Tackling the Top 10 Patient Safety Concerns with a Culture of Safety – Part 2

The ECRI Institute recently published their Top 10 Patient Safety Concerns for Healthcare Organizations for 2017. In part 1 of this article, we explored some ways you can target these concerns by developing a culture of safety.

Let’s finish our countdown with the remaining top 5 patient safety concerns for healthcare organizations.  

5. Antimicrobial Stewardship

The CDC has been pushing antimicrobial stewardship for quite some time, and it’s still a major issue. We just don’t have antibiotics anymore that can treat bacterial infections because we’ve been abusing them for so long. So, what can organizations do?

The first strategy is to hold subscribers accountable. If physicians are prescribing, we have to hold them accountable and set the guidelines. Some organizations have started with a physician advocate since physicians are more likely to listen to other physicians. Educating patients, families and the general public is important too, as are automatic stop orders.

Once again, leadership from the top is essential in addressing this safety issue. Leadership includes your medical staff and your pharmacist as well. Everyone has to be committed to the outcome and be held accountable. Use your physician peer-to-peer relationship and include your pharmacist as well as your physicians.

Once you have leadership buy-in, work on tracking your safety events. You need to be doing this in real-time, not after the fact or three months later. There’s no point in presenting data to a committee with information that’s so old it can’t possibly be used.

You also need to be tracking your implementation of your processes, including automatic stop orders. Does your pharmacist have a way to report interventions with an automated process that uses one sheet, one entry form and one process? When they click, is all the information they need available? Let technology work for you. Technology should always be one of the action steps that you put in your performance improvement action plans. It’s not just about tracking action tracking. It’s improving so you can take action.

One way to start is with a hierarchy of action steps. We all tend to do the same things over and over again and then wonder why the problem pops up again next year. The National Center for Patient Safety offers a recommended hierarchy of actions, ranging from stronger to weaker actions. Looking at the weaker actions, we can see that often, the only steps we take are about creating a new process. We say, “Let’s just change the policy. Let’s just train everybody, because the problem is always the staff. We have to train them, educate them and coach them.”

This is the wrong approach. Look at the process instead. Weight and monitor your strong actions and see what’s working best at your facility. Take new devices, for example. Do you have a safety event that lets your staff enter near misses and the actual events that happened as a result of equipment? Whether it’s IT, medical equipment or alarms, you want to be able to get those near misses up front so you can identify what needs to be bought. Equipment costs money, and we know how hard that is to get sometimes.

Device use, purchasing and testing is another high strong action plan. Standardizing equipment can be done with new practices and processes streamlined to eliminate redundancy. Engineering control or interlock (forcing functions) allows you to create your systems that can walk you through a workflow process. Workflow processes are great because they lock you out forcing you into the right direction and educating you along the way.

Don’t forget to include checklists. This is a perfect process to use with a mobile device. As you are walking around the facility, you can be looking at information like patient identification and surgical procedures and watching people work in real time. Read back is also critical. Enhancing the documentation and communication is a good weighted action step.

Now that you’re empowered with this information, go back and look at your action plans. Help your staff. Get them excited about really doing something productive. They need to not just be blaming someone but looking at the process.

4. Critical Test Result Reporting and Follow-Up

We’ve been doing critical test results for a very long time, but they’re still a problem because clinicians and departments are still so focused on tasks. You’ve got to get the paper filled out, the order done, the lab drawn and get the test. Then what? What are you supposed to do next?

The first step is to analyze your test process. Have a very specific safety event that doesn’t focus just on labs, but radiology too. All of the accreditation agencies are looking at radiologic testing, and this process has a huge impact from a safety perspective. Have all the steps in the processes and create a report immediately, with a click of the button, and drill down to your problems.

This process can give you a huge return on investment. When you go back to your facilities, you can tell them that you need a process that’s going to give you real-time information, right now, that you can click and filter and drill down into. You need dynamic data, not dead data, so you can get information back immediately and actually analyze and use it.

3. Implementation and Use of Clinical Decision Support

This safety concern is mostly about your EHR. However, while EHR has an important function and is concerned with the care of the patient, decision support is something you can be doing as well. Quality risk is operations. Let’s look at some of the strategies you can use to support your staff.

You’re probably already using physician order entry with protocol orders. But what about flags and alerts? Everybody thinks about putting them in the EHR, but what about in your safety event processes? What about in your quality processes? Do you have a very simple visual way to see exactly what you need to focus and work on?

Visibility and accessibility are very important. Why have data and analysis charts if your staff doesn’t know about them, are the last people to know or are waiting for a paper post to be out on the unit sometime after the committee meeting three months later? You want visibility and accessibility in real-time, with a click of the button.

What about IT and clinical? Although we’re now seeing clinical informatics in facilities, most still rely on history, structure and the way things have always been done. We have to overcome this barrier. We need a workplace focused on performance with quality risk management platform that we can go and use every day as an information management system. That’s a vast improvement over focusing everything on EHR.

2. Unrecognized Patient Deterioration

Healthcare has done a great job over the past several years to really monitor care, including following best practices for stroke, heart attacks and similar events. We need to approach patient deterioration the same way. Rapid response teams worked for a long time, but they seem to have dropped off of the radar. We need to go back to assessing the patients, and that goes back to your nursing process.

Assessing a patient’s risk early is not just a check box on an admission documentation, but a thorough assessment that really identifies the risks for deterioration. Teach your staff more and cultivate their competencies. Redevelop that rapid response team. They need to be able to plan appropriate care for everyone’s individual needs based on that risk assessment. It’s not a standard, with standard vital signs, medications and safety rounds. It needs to be individualized. Use your tools, all those clinical systems that create flags, and use your quality risk management platform too. That’s the one that will give you early warning ideas.

Plan for appropriate care and educate your patients as well. It’s critical to involve the patient in everything you do. Your technical monitoring should be monitoring your practice as well as your patients. You already have compliance checklists for things like sepsis, maternal serious events, clinical bundles, etc., so use all of those. Automate them, put them on a mobile and go around and use them in real time.


1. Information Management in EHRs

Information management is about your EHR, and it’s a great system where everything can be standardized and completed. One thing you should have done immediately when implementing your EHR system was to get your frontline staff involved. One problem you might be facing, however, is turnover. When this happens, new staff members fail to adopt the system because some of them don’t like automation. But that doesn’t mean you should stop tracking.

Here are 10 serious issues still plaguing information management. Some of them have been around for a long time and are not only high-volume problems, but also have the highest potential to cause harm.

  1. Infusion errors can be deadly if simple safety steps overlooked
  2. Inadequate cleaning of complex reusable instruments can lead to infections
  3. Missed ventilator alarms can lead to patient harm
  4. Undetected opioid-induced respiratory depressions
  5. Infection risks with heater-cooler devices used in CV surgery
  6. Software management gaps put patients and data at risk
  7. Occupational radiation hazards in hybrid ORs
  8. Automated dispensing cabinet setup and user errors cause medication mishaps
  9. Surgical staples misuse and malfunctions
  10. Device failures caused by cleaning products and practices.  

Building a Culture of Safety

When all is said and done, a culture of safety is about core values and behaviors resulting from a collective and sustained commitment by organizational leaders and managers in healthcare that emphasize safety every day.

Every day when your staff walks into the facility, safety should be priority number one. Let’s all do the safety dance, because that’s what it’s all about. Make it fun every day. It’s not a drudgery, but something we need to do for each other.

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About the Author Faris Islam


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