1. R EDUCING ALL CAUSE HARM Memorial Medical Center Port Lavaca, TX Presented By Erin Clevenger, RN

2. HOSPITAL SAFETY PROFILE Number of HACs we are pursuing Number of HACs with results (40% reduction for HACs; 20% reduction for readmissions Number of HACs at 0 harm Number of avoided harms 987151 Estimated number of patient harms avoided since the initiation of Partnership for Patients in our facility! 151

3. H ARM RATES ( PER 1000 DISCHARGES ) HACsBaseline Performance Target Performance Current Performance ADE23.814.30 CAUTI7.24.30 CLABSI1.30.80 Falls000 OB AE4.62.80 Pressure Ulcer000 SSI5.93.517.9 VTE83.3500 Readmissions114.991.973.5 Average26.818.610.

4. ADVERSE DRUG EVENTS To help reach our goal: Medication Reconciliation required with each change in patient status/location Drug Interaction software loaded into our computerized charting program(allergies, medications, foods)

5. CAUTI To help reach our goal: Added “Remove Urinary Catheter On ____” to post-op orders Reinforced catheter insertion techniques Reinforced acceptable indications for catheters

6. CLABSI To help reach our goal: Completely revised central line protocols Added central line education to annual nursing skills lab Placed Central Line Insertion tackle boxes with all needed supplies in each department (with laminated copy of procedure)

7. FALLS To help reach our goal: Fall Risk screen is required on each admission assessment and with change in status (nurse can not move on in computerized chart without completing) High risk screen triggers reflexes like fall precaution program, more frequent toileting, rooms closer to nurses station, etc.

8. PRESSURE ULCERS Things we use to sustain 0: Skin breakdown risk assessment is required in our computerized initial physical assessment. Higher risk score triggers reflexes such as the turn program, nutrition consult, etc.

9. P OTENTIALLY PREVENTABLE VTE To help reach our goal: VTE risk screen done at admission (and with change in status), and protocols put in place for high risk patients VTE prophylaxis added to post-op orders Additional IPC’s ordered to meet the inpatient demand

10. POTENTIALLY PREVENTABLE READMISSIONS To help reach our goal: Assisting patient with scheduling follow-up visits Providing more in-depth disease specific teaching Still need to implement the full Project RED discharge checklist, we plan on doing more readmission reduction work in 2013

11. WORDS OF WISDOM Include front line staff from the start: When forming teams or creating plans, involve staff nurses. You will receive excellent feedback and ideas. When the time comes to implement new policies or procedures, these nurses will be wonderful advocates for your team, and will encourage compliance from their peers, because they had a role in the development process. Pre-plan your sustainability action: With so many HAC’s, it’s easy to focus in on 1 or 2 areas which may allow performance in other areas to decline. Plan ahead on how you will keep awareness and adherence ongoing for each area (ex.: monthly bulletins with updates on performance; reminders posted in break rooms, bathrooms, e-mails). Avoid the “set it and forget it” mindset that frequently occurs.