Grand Rounds Thursday, February 28, 2013 Patient Safety – No Problem Here

 v=hJbYwL2vfJE v=hJbYwL2vfJE v=hJbYwL2vfJE  Silent Killer, Josie King Story

Answer = Zero The correct question is:  Mizzou’s trips to the Final Four?  The number of children harmed in our MRI?  CMH’s strategic plan harm goal?  The chance that nobody in the Auditorium or off site spots isn’t currently on their smart phone or tablet?

2017 Goals and Strategies Demonstrate Quality Outcomes Goals Strategies A1. Eliminate harm A2. Improve the outcomes of the care provided B1. Effectively allocate staffing and other resources to meet needs B2. Increase transparency and accountability B3. Build upon a culture which is agile/nimble and engaged in innovation at all levels B4. Enhance team behaviors to promote service excellence for internal & external customers C1. Assertively act to retain current regional position and take proactive steps to secure and grow complex patient referrals in Southwest Missouri and Eastern Kansas C2. Grow inpatient and specialty outpatient services at CM-South C3. Improve the relationship with and connection to primary care physicians C4. Enhance access across our system D1. Enhance and grow the Pediatric Care Network (PCN) D2. Work with commercial payers and/or adult Accountable Care Organizations to be their pediatric network D3. Leverage system expertise to build business opportunities outside of traditional market areas (e.g., international) E1. Enhance the research enterprise with cohesive oversight/ guidance, broad-based funding, and a focused research portfolio E2. Increase the caliber of CMH’s educational programs ensuring leading-edge teaching approaches

Answer = Ten What is the best question:  Years since I completed my residency?  Number of HACs being tracked by the Children’s Hospitals Solution for Patient Safety Consortium?  Number of central line infections (CLA- BSIs) at CMH last year?  Mike Artman’s golf handicap?

Safety Event Classification Near Miss Safety Event Precursor Safety Event

Near Miss Safety Event  Does not reach the patient.  Error found by detection barrier or luck.

 v=KNqWPswYYaA v=KNqWPswYYaA v=KNqWPswYYaA  Amazing near miss car crash

Precursor Safety Event  Reaches the patient.  Minimal or no detectable harm.

 v=CKkXQxQyYpU v=CKkXQxQyYpU v=CKkXQxQyYpU  4 yr old Turkish Boy's Amazing Escape

Serious Safety Event  Reaches the patient.  Causes moderate or severe harm,  Or causes death.

 v=RPBlEE3xIE0 v=RPBlEE3xIE0 v=RPBlEE3xIE0  A closer look at a medication error

Answer = Too numerous to count What is the best question:  Days since Burry retired?  Near miss safety events in our MRI?  Surgical site infections in the past academic year?  Losses by the KU football team in past 10 years?

 v=plvIEf7JsKo v=plvIEf7JsKo v=plvIEf7JsKo  Dangers of MRI

Answer = Four What is the best question:  Number of times Jason Newland has competed in the Hawaii Ironman?  Number of people who have given Jason a hard time this week?  Number of near miss wrong site surgery events since Jason has been the Medical Director of Safety?

 v=SxDx2DlL0UY v=SxDx2DlL0UY v=SxDx2DlL0UY  Tom Shillue's Wrong Side Surgery

 v=t6mr3gxXx64 v=t6mr3gxXx64 v=t6mr3gxXx64  Jess’s story

Jess’s Story “The Holter monitor test was never looked at until after I died, more than a year after I had the test.”

“Zero”

2012 PICU Quality Improvement Report Chris Hubble, MD Kathy Baharaeen, RN

2012 PICU Quality Improvement Report  CLA-BSI Total Number 1523 Total CVL days Rate2.67/1000 days4.19/1000 days  36% reduction

2012 PICU Quality Improvement Report Unplanned Extubations Totals 12 38

2012 PICU Quality Improvement Report PICU – Catheter Associated UTIs (CA-UTI) Nurse driven removal algorithm  Rate before algorithm (July – Dec 2011) = 5.83  Rate after algorithm (July – Dec 2012) = 2.24  60% reduction

2012 PICU Quality Improvement Report Total Patient Days Deaths4565  patient mix equal  20 lives saved

 feature=player_embedded&v=G POQ8pzY0kY feature=player_embedded&v=G POQ8pzY0kY feature=player_embedded&v=G POQ8pzY0kY  Labels Out