1. Things That Work: Patient Safety Walk Rounds
Marlene R. Miller, M.D., M.Sc.
Karen Frush, M.D.

2. Safety ‘Walk Rounds’
“Organizations improve upon safety only when leaders are visibly committed to change, when they enable staff to openly share safety information, and when staff feel that their comments are heard and acted upon. When an organization does not have such a culture, staff members are often unwilling to report adverse events and unsafe conditions because they fear reprisal or believe reporting won’t result in change.”

3. The Hopkins Experience

4. Children’s Center Safety Rounds
Every Wednesday 10:00 AM (since 2003)
Every Tuesday 10:00 AM (since 12/2004)
Covers all Children’s Center units and outpatient clinics and Emergency Dept and Pediatric Pharmacy
C9, 8W, PICU, RR, C6, C4, 3E, PCRU, NICU, Peds ED, HLPC, Pharmacy, JHOC Specialty Clinics
Senior Leaders (Chairman, Chief of Surgery, Board of Trustees)
Focus on proactive safety concerns

5. Scope & Impact of Safety Rounds
Total # issues/projects: 145
Active issues/projects = 43
Completed issues/projects = 102
Each unit/clinic has 3-5 active issues/projects
At first, much ‘low hanging fruit’; issues are more complex now
Units now keep lists and wait for us
¾ of units had Safety Climate scores >60%

6. “next patient will be harmed by 4 vials…”

7. New Products

9. Zofran/Anzemet
JHH therapeutic interchange made Anzemet first drug of choice for nausea
It is not uncommon for patient to not respond to Anzemet and need Zofran
Zofran needed to specially come up from Pharmacy
WHAT ABOUT THE RECOVERY ROOM?
Worked with P&T Committee to place Zofran in all Recovery Rooms

11. Safer Outpatient Prescribing
No requirement to record a weight on pediatric prescriptions
Without a weight, an external pharmacy that wanted to dose check was powerless
Revamped all ambulatory prescription pads to include a line for recording weight
Required that JHH Pharmacies perform a weight-based dose check before dispensing

12. Safety Needles….safer for whom?
Entire hospital changed to safety needles
HLPC found over several months that ~8 25G needles had no holes bored
(HLPC does >150 immunizations a week)
Worked with JHH, pulled needle from CC, substituted new safety needle, no further problems

14. The Duke Experience

15. Tools to Improve the Culture of Safety
Voluntary Reporting System
Non-punitive reporting policy
Team training; Crew Resource Management
Unit based safety teams
Safety walk rounds

16. Goals of Safety Walk Rounds
Identify procedures or processes that could put patients at risk
Identify opportunities to improve care and reduce risk
Close the gap between leadership and frontline perspectives on safety
Allow executives opportunities to model safety as a priority, provide appropriate resources to improve care

17. Safety Walk Rounds Initiated in Children’s Hospital January 2004
Included all areas caring for children
Intermediate care, ICN, PICU, BMT, FTN, ED, Psychiatry, Radiology, CHC (outpatient)
Improvement in hospital safety survey noted by October 2004
Expanded to Duke University Hospital January 2005

18. Identifying Problems: What’s the Next Thing To Harm a Patient?
Medication safety
PICU - expired syringes
PBMT – late medication delivery
Home Health – pump labeling

19. Identifying Problems: What’s the Next Thing To Harm a Patient
Identifying Problems: What’s the Next Thing To Harm a Patient? Medication Safety

20. Identifying Problems: What’s the Next Thing To Harm a Patient?
Environment of care
Patient security
Unrestricted access
Hazardous environments

21. Identifying Problems: What’s the Next Thing To Harm a Patient
Identifying Problems: What’s the Next Thing To Harm a Patient? Environment of Care

22. Identifying Problems: What’s the Next Thing To Harm a Patient?
Patient identification
ID bands
Name changes

23. Solving Problems: Patient Name Changes
Safety risk: name changes in patients, especially from ICN, lead to incorrect radiographic study/procedure performed:
Approximately 40 events in past year
Unnecessary exposure to radiation
Potential risk of complications associated with unnecessary procedure
Initial interventions:
Limited in scope (Peds Radiology and ICN)
Policy and procedure focused – errors still occurring
“The problem is unsolvable”

24. Impact of Safety Walk Rounds
Concern raised during walk rounds with Chief Patient Safety Officer and hospital executives
Other departments experienced similar issues
RCA: > 3000 potential entry points to change name
Required IT, Medical Record solution

25. The Solution
Employees with ability to change patient names reduced from 3000 to ~ 10
Patient data computer system does not allow unauthorized employees to change names – provides a true “hardwired” system solution
Education for staff, patients, families included in process
Ongoing monitoring and control
Medical Records performs audits of all name changes
All inpatient name changes are reviewed by Children’s Safety/Quality Core Team

26. Next Steps Expansion to Health System level
Academic medical center
Community hospital
Clinics
Incorporation of patients and families
“You’re the generalist, I’m the specialist”