infection Preventionist Angela Rupp of Lurie Children’s Hospital of Chicago, their collaborative investigation expedited the nationwide recall of liquid docusate, a medication used to treat constipation. This product was later found to be contaminated with the bacterium B. cepacia, which was directly responsible for the sudden outbreak of infection at both hospitals.

As a result of their work and commitment to promoting a culture of safe patient care, Whaley and Rupp will be recognized with the Heroes of Infection Prevention Award during a special ceremony in Portland by the Association for Professionals in Infection Control and Epidemiology (APIC).

“It is a great honor to have one of our own be nationally recognized for this heroic award in patient safety,” said Trudy Leidich, Texas Children’s assistant vice president of Quality and Safety. “We are grateful to Elaine and our Infection Control team for identifying the direct source of contamination in order to keep our patients safe and free from preventable harm.”

B. cepacia is the name for a group of bacteria that can be found in soil and water and are often resistant to antibiotics. The bacterium can cause life-threatening infection in high-risk, medically complex children, such as children with cystic fibrosis and immunocompromising conditions.

In February 2016, when a small cluster of patients at Texas Children’s and Lurie Children’s Hospital came down with B. cepacia infection, Whaley and Rupp initiated separate outbreak investigations. But once the two hospitals’ clusters were confirmed to be identical, the patients were combined to facilitate the investigation.

After thorough analyses, their investigation found that the ducosate product at each hospital came from the same manufacturer. After reporting these findings to the Centers for Disease Control, the Food and Drug Administration was called into the investigation which subsequently resulted in a national product recall. This recall protected patients at Texas Children’s and patients at other pediatric hospitals across the nation from this serious pathogen.

The nursing team on 14 West Tower (WT) has reached an impressive milestone – 500 days and counting without a Central Line Associated Blood Stream Infection (CLABSI). Training, practice, diligence, team work and a collaborative focus on safety contributed to this team accomplishment.

Several new patient safety procedures were implemented to achieve this goal. Twice a year, each nurse on the unit completed return demonstration on a sterile dressing change and a sterile cap change during Critical Competency sessions, and thereafter got checked off on these skills at least once per quarter.

The unit recently started a new system in which all nurses are divided into three groups. Each group is assigned to a specific time of the year. During their assigned time, they work with central line champions to verify their central line maintenance techniques are up to par and are given real time live feedback. These observations ensure that each nurse performs these specialized skills in the safest and most evidence-based manner.

“We care for many patients on 14 WT who have central lines,” said Karen Santos, nightshift patient care manager on 14 WT. “Our team has been greatly involved and highly motivated to learn and diligently follow all of the correct steps and processes it takes to care for central lines.”

The Unit Quality Practice Council members also have been involved in these efforts to prevent CLABSIs by engaging all staff members on the importance of proper care of central lines. The unit has six nurses who volunteered to become central line champions. They attend monthly meetings to learn more about central line care, share any new knowledge and information with the rest of the team, complete monthly observations of central line care and access, help with annual check-offs, and act as safety advocates for our patients with central lines.

The 14 WT team takes pride in keeping our patients healthy, safe, and free of central line infections. The unit’s leadership team recognized this 500-day milestone with an early morning breakfast celebration to show how proud and appreciative they are of each and every nurse who helped bring this goal to fruition.

The countdown of success is constantly on display to remind 14 WT team members to keep patient safety on the forefront of their minds. Safety is our priority!