Providence Healthcare
Providence Healthcare

When Things Go Wrong - Learning from Patient Safety Incidents

Nov 02, 2017

By Anne Trafford, Vice President, Quality, Performance, Information Management and CIO

Our first responsibility and priority is to keep our patients safe. We are relentless in our commitment to eliminate unnecessary harm. How do we ensure a safe system? Part of this work is proactive. Teams across our network are constantly developing and implementing new evidence-based policies and initiatives to mitigate and prevent patient-safety risks. Great examples of this work are easy to find: our annual quality and patient-safety target setting, our ongoing education and our initiatives to eliminate unnecessary harm are just a few.

However, as care providers we have an additional, equally important responsibility: to be vigilant and reactive. We must catch system failures and make changes – the right changes – as soon as possible when things go wrong.

To celebrate Canadian Patient Safety Week 2017, we are sharing some of our processes and infrastructure for the reactive side of patient safety. The two examples below illustrate these processes: the immediate follow up after an incident or identification of a hazard, the quality-improvement and learning processes that follow and the positive changes that happen as a result.

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Heidi Hunter, Quality Improvement Manager: "A few months ago, a patient in our Geriatric and Medical Rehab program was given his cup of medications, including one that was still in its sealed blister pack. Unknowingly, the patient took all his meds at once, not realizing that one was still sealed.

"We quickly discovered that the medication had remained in its blister pack because it required a safe-handling technique by the nurse using nitrile gloves. These gloves, however, were nowhere to be found on the unit and the medication remained in the blister pack in error. After swallowing the blister packaging, the patient was treated for a perforated bowel and underwent a lengthy surgery.

"I conducted a root-cause analysis in consultation with the patient, his Power of Attorney, front-line staff, Nursing Practice, and Pharmacy, resulting in several process changes to mitigate this risk in the future. Some of the recommendations included: standardized placement of nitrile gloves on every med cart; a visual cue when the gloves need replenishing; and a tighter process for having the Ward Aides replenish the gloves.

"We are piloting these recommendations on B4. So far, all signs indicate that these process changes are making a difference, and the results will be monitored until we're absolutely comfortable that these are the right changes. We'll be looking to roll-out this process across our Hospital and long-term care home soon."

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Johanna Skippon, Quality Improvement Coordinator: "In just a short time, we had two incidents – thankfully both resulting in minimal or no harm - resulting from food carts, one of which lightly hit a patient, and one that almost hit another. Most of us who work in hospitals are accustomed to seeing these large food carts being manually pushed through the hallways, and we are conscious of keeping an eye open for them and understanding how much space they take in the halls.

"These two incidents alerted us to the fact that patients are not familiar with the carts, and those staff pushing the carts don't always have good sight lines.

"We immediately took action as we realized this is a growing concerns, especially in the area closest to our Central Tray Services. We investigated how and where these accidents occurred and have developed several new cues and processes to help ensure this doesn't happen again. Some of the things we will be rolling out include safety mirrors; a Stop/Look sign on the door exiting the Central Tray Service area; and caution tape on the floor marking where the door opens.

"We are now shifting our focus to addressing how to minimize potential cart accidents on the Hospital units."