Patient Safety

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Patient Safety

• Development of the Unit Based Patient Safety
  Officer

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East Alabama Medical Center
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EAMC

• 314 bed, Not-for-Profit Acute Care Hospital
• 38-bed Skilled Nursing Facility.
• Level II Trauma Center
• Opelika, Alabama
• 110 miles from Atlanta
• 120 miles from Birmingham

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History of Patient Safety and evolving Safe
Culture at EAMC

• Multiple Safety related committees
• Medication Safety Committee
• JCAHO Readiness Committee (NPSG)
• Environment of Care Committee (Life Safety Code)
• Nursing Documentation Committee
• Institutional Safety / Quality Measures in
  Strategic Goals
• Quality Initiatives
• CMS Demo Project
• SSIP
• IHI

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Model
Medication Review Committee
Environment of Care Committee
JCAHO Standards
Customer Service Committee
Partners in Care Program
IHI Initiatives
Quality Initiatives
Life Safety Code
Strategic Goals
Nursing Documentation Committee
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Model
Medication Review Committee
Environment of Care Committee
JCAHO Standards
Customer Service Committee
Unit Based Patient Safety Officer
Partners in Care Program
IHI Initiatives
Quality Initiatives
Life Safety Code
Strategic Goals
Nursing Documentation Committee
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Model
Medication Review Committee
Environment of Care Committee
JCAHO Standards
Customer Service Committee
Unit Based Patient Safety Officer
Partners in Care Program
IHI Initiatives
Quality Initiatives
Life Safety Code
Strategic Goals
Nursing Documentation Committee
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Selection Process of the Unit Based Patient
Safety Officer

• Vested Interest
• Staff Level Position
• Clinical Ladder Project
• Full Time
• Across shift coverage
• Multi-Departmental Experience
• Leadership Skills

East Alabama Medical Center Patient Safety
Officers
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Safety BootCamp

• Human Factor Engineering
• Design reliability into processes
• Effective Communication and Team Work
• Critical Conversation Tools
• SBAR Tool

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Daily Task of the Unit Based Patient Safety
Officer

• Daily Safety Briefing (Beginning and End of
  Shift)
• Environment of Care Rounds on Unit
• Daily Incident Reporting Follow-up
• Direct Patient Care
• Compliance Monitors
• Other Responsibilities
• Rapid Cycle Testing
• Staff Education

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Model Application

• Patient Safety Officer Meeting every other
  Tuesday
• 2 hour Meeting
• Set Agenda includes
• Medication Safety
• Fall Prevention
• Regulatory Compliance (NPSG)
• Quality Initiatives
• Departmental Reports
• Safety Briefings

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Daily Safety Briefing
Safety Briefing Start of Shift Check all that
apply Patients with SAME LAST NAME
________________________ Patients HIGH RISK
FOR FALL __________________________ Patients
in RESTRAINTS ______________________________
Patients with LATEX ALLERGY ____________________
______ Patients with PROCEDURES / SURGERY
__________________ REMINDERS
MEDICATION BUNDLE UPS
SCORE AT 10AM / 10PM and AFTER PROCEDURE
BRADEN SCORE / WOUND TREATMENT
SHEET End of Shift ______________________________
____________________ Any safety issues related to
MEDICATION TODAY _______________________________
___________________________ Any safety issues
related to FALLS _______________________________
___________________________ Other SAFETY ISSUES
__________________________________________________
________
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Medication Bundle

• Carry the MAR to the Room to compare the
  Medication pulled to Medication Ordered
• Say the name of the patient OUT LOUD as you
  compare the name on the armband to the name on
  the MAR
• Say the name of the medication OUT LOUD as you
  compare to Drug on MAR
• Chart the Medication on the MAR in the room as it
  is given

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Medication Error Reporting
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JCAHO National Patient Safety Goal

• Partners in Your Care Program
• Hand Washing
• Staff Education of Program
• Increase in Alcohol and Soap Usage
• July Focus
• CEOs Mother Judge Poster Presentations
• Protest against Germs

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Benefits of Unit Based PSO

• Ownership of Organizational Strategic Goals at
  the Departmental Level
• Ownership of Quality Initiatives at the
  Departmental Level
• Ownership of Cultural Change at the Departmental
  Level

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Ownership
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Barriers

• Staff Responsibilities Direct Patient Care
  Priority
• Departmental Variations Long Term / Acute Care
• Shift Variations Functionality
• Project Overload So much to do..so little time
  to do it
• Staff Resentment Compensation

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Compensation

• Financial
• 1.00 per hour
• Leadership Development
• Clinical Ladder Projects
• Annual Safety Conference Travel

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Summation of our Goal

• Create an environment that supports patient
  safety
• Just Culture
• Support Departmental and Institutional
  Quality/Safety Initiatives
• Develop,Implement and Evaluate Best Practices in
  their departments.

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What have we learned along the way?

• The best ideas come from those who actually
  perform the work. LISTEN
• Empower the work force to make things happen.

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Questions?

• ?

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Contact Information

• Marty Ledbetter
• East Alabama Medical Center
• 2000 Pepperell Pkwy
• Opelika, AL 36801
• 334 528 3008
• Marty_Ledbetter_at_eamc.org