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Safety Counts! a newsletter highlighting safety at Hallmark Health System
Safety Counts Jan 2015 - Download entire PDF by clicking
Vol 3, No. 1, Jan 2015
Emergency Preparedness, policies and awareness are key
When the first patient diagnosed with the Ebola virus in the U.S. was admitted to a hospital in Dallas in September, Hallmark Health System (HHS) already had a general emergency plan in place and detailed policies relating to infectious disease precautions. The plan is regularly tested through mock drills, some of which have included proper protocol for protective suiting.
Rick Westhaver, RN, emergency preparedness coordinator, and Gerri Healey, director of respiratory services, built on this solid foundation to develop a specific plan to standardize the risk assessment, triage, transportation and management of patients with possible or confirmed cases of the Ebola virus. The plan follows guidelines developed by the CDC and the Massachusetts Department of Public Health, “but tailored to what works in our system,” said Westhaver.
HHS’s Ebola guidelines require Personal Protective Equipment (PPE) that covers all exposed skin and a buddy system to ensure proper protocol for putting on and taking off the protective suiting in a portable anteroom set up outside designated isolation rooms. Also part of the protocol is a security officer stationed at the door who controls access.
In addition, Westhaver and Healey have conducted dozens of trainings in person and through net-learning. “We initially concentrated on Emergency Department and Admitting staff and outpatient practices,” and we’ve probably spoken to 600 staff by now,” he said. They also have provided videos and weekly email updates.
“We need to train a lot of people to be ready to execute a plan that we may never need,” he said. “Staff has been great in embracing the training and in educating themselves about the virus. The bottom line is that we are ready.”
The five "rights" of
It was her first day off orientation as a nurse at Melrose-Wakefield Hospital and an extremely busy day on her inpatient floor. Among her patients was a very sick man with a tracheostomy and a feeding tube. He also had diabetes and required regular administrations of insulin.
“I was running behind and had several patients who needed their meds,” she said. Many patients with diabetes are on a sliding scale of medications; the dose varies depending on the blood sugar level. The policy for sliding-scale insulin administration is to get a co-signer for the medication “to doublecheck that the dose is correct,” she added. She found a fellow nurse – someone with 20 years of experience – who co-signed and the patient got his insulin. Because it was so busy, the dose was not verified and the patient received a higher dose than he needed.
“I didn’t realize I’d made an error until I got to my next patient and was following the protocol,” she said. She immediately told the charge nurse, who called a supervisor and a physician. The patient was given a second medication to counteract the extra insulin and was monitored closely overnight. Fortunately, the error did not cause him harm.
“I felt terrible. I don’t know how I made it through that first shift,” she said. “I was going to quit. But everyone was very supportive. I sat down with senior managers and we talked about how the error happened and what processes could be put in place to minimize the chance of this type of error happening again.”
She has learned three very valuable lessons. “First, stop and think. Ask yourself ‘does this make sense for this patient’? Second, take your time when administering medications, even if you are being pulled in several directions, and follow the policies in place. And third, speak up when you make an error. It’s much better to be embarrassed than to have harmed a patient!”
Revitalized committee looks at products, protocols to improve safety around needles and other sharps
The CDC estimates that across the country more than 1,000 hospital staff are injured each day with some kind of needle or other sharp instrument or device. In Massachusetts, all sharps injuries are reported to the Department of Public Health and at HHS that reporting is done by Occupational Health staff.
While HHS is doing well in keeping the rate of sharps injuries down, a newly revitalized sharps committee wants to do even better. Committee members represent key areas and staff involved in purchasing, using, cleaning, and disposing of sharps – central supply, purchasing and facilities; nurses, physicians, phlebotomists; and outpatient physician practices.
“Our primary mission is to study trends in sharps injuries and to evaluate products and procedures used throughout HHS that relate to sharps safety, recommending changes as needed,” said Pat Conway, RN, practice coordinator of Employee Health and Infection Prevention.
Safety scalpels used in the operating rooms are one class of product under discussion and trial. Each trial enables staff input on the pros and cons of the product before a final decision is made. “We also evaluated a recent needlestick trend for the slide-up-and-lock type of insulin needle,” said Conway. The vendor was notified and staff reeducated on proper use of the safety feature, which led to an immediate reduction in needlesticks.
Although the committee has only been working for a few months, “we are committed to reducing the risk of employees incurring sharps injuries by identifying and implementing safe alternatives wherever we can,” said Conway.
A vital step in ensuring patient safety
Medication reconciliation is a best-practice, standardized process that results in a complete, accurate and current list of a patient’s medications. While medication reconciliation is important at all stages of care, it’s particularly important when patients transition from one level of care to another – from hospital to home, for example.
“This is a critical stage,” said Kathy Foss, RN, director of Quality and Patient Safety for Hallmark Health VNA and Hospice, “since so many things can be changing for patients in a very short period of time. For example, the medications a patient was given in the hospital may be different, or may be a different dosage, than those the patient had been taking at home. Even nuances in meds, such as brand-name versus generic, can make a difference.”
At each visit, home health staff not only verify the medications list with the physician but also review medications with the patient and family, including how the patient is taking a medication. “Teaching patients or family members to manage medications is critical to their success in remaining healthy and at home,” said Sylena Keeping, RN, vice president of operations.
During a home visit, staff also assess the effectiveness of medications prescribed, occurrence of side effects and adherence to medication regimen, and consult with the patient’s physician as needed.
The Hallmark Health VNA and Hospice adheres to guidelines set forth in the national Home Health Quality Improvement campaign and its best practice intervention package for medication management.“
Medication errors are the number one cause of rehospitalization for patients recently discharged,” said Keeping. “The purpose of medication reconciliation is preventing errors during the transition from one care setting to another and ensuring safe medication management among all care settings. This requires timely and accurate communication and collaboration among all providers of care.”