Patient Safety: Lessons Learned

A Year in Review

December 2014

By Steven Chinn, DPM, MS, MBA, Administrative Director, Accreditation & Regulatory Affairs

2014 has been a year of continual improvements. As a hospital, we are more aware that bad things can happen to patients. This awareness has led to more reporting of potential and near miss events. In the last quarter alone, there was almost a 20 percent increase in SAFE reports compared to the previous year. Although physician reporting only constitutes about two percent of the total, the raw numbers overall are increasing. Managers are more aware of their responsibility to follow up and communicate with staff and physicians about issues and improvements that need to be made. And as a result, there are numerous ongoing initiatives to improve safety.

The Graduate Medical Education program with the guidance of Larry Katznelson, MD, Associate Dean, started the Residents' Safety Committee made up of residents and supported by faculty physicians and hospital administration. This committee has identified projects needed to improve the culture of safety, the SAFE reporting system and the handoff communication process. Many of the residents, like the front line nurses, are at the sharp end of care and are often the first to identify a broken system. And like many of us, when confronted with barriers or obstacles, residents will figure out a workaround, which may or may not be ideal or replicable.

The types of events that occurred over the past year could be classified as either having awareness or knowledge-based causes. We had unintended retained guide wires due to the proceduralist not being aware that you never let go of the wire during placement. There were medication orders selected with the incorrect dosing because the prescriber was not aware of the multiple or drop down options in EPIC. The patient who fell out of bed was probably unaware of the effects of the medication or the fact that the tubing and lines created a tethering effect. And then there is the issue of pressure ulcers. We suspect that some of these were present on admission to the hospital, but because the skin assessment was either incomplete or not documented, many cases of pressure ulcers had to be reported as a health care acquired condition.

Adverse events can occur to any patient, in any setting, at any time. As we all know, adverse events add no value to the patient and certainly contribute to cost. Patients have to undergo more interventions (more nursing and physician time), use precious resources (occupy beds that are needed for other reasons), create more dissatisfaction (for the patient, family and the care team) and are at increased risk for more health care acquired conditions. This list does not factor in our time to respond to queries from risk management, guest services or quality, as well as the multiple meetings we must attend to review and discuss these cases. Awareness of the impact of adverse events should be in all of our minds if we intend on making a difference in treating humanity, one patient at a time.

On December 2, 2014, the U.S. Department of Health & Human Services announced that efforts to improve patient safety nationally have resulted in an estimated 1.3 million fewer patients harmed, 50,000 lives saved and $12 billion in health spending avoided from 2010 to 2013. Click here to review the full report.

This improvement is due to a reduction in health care acquired conditions, such as adverse drug events, catheter-associated urinary tract infections, central line associated blood stream infections, pressure ulcers and surgical site infections.

At Stanford Health Care, we have made headway against many of these issues, but still have a ways to go. Let's make this coming year even safer for our patients. Happy Holidays!