November 17, 2015

111815errorpreventioninside640

The Epilepsy Monitoring Unit (EMU) had one hospital-acquired pressure ulcer (HAPU) in a period of 892 days, which translates to 647 days and 244 days without a HAPU occurrence. These notable milestones demonstrate the value of teamwork and commitment to cultivating an environment of safe patient care.

When epilepsy patients are admitted to the EMU for an electroencephalography (EEG) study, electrodes are attached to their scalp, forehead and cheeks. These electrodes, which enable the recording of brain wave activity to diagnose seizures and other neurological disorders, can lead to skin breakdown at the electrode sites resulting in a pressure ulcer.

“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,” Texas Children’s Clinical Specialist Joellan Mullen said. “Today, we have brought our HAPU incidence rate to zero.”

In an effort to reach this milestone, EMU nurses, technicians, physicians and physician assistants collaborated to develop techniques to enhance skin care management and pressure ulcer prevention. These best practices were published in the 2014 issue of the Journal of Pediatric Nursing co-authored by Mullen and Texas Children’s EMU/EEG Clinical Manager Wendy Morton.

Several improvements were implemented to reduce HAPUs:

  • Patients were prepped with a less abrasive solution to remove oils from the skin before electrodes were placed on the scalp and forehead
  • Disposable electrodes were used to reduce the potential risk of infection instead of using the same electrodes for patients following equipment disinfection
  • Crib mattresses were replaced with pressure-reducing cushions to distribute weight evenly
  • A breathable, fishnet dressing was wrapped around the electrodes on a patient’s head to prevent moisture and pressure on the scalp. Prior to this change, the entire head was wrapped tightly in gauze which increased the potential of skin breakdown at the electrode sites.
  • Wireless technology was implemented to allow greater mobility for patients. Instead of being tethered to the wall, the electrodes are hooked up to a small monitor that patients wear as a backpack so they can move freely in the unit instead of being confined to the bed.
  • Nurses performed skin assessments for pressure ulcers twice per shift – before the electrodes were placed on the patient and after they were removed.

Additionally, the Skin Champions Program helped staff significantly reduce the occurrence of pressure ulcers in the EMU and in high acuity areas of the hospital like the intensive care and cardiovascular units.

Two skin champions were chosen from each unit to serve as coaches and ensure compliance with proven pressure ulcer prevention strategies. While all EMU staff members are trained in HAPU prevention, skin champions undergo more intensive training and must attend monthly educational sessions with a certified wound-ostomy nurse.

“Ensuring our nurses and technicians are equipped with the knowledge and tools to take preventive action are key to creating a harm-free environment for our EMU patients,” Mullen said. “I am proud of our team for helping us achieve this milestone.”

June 9, 2015

61015errorprevention640

Since implementing error prevention training almost a year ago, more than half of Texas Children’s employees – 8,075 clinical and nonclinical staff – have completed their required training. While these numbers are impressive, our goal is to achieve 100 percent compliance by Tuesday, June 30.

In July 2014, Texas Children’s launched error prevention training to ensure all employees and medical staff across the organization are equipped with the necessary tools to keep patients safe. This training initiative is a critical component of our CareFirst promise – to focus on what’s right for our employees and medical staff, and most importantly, what’s right for our patients, their families and their care.

Error prevention training is based on the notion that every Texas Children’s employee – regardless of job title or position – plays an important role in preventing and eliminating preventable harm to patients.

“Every day, we provide care to the sickest of the sick at Texas Children’s, and when you’re taking care of that many severely ill children and women, it’s a great challenge,” said Texas Children’s President and CEO Mark A. Wallace. “Everyone recognizes that creating a safe environment – focusing on safety and error omission – is job one. Doing no harm to our patients is first and foremost.”

That’s where error prevention training comes into play. Texas Children’s Chief Safety Officer Dr. Joan Shook says delivering clear, concise and complete communication is paramount to ensuring the safest possible patient care.

“Once training is completed, employees know how to effectively communicate concerns requiring action, how to support a questioning attitude, and how to employ three-way communication to achieve greater clarity,” Shook said. “When everyone speaks a common language and shares the same expectations, we can eliminate preventable harm to patients.”

As part of our commitment to patient safety, Texas Children’s has pledged that every member of our workforce and medical staff receive this critical training. Frontline staff are required to take three hours of classroom training and non-clinical employees can complete their training online.

June 30 is the deadline to compete error prevention training. Click here to log in to the E-learning module.

“Error prevention training will propel us to the next level of safety at Texas Children’s and encourage employees to speak up when something doesn’t seem quite right,” Shook said. “We have a moral obligation. If we can prevent harm to patients, let’s prevent it.”

Click here to watch a CareFirst video highlighting how each of us can make patient care safer at Texas Children’s by advancing error prevention initiatives.

December 2, 2014

H

Texas Children’s cares for some of the country’s most critically ill patients, and safe, quality care for every patient is the most important responsibility of each staff member and employee here. Equipping our staff and employees with the knowledge and tools to take preventive action is key to creating an environment of safe patient care.

In an effort to illuminate the importance of everyone’s role, each month we will share patient safety stories that help heighten staff and employee alertness and accountability and, ultimately, reduce harm. This month’s story is a reminder that being familiar with your surroundings and knowing what to do in an urgent situation can help improve the outcome.

Jason* was a relatively healthy 9-year-old boy when he was admitted for a routine operation. After the procedure, he went to the PACU for recovery. There, a PACU nurse noted Jason’s ECG monitor tracing looked unusual. An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical activity of the heart and then translates the heart’s electrical activity into line tracings on paper.

The nurse asked the anesthesiologist to review Jason’s ECG tracing, and shortly afterward, Cardiology was called. Jason was evaluated and diagnosed with Wolff-Parkinson-White (WPW) syndrome, a rare heart condition that causes rapid heartbeat and has been associated with sudden death.

The nurse’s attentiveness made the diagnosis of WPW possible. Jason had a corrective procedure this summer. The subsequent evaluation and the procedure will help ensure that he does well with this diagnosis and has the best possible outcome.

Actions everyone can take:

  1. Ask a question. If something doesn’t look quite right – whether it’s an issue with a patient, coworker or a process – question it.
  2. Request a change. Identify the person who can help you change the situation, and bring the matter to their attention.
  3. Voice a concern. Don’t dismiss your intuition or assume someone else will notice the problem. Your voice might be the life-changing difference for a patient.
  4. Go up the chain of command. Always know that you can go up the chain of command if necessary to bring the matter to someone else’s attention.

* Patient safety stories are based on events at Texas Children’s Hospital. Patient names and some of the circumstances of the event may have been changed to protect patient privacy.

For the latest quality and safety information, visit the Patient Safety website on Connect.

November 4, 2014

H
Texas Children’s cares for some of the country’s most critically ill patients, and safe, quality care for every patient is the most important responsibility of each staff member and employee here. Equipping our staff and employees with the knowledge and tools to take preventive action is key to creating an environment of safe patient care.

In an effort to illuminate the importance of everyone’s role, each month we will share patient safety stories that help heighten staff and employee alertness and accountability and, ultimately, reduce harm. This month’s story is a reminder that being familiar with your surroundings and knowing what to do in an urgent situation can help improve the outcome.

When congenital heart disease patient Emily came to the hospital for diagnostic testing, her family and the diagnostic team expected a routine clinical visit like she’d had many times before. But this visit ended differently. During testing, Emily’s condition began to deteriorate unexpectedly. The diagnostic team rarely treated acute patients and was not accustomed to calling for help. Their unfamiliarity with emergency protocol delayed a call to *9999, and once the response team arrived, there was additional delay in finding the code cart.*

Actions everyone can take:

  1. Know how to get help in an emergency. If you don’t know, ask your leader today.
  2. Know your surroundings and the location of emergency equipment. Some areas have code carts, automatic electronic defibrillators, panic buttons and other emergency equipment. Make sure you know what emergency support is available in your area, where it is and when it should be used.
  3. Be alert. Don’t take routine situations for granted, even if it’s something you’ve done many, many times before.

*Patient safety stories are based on events at Texas Children’s Hospital. Patient names and some of the circumstances of the event may have been changed to protect patient privacy.

For the latest quality and safety information, visit the Patient Safety website on Connect.

July 22, 2014

72314errorprevention640

“Please don’t hurt me. Heal me, and be nice to me.”

In that order, those are our patients’ most basic needs. Preventing errors and not harming patients are the most important responsibilities of every Texas Children’s employee.

Organization-wide Error Prevention Training launched last week to help ensure every one of us is equipped with the information and tools to keep patients safe.

This video explains why preventing errors is so critical and how each of us can make care safer at Texas Children’s.

“We take care of the sickest of the sick at Texas Children’s, and when you’re taking care of that many severely ill children, it’s a real challenge,” said President and CEO Mark A. Wallace. “Everyone recognizes that creating a safe environment – focusing on safety and error omission – is job one. Doing no harm to our patients is first and foremost.”

The Error Prevention work launched as part of the CareFirst initiative, began in January. CareFirst is primarily two things: an intense study of our core clinical areas at the main campus and an aggressive, strategic plan for how we will address our most crucial needs in those areas. The initiative is focused on the main campus Emergency Center, Critical Care units, and the Operating Rooms/PACU, because these areas provide the highly complex services that our most critically ill patients need. While CareFirst centers around expanding to better accommodate the critical needs of these high patient volume areas, its purpose is greater.

“If we don’t have the right environment, the right tools, the right people or the right structure, then it becomes very challenging to deliver the very best possible care – the safest care,” said Surgeon-in-Chief Dr. Charles D. Fraser. “Systems under duress – whether it be in the operating room or the emergency room or the intensive care unit – where there’s duress, then people become fatigued or distracted, and that’s an environment that is ripe for an error.”

The staff and employees involved in CareFirst work are vetting options to create the physical space and support needed in the core patient care areas. Combined with the Error Prevention training that kicked off last week, CareFirst ultimately will advance our efforts to ensure an optimal environment to receive and give the safest possible care.

“CareFirst is about making a promise to every child and woman who comes here that we will not harm them and equipping our facilities to ensure we keep that promise,” Wallace said. “It is far more comprehensive and much more important than expanding and building. It’s about doing what’s right for our employees and medical staff, and most importantly, what’s right for our patients, their families and their care. Ultimately, it’s about putting the care and safety of all of our patients and our people first.”

Error prevention training began in Hematology/Oncology in mid-July and will continue throughout other clinical areas over the next several months. In addition, online training will be provided for all non-clinical employees. Ultimately, every staff member and employee within Texas Children’s will receive error prevention training.

“My wish, my hope for every one of the 10,000 employees that will be going through training, that will hear about CareFirst, is that they stop and think about their individual role in supporting and delivering on zero harm,” said Chief Nursing Officer Lori Armstrong. “Everyone plays a role.”