Check your Greatness Profile
Patient Safety and Error Reduction Profile
This process provides the hospital with a rapid assessment and benchmarking tool to evaluate its global performance in the area of patient safety and hospital error reduction. It evaluates performance and capability in the following six areas:
· Governance and accountability
· Management practices
· Audit, analysis and corrective actions
· Culture
· Systems and Human Factors
o Prevention
o Surveillance
o Reporting
· Medical care.
The assessment uses a combination of qualitative and quantitative techniques that include direct interviews with key individuals, inspection of critical documents and policies and a limited analysis of key data sets. The results demonstrate where the hospital currently stands in relationship to evolving best practices and expectations targets areas of opportunity.
The results can also direct the leadership to high impact areas and evidence-based strategies that
 | Eliminate medical errors |
| Improve clinical outcome |
| Enhance patient satisfaction, trust and confidence |
| Reduce costs |
Profile Content and Audit Areas
Part 1. Governance and Accountability
· Do the organizational values and mission place an appropriate emphasis on accountability and prevention?
· Is the board creating a positive atmosphere and context for reporting
o Are there clear policies to report errors to patients
§ Do they comply with JCAHO recommendations on disclosure? Compare with VA system?
o Are there policies for reporting to state bodies where required?
· Does the governing board monitor organizational performance and trends, and does it establish minimum standards of performance for key quality and safety indicators?
Part 2. Management practices from outside health care
Has the organization achieved deemed status (private sector certification of federal and state quality requirements) through accreditation with JCAHO or AOA? Basic state and federal safety, Life Safety Code?
Are established industry approaches utilized in infectious disease surveillance, prevention and control; and
blood and blood product handling such as:
· Incident reporting
· Root cause analysis
· Automated medication dispensing systems
· Bar coding technology to avoid misidentification errors
· Aviation‑style checklists for care processes that can be routinized
· Promoting a "culture of safety"
· Crew resource management, a model for teamwork training and crisis response
· Simulators (of patients or clinical scenarios) as a training tool
· Human factors theory in the design of medical devices and alarms
· Risk Management Committees
o Does the hospital have a formal Risk Management Program?
o Does this program emphasize ‘damage control’ or does it have a record of performance that includes prevention, error reduction and quality improvement?
Part 3. Audit, Analysis and Corrective actions.
· To what degree does audit of billing data demonstrate gaps in detection, internal reporting and analysis of process of care breakdowns?
· To what degree does the other organizational surveillance and detection tools and committee integrate information that bears on quality, safety and error prevention?
o How vulnerable to suppression or loss is this information, are critical time lags or bottlenecks apparent?
Part 4. Organization, Structure, and Culture
· “Closed" Intensive Care Units and Other Models of Care for Critically III Patients
· Nurse Staffing, Models of Care Delivery, and Interventions
· Promoting a Culture of Safety
Part 5. Systems Issues and Human Factors
· Human Factors and Medical Devices
o The Use of Human Factors in Reducing Device‑related Medical Errors
o Refining the Performance of Medical Device Alarms
o Equipment Checklists in Anesthesia
· Fatigue, Sleepiness, and Medical Errors
· Information
o Information capture and integration
o Information Transfer
§ Information Transfer Between Inpatient and Outpatient Pharmacies
§ Sign‑Out Systems for Cross‑Coverage
§ Discharge Summaries and Follow‑up
§ Notifying Patients of Abnormal Results
o Prevention of Misidentifications
§ Bar Coding
o Strategies to Avoid Wrong‑Site Surgery
o Computerized physician order entry and decision support as a means of reducing medication errors
· Crew Resource Management and its Applications in Medicine
o Incident response training
§ Code 99
§ Trauma response
§ Dangerous or threatening patient
§ Community disaster
· Internal and external
o Simulator‑Based Training and Patient Safety
· Safety During Transportation of Critically III Patients
o Interhospital Transport
o Intrahospital Transpor
PART 6. MEDICAL CARE
To what degree are the following clinical approaches part of the basic strategy of improving clinical quality and safety?
| Morbidity and Mortality Conferences |
| Autopsy |
| Medical Staff or Departmental Grand Rounds |
| Bioterrorism Response Plan |
| Evidence Based Patient Safety Practices & Targets (From “Making Health Care Safer” Items in italics represent the most highly rated practices.) |
Section A. Adverse Drug Events (ADEs)
Section B. Infection Control
Section C. Surgery, Anesthesia, and Peri-operative Medicine
Section D. Safety Practices for Hospitalized or Institutionalized Elders
Section E. General Clinical Topics
Section F. Role of the Patient
Section A. Adverse Drug Events (ADEs)
Ø Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs)
Ø The Clinical Pharmacist's Role in Preventing Adverse Drug Events
Ø Computer Adverse Drug Event (ADE) Detection and Alerts
Ø Protocols for High‑Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants
Ø Unit‑Dose Drug Distribution Systems
Ø Automated Medication Dispensing Devices
Section B. Infection Control
Ø Practices to Improve Hand washing Compliance
Ø Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections
Ø Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance ‑ Clostridium. Difficile and Vancomycin‑resistant Enterococcus (VRE)
Ø Prevention of Nosocomial Urinary Tract Infections
§ Use of Silver Alloy Urinary Catheters
§ Use of Suprapubic Catheters
Ø Prevention of Intravascular Catheter‑Associated Infections
§ Use of Maximum Barrier Precautions during Central Venous Catheter Insertion
§ Use of Central Venous Catheters Coated with Antibacterial or Antiseptic Agents
§ Use of Chlorhexidine Gluconate at the Central Venous Catheter Insertion Site Subchapter Other Practices
Ø Prevention of Ventilator‑Associated Pneumonia (VAP)
§ Patient Positioning: Semi‑recumbent Positioning and Continuous Oscillation Subchapter
§ Continuous Aspiration of Subglottic Secretions (CASS)
§ Selective Digestive Tract Decontamination
§ Sucralfate and Prevention of VAP
Section C. Surgery, Anesthesia, and Peri-operative Medicine
Ø Localizing Care to High‑Volume Centers
Ø Learning Curves for New Procedures ‑ the Case of Laparoscopic Cholecystectomy
Ø Prevention of Surgical Site Infections
§ Prophylactic Antibiotics
§ Peri-operative Normothermia
§ Supplemental Peri-operative Oxygen
§ Peri-operative Glucose Control
Ø Ultrasound Guidance of Central Vein Catheterization
Ø The Retained Surgical Sponge
Ø Pre‑Anesthesia Checklists To Improve Patient Safety
Ø The Impact Of Intraoperative Monitoring On Patient Safety
Ø Beta‑blockers and Reduction of Peri-operative Cardiac Events
Section D. Safety Practices for Hospitalized or Institutionalized Elders
Ø Prevention of Falls in Hospitalized and Institutionalized Older People
§ Identification Bracelets for High‑Risk Patients
§ Interventions that Decrease the Use of Physical Restraints
§ Bed Alarms
§ Special Hospital Flooring Materials to Reduce Injuries from Patient Falls
§ Hip Protectors to Prevent Hip Fracture
Ø Prevention of Pressure Ulcers in Older Patients
§ Use of pressure relieving bedding materials
Ø Prevention of Delirium in Older Hospitalized Patients
Ø Multidisciplinary Geriatric Consultation Services
Ø Geriatric Evaluation and Management Units for Hospitalized Patients
Section E. General Clinical Topics
Ø Prevention of Venous Thromboembolism
Ø Prevention of Contrast‑Induced Nephropathy
Ø Nutritional Support
§ With a particular emphasis on early enteral nutrition in critically ill and surgical patients
Ø Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients
Ø Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans
Ø Pneumococcal Vaccination Prior to Hospital Discharge
Ø Pain Management
Ø Use of Analgesics in the Acute Abdomen
Ø Acute Pain Services
Ø Prophylactic Anti-emetics During Patient‑controlled Analgesia Therapy
Ø Non‑pharmacologic Interventions for Postoperative Plan
Section F. Role of the Patient
Ø Procedures For Obtaining Informed Consent
§ Asking that patients recall and restate what they were told
Ø Advance Planning For End‑of‑Life Care
Ø Other Practices Related to Patient Participation
© Kluber and Courtright, CareCompanion 2003