Patient Safety - Fall Prevention
Improving Perinatal Care
Medication Reconciliation
For Information about these or any of the quality improvement projects at Northeastern Vermont Regional Hospital, contact:
Colleen Sinon, VP Quality Management
802-748-7349
c.sinon@nvrh.org
PO Box 905
St. Johnsbury, VT 05819
| PROJECT NAME: Patient Safety - Fall Prevention |
TIME FRAME: January 2005 - December 2007
DESCRIPTION: Patient Safety - Fall Prevention
As part of the admissions process, patients are evaluated/assessed on their risk for falling. If determined a high risk for falling, the patient will be given a yellow lap blanket, yellow socks and a yellow bracelet to wear - so he/she is easily identified by all hospital staff. The color yellow was chosen because it serves as a symbol for “caution”. Staff will automatically know that these patients should not be walking around/moving without assistance. The project is a proactive strategy to lower the average fall rate of patients at NVRH, with the goal of eliminating patient falls.
DESCRIPTION OF THE PROBLEM, INCLUDING HOW THE PROBLEM WAS IDENTIFIED AND SUPPORTING DATA:
Across the country, hospitals have high patient fall rates. In 2002, IHI sponsored an initiative, Quantum Leaps in Patient Safety, to work on preventing falls in hospitals. In an effort to continue this initiative, NVRH, which has a lower fall rate the national average, created it’s own fall prevention program in an effort to continue improvement of patient safety. PROJECT GOAL, WITH APPROPRIATE MEASURE:
• Goal: Reduce the fall rate, and eventually eliminate patient falls with a proactive approach to promoting patient safety.
Measure: Decrease in patient falls, eventual result being no falls.
• Goal: Educate the entire hospital community and increase awareness of the fall prevention program. It’s a community-wide effort.
Measure: Hospital staff understanding the use of the yellow (“caution”) socks, bracelets and lap blankets and knowing what to do if a patient appears at risk.
DESCRIPTION OF INTERVENTIONS AND BACKGROUND:
An off-shoot from the Lift Free Team, the Fall Prevention team was created to design a proactive, systematic approach to prevent patient falls in the hospital. After doing research, the team outlined a program and presented it to the rest of the staff for their input. The program included identifying patients who were at risk for falling with socks, bracelets and lap blankets of a designated color, making it obvious to all staff that the patient is at risk of falling. The team surveyed the staff to determine the best color to use to identify these patients. The staff consensus was yellow because it represented the need to use “caution”.
Yellow socks, lap blankets and bracelets have been ordered, and Mary Young, Fall Prevention Team leader, created the signs to be placed in the bathrooms of the patient rooms, to serve as a reminder to the patient to call for help instead of trying to use the bathroom on his/her own.
During the time of admission, patients are evaluated/assessed and are determined whether or not they are at risk for falling. A number of criteria are taken into consideration to determine the level of risk, for example: history of falls prior to or during hospitalization, contributory diagnoses, gait disturbances, cognitive ability/developmental status, and presence of tubes/line.
Once a patient is determined a high risk and is admitted, she/he will be given the yellow lap blanket, the yellow bracelet and yellow socks so they are easily identified by any hospital staff.
EVALUATION PROCESS AND RESULTS, IF AVAILABLE:
• The hospital keeps records of all patient falls (which is already a low percentage); the Fall Team and clinical management will track these numbers monthly to follow progress of the fall prevention program.
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| PROJECT NAME: Improving Perinatal Care |
TIME FRAME: June 2006 - present
DESCRIPTION: NVRH has joined the ranks of over 40 other hospitals from across the country in the Learning and Innovation Community for Improving Perinatal Care through the Institute for Healthcare Improvement’s (IHI) IMPACT Network. Led by Doreen Brado, RN, BC, MSN, the NVRH Perinatal Care Team, comprised of physicians, nurses, certified nurse midwives, and senior management, has collaborated with the other hospitals on strategies to ensure high quality perinatal care including:
• applying IHI’s reliability model
• implementing Elective Induction and Augmentation Bundles
• adopting a common language for electronic fetal monitoring and training all members of the care team together in its use
• applying appropriate communication techniques
• adopting processes to understand and honor patient preferences
• communicating with patients to better manage and reduce risk
IHI’s Perinatal Trigger Tool, used to identify adverse events in the perinatal period, has been utilized to assist the team in developing a focus for improvement projects.
DESCRIPTION OF THE PROBLEM, INCLUDING HOW THE PROBLEM WAS IDENTIFIED AND SUPPORTING DATA: NVRH formed a perinatal care team to evaluate clinical practice, safety, and patient outcomes. Good care relies on effective, high functioning teams, complemented by complete and accurate documentation of all care provided. Historically, training and education for physicians and nurses occurred separately. Through participating in the (IHI) Improving Perinatal Care Community, the NVRH team has moved to a model of collaborative training..
PROJECT GOAL, WITH APPROPRIATE MEASURE: Ensure high quality perinatal care through a model of collaborative training for physicians and nurses in the areas of:
• Goal: “Bundle” implementation to improve delivery of perinatal care for both mom and baby.
Measure: Chart audits reveal documentation and assessment complete and accurate before augmentations.
• Goal: Focusing on patient centeredness
Measure: Mother (and family) feel well informed/educated on situation to feel in control of the birth process.
• Goal: Ensuring a timely and efficient system
Measure: Communication and teamwork will serve as the driving force in superior patient care.
DESCRIPTION OF THE INTERVENTION(S):
This initiative has three main areas of focus:
1) Improving the safety, effectiveness, and reliability of care - The team will examine and develop processes that help create a culture of patient safety, and that clinicians believe are important in contributing to good care for both the mother and the fetus. Teams will implement “bundles” focusing on improving the delivery of perinatal care. This is the area of focus that the NVRH Team is currently implementing.
2) Focusing on Patient Centeredness - ensuring that mother (and family) have all the knowledge needed to make informed decisions about care, and that they are the source of control on the birth process is a key principle.
3) Ensuring a Timely and Efficient System - NVRH will apply principles of a high reliability organization. Focus on developing processes to improve communication and teamwork will result in a clear understanding of what is needed for superior patient care, for all members of the team at all times.
The NVRH Perinatal Care Team is currently implementing two “bundles” in their effort to improve delivery of perinatal care: the Elective Induction Bundle and the Augmentation Bundle.
For this initiative, a combination of experts and front-line practitioners have identified “best practice” processes from the research and evidence that will decrease the risk of birth trauma and other adverse events. The individual processes are elements of a larger entity called a “bundle” - a group of interventions related to a disease or care process, when executed together, result in better outcomes than when implemented individually. For example, the Elective Induction Bundle looks at ensuring certain aspects have been considered and documented prior to initiating an induction of labor. The specific information this bundle is focusing on is: documentation of gestational age, documentation of fetal well being, documentation of a complete pelvic assessment (including cervical examination), and documentation of the absence of hyperstimulation (excessive stimulation of uterine contractions) during the intervention. The Augmentation Bundle looks at similar information. Estimated fetal weight, reassuring fetal status, pelvic examination, and absence of hyperstimulation, all must be assessed and documented prior to the start of augmentation. In order to successfully implement these bundles, the NVRH Perinatal Care Team has had to work on adopting a process that works for all care providers.
EVALUATION PROCESS AND RESULTS, IF AVAILABLE: NVRH utilizes an IHI tool that looks at the patient’s entire record. Nurses do regular audits of patients’ charts to ensure accuracy and continued improvements. The trigger tool goes through the specific areas of the chart that should have specific standardized documentation. This process increases awareness to the providers and staff and creates a healthy rapport. For example, ensuring that obstetrical providers and nurses have the same interpretation of a clinical situation and are utilizing a “common language” are imperative. This project is creating new avenues for providing educational opportunities. All of this leads to improved documentation with the outcome of more accurate data. Often times it’s the nursing staff doing the auditing, communicating their findings to the team and identifying areas needing improvement as well as suggesting possible solutions. This has proven to be a powerful tool, giving the providers and staff ownership of the process and a sense of accomplishments as they see the positive results of their efforts.
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| PROJECT NAME: Medication Reconciliation |
TIME FRAME: January 2005 - ongoing
DESCRIPTION: Medication reconciliation is the process to evaluate the patient’s current medication regimen and assure that an accurate record is maintained throughout the hospital stay.
DESCRIPTION OF THE PROBLEM, INCLUDING HOW THE PROBLEM WAS IDENTIFIED AND SUPPORTING DATA:
The medication reconciliation program came to NVRH by way of several different committees that are involved in reducing medication errors. The initiative was originally part of the Institute of Healthcare Improvement’s 100,000 Lives Campaign. Stemming from IHI’s six interventions, that have as their goal the saving of 100,000 lives from hospital errors, NVRH implemented its own Medication Reconciliation Action Team (MRAT). While collecting patient medication lists had always been a pertinent aspect of the nurse’s admission assessment, the work of the MRAT group was to streamline the job, and fine tune it to the hospital’s information system.
Studies have found that a particularly vulnerable time for medication errors is at the time of “hand-off”, when a patient is transferred between services or departments. With a system in place where medication reconciliation has already been addressed on one page, the likelihood of errors is greatly reduced.
The biggest hurdle is that medical staff needs to rely on the patient for an accurate listing of medication. The process is only as good as the information provided by the patient.
PROJECT GOAL, WITH APPROPRIATE MEASURE:
• Goal: To help improve patient safety, reduce risk of adverse drug events, and improve satisfaction with healthcare experience.
Measure: Patient satisfaction with healthcare experience.
• Goal: To have an effective process for obtaining and documenting a complete list of the patient’s medications, with the patients involvement upon admission to the hospital.
Measure: Use of admission assessment screen in information system developed by MRAT Team and IS department, data is used to produce Medication Reconciliation Form and placed in patient’s chart for physician use.
• Goal: Creation of a user-friendly process and tools that will add value to the patient safety program and support clinical management from the physicians perspective.
Measure: Physicians, clinical staff and management use the new process and tools with ease, in turn improving patient care and satisfaction.
DESCRIPTION OF INTERVENTIONS AND BACKGROUND:
The MRAT team has worked closely with the Information Services Department to develop transfer/discharge forms that are produced from the hospital’s information system once the data collected during the admission process has been entered into the system. The admission piece of the medication reconciliation process is only intended as a starting point from which the physician can evaluate the situation and order the appropriate medications for the hospital stay. The potential lack of accuracy is the reason for reconciling the list.
The medication reconciliation form is the tool used to document the current medication list based on information from the patient, caregiver, or pharmacy, if necessary. The medication list is printed, evaluated for accuracy, edited if needed, then placed in the patient’s chart, in the physician order section. The attending physician is responsible for reconciling each prescription, over-the-counter medication, and herbal preparation. The medication reconciliation process needs to occur prior to the patient receiving any medications. Every effort should be made to reconcile the medication list upon admission.
EVALUATION PROCESS AND RESULTS, IF AVAILABLE:
The MRAT Team meets to address the reconciliation process and gather physician specific information regarding use of forms as well as try to determine the perceived value of the program. The focus is on creation of a user friendly process and tools that will add value to the patient safety program and support clinical management from the physician perspective.
Throughout the implementation of using the transfer/discharge medication reconciliation form it has been determined that there should be two separate forms for transfer and discharge. The MRAT team are taking the necessary steps to implement this change and will continue to monitor progress.
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