March 14, 2017

This week — March 12 through March 18 — is National Patient Safety Week. It also is that time of year when college basketball teams give it their all for the ultimate title. With a little imagination, this is what it might look like if we combined Patient Safety at Texas Children’s and March Madness.

To win at patient safety and basketball, a team of dedicated coaches and players is needed! At Texas Children’s, we have hundreds of great Safety Coaches, 372 recruited and trained to be exact, much more than any basketball team.

Team Texas Children’s is comprised of multiple devoted and enthusiastic players and they are: Texas Children’s Hospital West Campus, Texas Children’s Pavilion for Women, Texas Children’s Medical Center Campus, Outpatient Clinics & Health Centers, and Texas Children’s The Woodlands, our newest member to the team. Each player performs a vital role in Texas Children’s pursuit of the ultimate goal, Zero Patient Harm.

The scoreboard shows that West Campus is scoring big for Patient Safety with day and night executive safety walk rounds, monthly microsystem Safety Coach meetings, daily campus safety briefings, and multidisciplinary case conferences to learn from precursor and/or near miss safety events.

The Pavilion for Women is a proven player. They hit the target of 100 percent compliance with antenatal steroids administration; reduced obstetric adverse events by almost 50 percent; saw a significant reduction in post cesarean surgical site infections; and are implementing the use of a Fetal-Maternal Early Warning System for early recognition of a patient who may need a higher level of care.

Main Campus is a versatile player. When playing as a point guard, they lead the team in assists and aid in directing plays to improve patient safety. Main Campus has been working hard at implementing new practices to prevent intraventricular hemorrhages in newborn patients, enhancing staff knowledge about alarm management, and establishing new processes to care for aggressive behavioral health patients, which help keep patients and staff free from harm. They also provide leadership to the Safety Coach Program.

Outpatient Clinics and Health Centers have exceptional moves aimed at fall reduction, critical lab reporting, recognizing and responding to medical emergencies, and the identification of potential safety issues with the help of a Safety Coach.

New to the team this year is The Woodlands. The Woodlands ballers have been busy perfecting their game. They participated in three days of “live action” simulation activities prior to the opening of the ambulatory clinics, where they identified possible threats to patient safety that could be eliminated before seeing their first patient! All of the Woodlands team leaders completed “QI Boot Camp” (a review of quality improvement principles) and all staff and leaders completed Error Prevention Training to further emphasize the importance of building a culture of patient safety. Patient safety is being especially highlighted at the Woodlands through more simulation training and testing throughout the month of March as they prepare for their April 11 inpatient opening.

The Team’s playbook is full of special moves to eliminate harm. It includes the use of error prevention tools and techniques, compliance with steps to prevent CLABSIs, CAUTIs, VAPs, SSIs, PIVIEs, ADEs, pressure injuries, unplanned extubations, falls, readmissions, and more. Team Texas Children’s outperforms any college basketball team when it comes to key plays.

Whether your role is on the court, providing patient care, or off the court like keeping things clean, repaired, and ready to go, you are part of Team Texas Children’s. You are instrumental to Team Texas Children’s ultimate goal! Zero Patient Harm is within our reach!

To assist Team Texas Children’s in Scoring Points for Patient Safety (and have a little fun too), click on the links below.

January 10, 2017

11117clabsi640Texas Children’s neonatal intensive care unit (NICU) 2 nursing team has a big reason to celebrate – they reached 365 days and counting with zero central line-associated bloodstream infections (CLABSI), which demonstrates the value of team work and our hospital’s commitment to cultivating an environment for safe patient care.

In November 2015, NICU 2 reported three CLABSI infections. Since then, the rate of CLABSI occurrences has dropped to zero.

“Last fall, we were concerned about the number of CLABSIs we were having not only in the NICU but across the organization,” said NICU Clinical Nurse Specialist Alex Luton. “Together, with our infection control counterparts in education and vascular access, we implemented a massive educational initiative that trained more than 2,000 nurses across the organization on several key skills in central line care.”

Besides opening dialogue with the bedside nurses and care providers to identify and close any gaps observed around central line care, current hospital policies and practices were reviewed against national standards to identify areas of care that could be standardized to reduce CLABSI occurrences.

“Prior to this initiative, units had their own way of accessing and maintaining the central line,” said NICU Education Coordinator Rachel Leva. “Now, all nurses follow the same standard procedure for central line maintenance across the hospital system which has significantly helped us reduce our CLABSI rates in NICU 2.”

Creating the new role of central line resource nurses (CLRNs) has also provided an added layer of support for CLABSI prevention. To help bedside staff focus on other important patient care responsibilities, the CLRNs round on all patients with central lines during every shift.

“By providing central line care support and education, we’ve been able to address concerns early before they potentially manifest into a bloodstream infection,” said Ivy Lynn Ersan, a CLRN in NICU 2. “For instance, if a patient sweats a lot or has a lot of secretions, we may need to check on the patient more frequently per shift and change the dressing sooner than later to ward off an infection.”

Other strategies implemented in NICU 2 to reduce CLABSI include:

  • Central Line Champions Program – Specially trained to observe and audit central line care practices, these champions serve as coaches to ensure compliance with proven CLABSI prevention strategies. While all NICU staff are trained in CLABSI prevention, central line champions undergo more intensive training and must attend monthly educational sessions.
  • Hand Hygiene – NICU 2 nurses participated in a house-wide hand hygiene competition and posted signs in the unit as a visual cue to keep hand hygiene top of mind. NICU 2 leadership worked closely with Facilities to ensure ample supply of free standing hand sanitizer in the unit.
  • Weekly CLABSI meetings – Meetings are held every Tuesday to review and share information on CLABSI occurrence and identify any gaps in practice that need to be addressed. Attendees at these meetings include members from the vascular access, infection control and CLRN teams. A representative from Facilities also attends to ensure the working environment is conducive to safe patient care.

NICU 2 Assistant Clinical Director Tanya Williams says one important aspect that helped NICU 2 nurses achieve this milestone was their questioning attitude.

“Our nurses are not afraid to ask questions when something doesn’t seem right,” Williams said. “I think fostering this culture of a questioning attitude is how we were able to get this far. I am so incredibly proud of our nurses and our CLABSI partners for helping us achieve this patient safety milestone.”

October 18, 2016

101916patientsafetyinside640Texas Children’s was recently named October 2016 Hospital of the Month by Solutions for Patient Safety (SPS) in recognition of our outstanding achievements in cultivating an environment of safe patient care.

The SPS is a network of more than 80 children’s hospitals across the U.S. that share a common vision that no child will ever experience serious harm while we are trying to heal them.

“At Texas Children’s, we care for some of the country’s most critically ill patients, and we understand safe, quality care for every patient is the most important responsibility of each staff member and employee here,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “Ensuring our staff and employees are equipped with the knowledge and tools to take preventive action are key to keeping our patients safe.”

Through our organization-wide error prevention training program implemented in 2014, employees and staff are now more comfortable in applying proven safety behaviors in their everyday work to ensure error prevention alertness and personal accountability are always top of mind. These safety behaviors include effectively communicating concerns requiring action, supporting a questioning attitude and using three-way communication to achieve greater clarity so that everyone speaks a common language in the delivery of patient care.

To propel error prevention training to the next level, Texas Children’s launched the Safety Coach Program which consists of clinical and nonclinical frontline staff and providers who are trained to observe employee interactions and provide feedback to reinforce safety behaviors and skills taught in error prevention training.

“Since the program’s launch in February of last year, we’ve had 16 classes and trained 334 coaches throughout the organization,” said Texas Children’s Patient Safety Specialist Tiffany Wrenn. “Our program has contributed to people’s’ increased comfort level in speaking up when there is a concern resulting in a 5.2 percent significant improvement in communication openness as reported in our latest AHRQ Hospital Patient Safety Culture Survey.”

The SPS also recognized Texas Children’s systemwide efforts in reducing hospital acquired conditions by reassessing current practices to identify areas of improvement.

When patients in the Epilepsy Monitoring Unit (EMU) developed a hospital acquired pressure ulcer (HAPU) due to skin breakdown from the electrodes affixed to their scalp and forehead during an electroencephalography (EEG) study, Texas Children’s Clinical Specialist Joellan Mullen and her EMU colleagues collaborated to develop techniques to enhance skin care management and HAPU prevention, which were later published in the 2014 Journal of Pediatric Nursing.

These best practices included using a less abrasive solution to remove oils from the skin before electrodes were placed on the forehead, wrapping a breathable fishnet dressing around the electrodes to prevent moisture and pressure buildup on the scalp and implementing wireless technology to allow greater mobility for EMU patients.

“Before revising our quality improvement practices for HAPU prevention, 10 percent of our EMU patients developed a HAPU, averaging three or four occurrences per month,” Mullen said. “Today, we have seen a reduction in HAPUs within our unit after implementing these changes.” The creation of the Skin Champions Program also helped staff reduce the number of pressure ulcers in the EMU and in high acuity areas of the hospital like the intensive care and cardiovascular units.

Other units experienced their share of collaborative successes. To reduce the occurrence of central line-associated blood stream infections (CLABSI) in the neonatal intensive care unit, clinical specialist teams collaborated with infection control partners to review current policies and practices against national standards which led to the creation of a massive educational initiative for nurses. More than 2,000 nurses across the organization were trained on several key skills in central line care.

“We went through hand hygiene, cap changes, dressing changes, just accessing the central line, since we are doing all of that differently than we used to,” said Nicole Sheets, a nurse in the Pulmonary Adolescent Unit. “No matter where you are in the hospital, the standard of care is now the same across the entire organization.”

To learn more about Solutions for Patient Safety, click here. To read more about our patient safety achievements, click here.

July 19, 2016

72016pokemon640In light of the recent Pokémon GO craze, Texas Children’s wants to remind employees about our policies and our continued responsibility to promote a safe environment for our patients and their families while they are in our care.

A recently released mobile game called Pokémon GO encourages players to use their smartphones’ GPS and cameras to catch virtual Pokémon in various and unexpected locations. This game encourages players to wander in public places in search of Pokémon characters.

It has been reported the app is being downloaded and played at Texas Children’s locations, and some Pokémon characters are showing up at our locations including patient care and secured areas. As a result, this could potentially lead to many unsafe situations for our patients, their families and our employees. This includes:

Patient and family safety
  • Patients leaving their patient care areas without telling caretakers or parents
  • Patients entering unsecure/dangerous areas
  • Patient photos being posted to social media without knowledge/consent
  • Strangers entering Texas Children’s facilities with the sole reason to play Pokémon GO
  • Malware affecting their smartphones
Employee risks
  • All of the above
  • Leaving patient care areas
  • Violation of the following:
  • Use of Social Media Policy
  • Wireless Acceptable Use IM Policy
  • Employee Conduct Policy
  • Patient Photography Procedure
  • Patient Photography Policy
Information Services (IS) risks
  • App’s ability to compromise network’s security
  • Malware infecting the network
  • Productivity loss

There are no acceptable circumstances where the app may be downloaded or played at any Texas Children’s location.

Please be aware of the above risks and possible policy violations. IS has put measures in place to block this application from our networks; however, individuals may still have access to the app via their personal data plans. Information will be distributed to patients and families as well.

October 6, 2015

Return to Connect

10715SafetyCoachinside640With football season in high gear, many of you will be anxiously glued to your electronic devices cheering on our Houston Texans and their new quarterback. But, what does football have to do with Texas Children’s safety coaches?

Well, have you ever had a coach who ignited your passion for a sport, motivated you to push forward to achieve a goal or helped you become a better team player? That’s exactly what Texas Children’s safety coaches are all about. Just like a football team works together to score a touchdown, safety coaches help us reach our organization-wide goal: scoring multiple touchdowns in the “zero patient harm” end zone.

Every Texas Children’s employee – regardless of their job title or position – plays an important role in cultivating a harm-free environment for our patients. While all employees are required to complete error prevention training, Texas Children’s Safety Coach Program takes that training to a whole new level.

Safety coaches consist of clinical and nonclinical frontline staff and providers who are trained to observe employee interactions and provide feedback that reinforces safety behaviors and skills taught in error prevention training. These safety behaviors include how to effectively communicate concerns requiring action, how to support a questioning attitude and how to use three-way communication to achieve greater clarity.

“While all of us have been trained to use error prevention tools, it takes more than a single training session to hardwire these safety behaviors into our culture,” said Texas Children’s Patient Safety Specialist Sharon Jacobson. “Our safety coaches help us integrate proven safety behaviors in our everyday work to ensure error prevention alertness and personal accountability are always top of mind.”

Here’s an example of a safety coach at work:

“A safety coach working in the operating room observes an anesthesiologist express a concern about the volume of medication in a syringe. Because the anesthesiologist voices her concern, the team pauses before giving medication to the patient. They discover the wrong calculation had been used to prepare the medication. An error has been prevented. The safety coach provides the anesthesiologist and the care team with positive feedback for fostering a questioning attitude and preventing a potentially harmful patient safety event.”

So, you might be wondering, “How do I become a safety coach?”

As part of the recruitment process, Texas Children’s Patient Safety Team reaches out to departmental leaders across the organization to determine who on their team would be an ideal candidate based on the responsibilities and attributes outlined in the safety coach application packet. Once the forms are filled out, signed by the applicants and approved by their manager, the Patient Safety Team selects the candidates for the training program.

Safety coaches are required to take a mandatory 3-hour training course that includes an overview of the skills taught in error prevention training, a discussion on the attributes that embody a good safety coach and video scenarios that help safety coaches identify good versus not so good coaching moments. Since the program’s launch in February, Texas Children’s has more than 60 safety coaches across the organization, who all serve on a strictly volunteer basis.

“We’ve completed training sessions at Main Campus and West Campus, and are looking to get our first physician group going this month,” said Texas Children’s Patient Safety Specialist Tiffany Wrenn. “As you can see, our safety coaches play a vital role in helping all of our employees become Safety Super Stars.”

Return to Connect

September 22, 2015

92315EpicRover640More than 1 million patients are harmed each year in the United States because of medical errors. One of the most common, yet preventable medical errors involves the administration of medication.

Providing medicine to patients is more than just handing out pills or delivering drugs through an IV line. It’s a complex, multi-step process that involves meticulously checking and re-verifying that the medicine being prescribed, transcribed, dispensed and administered is going to the right patient every time.

As part of our commitment to patient safety, Texas Children’s has already begun implementing Epic Rover, a mobile software application that uses barcode technology designed to prevent medication errors and improve the quality and safety of medication administration.

Epic Rover is an extension of the electronic medication administration record (MAR) within Epic. Once this software is downloaded to an iPod Touch equipped with a scanner or sled, nurses and respiratory therapists scan the barcode on the patient’s wristband and the barcode on the prescribed medication at the patient’s bedside. The medication documentation then flows real-time into the MAR in Epic.

Bar Code Medication Administration (BCMA) helps our clinical staff verify the administration of medication more efficiently by assuring that the “five rights” are confirmed – right patient, right medication, right dose, right time and right route of administration.

“Medication scanning creates a significantly safer process and improves compliance with industry standards and regulations,” said Texas Children’s Clinical Informatics Director Jennifer Sanders. “It’s a safety measure for our patients and provides an additional safety net for our frontline nurses and clinical staff who are the last line of defense to prevent medication errors.”

Before Epic Rover, our nurses and respiratory therapists manually conducted the “five rights” checks. With BCMA, the entire process is done electronically. However, clinical staff must still rely on their critical thinking and judgment to ensure medication ordered by the physician matches the medication prepared and dispensed in the pharmacy before it is administered to the patient.

To help primary users adjust to the BCMA system, the Epic Rover rollout will be implemented in phases over a 9-week period with the completion of the final rollout phase on Saturday, November 21.

Epic Rover rollout schedule:

Dates          Weeks                  Grouping
9/22/15        1 and 2         PFW, Respiratory Therapy
10/6/15        3                   West Campus: 3W, PICU, EC, PACU, 5W/SIU
10/13/15      4                   Main: All EC areas, Floats
10/20/15      5                   9WT, 10WT, 11WT, 12WT, IRU
10/27/15      6                   PRCU, BMT, 14WT
11/3/15        7                   6N, 7N, 7S
11/10/15      8                   NICU 2, NICU 4, PFW NICU
11/17/15      9                   PICU, CVICU, 15WT

Mandatory training will include a Health Stream module, an Epic video and a 90-minute hands-on classroom training session. All staff must complete training before the go-live.

“Our goal is to reach 90 percent compliance in 90 days,” said Texas Children’s Clinical Informatics Supervisor Erin Davies. “We’re confident we will reach this goal because our clinical staff is committed to creating an environment of safe patient care.”

The implementation of Epic Rover would not be possible without the collaboration from several departments including Clinical Informatics, Information Services, Pharmacy, Respiratory Care, Nursing and the Nursing Professional Development team who helped create the training curriculum.

December 23, 2014

122414patientsafety640

The Solutions for Patient Safety (SPS) network has named Texas Children’s Hospital of the Month for the month of December in recognition of the organization’s efforts to improve patient safety and decrease patient harm. The award recognizes the hospital for many steps taken toward increasing patient safety including the organization of 10 different hospital acquired conditions (HAC) teams which include more than 100 employees and clinical staff. These teams review best practices from other hospitals within the network and implement those that work, while also sharing our successes with others. The award also recognizes the teams which have seen significant improvements since taking on new protocols. Over the last year, five teams have demonstrated significant decreases in harm by implementing process recommendations from the SPS network. The falls, surgical site infections, central line associated bloodstream infection and urinary tract infection HAC teams have fully adopted SPS prescribed bundles.

“As an organization, we are proud to be a part of a nationwide effort to decrease harm to patients,” said Trudy Leidich, director of quality and safety. “Through the Solutions for Patient Safety initiative, we have been able to share our best practices with other children’s hospitals and learn from their efforts as well. Being named hospital of the month is simply an acknowledgment that we are doing everything we can to improve safety within our hospital and we are honored to get this recognition.”

The SPS, formerly known as the Ohio Collaborative, began as a group of Ohio children’s hospitals working toward eliminating patient harm and soon expanded to a network of more than 80 hospitals across the nation, including Texas Children’s, which lead a national effort to implement the best strategies for creating the highest possible safety protocols for patient care.

Data sharing in the form of outcomes and process measures is another key component of the hospital’s participation in the collaborative. This data is combined with data from other participating hospitals to help identify trends and refine practice which result in an improvement of care. Since January 2013, Texas Children’s Hospital has submitted 100 percent of its HAC and Readmissions outcome data to the SPS.

Teams from Texas Children’s will continue this ongoing partnership with SPS and children’s hospitals across the nation to improve the quality and safety of care to our patients.