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January 24, 2005

Patient Safety is Driving Force
For New Clinical Collaboration

Nancy Dupont, a nurse, uses a water-less hand sterilizer.

Nancy Dupont, a nurse, uses a water-less hand sterilizer. Hand sterilizer stations have been placed throughout John Dempsey Hospital.

Photo by Peter Morenus

In a drive to make John Dempsey Hospital the safest hospital in the state, the Health Center has established a new initiative to improve patient safety.

The program, known as the Collaborative Center for Clinical Care Improvement, or C4I, was developed to adopt a team approach to addressing issues related to medication management, pain management, hospital-borne infection reduction, fall prevention, and culture change.

Dr. Steven Strongwater, director of Dempsey Hospital, says the care of patients depends on a complex system. On average, about 60 different people, working independently, interact with the typical hospitalized patient.

“It’s a complex, adaptive system, much like the weather,” says Strongwater. “We are focusing on finding errors in the system and ways to change them. Our goal is the development of institution-wide practices to enhance patient safety.”

Reducing falls is one area targeted for improvement.

“We know which hospital floors have a higher occurrence of falls and fall injury. We need to understand why, and make the necessary improvements in provider care and hospital equipment,” says Rhea Sanford, director of performance improvement and patient safety and subgroup leader for fall reduction. “We also need to gain a better appreciation of the care given to frail and vulnerable patients – who are not necessarily elderly.”

Last year, 80 hospital beds designed to reduce falls and injuries resulting from falls were delivered to the hospital as part of the fall-reduction initiative. “We may not be able to stop all falls, but our goal is to have zero injuries resulting from them,” Sanford says.

Medication and drug errors are another area of concern for C4I.

“Currently our system is a human one – it’s manually driven,” says Lisa Jaser, director of the Department of Pharmacy and the subgroup’s leader. “New drugs are constantly appearing on the market and the identification process is largely visual.

“Computer technology will go a long way to help guarantee accurate dosage and identification,” she says. “Our plan is to implement a barcoding system that will code medication and wristbands worn by patients. Caregivers will be able to double-check the match between medication, dosage, and patient at the bedside.”

Computer order entry by prescribers can also help by eliminating the need for written prescriptions, creating a medical history trail, and tracking medication orders throughout the hospital – from the Emergency Department to the Operating Room to the hospital floor, she adds.

Hospital-acquired infections will be the focus of a team led by Dr. Richard Garibaldi, chairman of the Department of Medicine. Approximately 5 percent of hospitalized patients acquire a hospital-borne infection.

“Many infections are not preventable, despite the best efforts of hospital staff,” says Garibaldi. “However, infections can be carried by health care givers, and those are the infections we want to prevent.”

Garibaldi’s team will concentrate on increasing influenza immunizations for both health care staff and patients; increasing and improving hand washing; and lowering surgical site infections and catheter-associated infections.

“We will improve the standard of care for all patients at John Dempsey Hospital,” he says, “and accomplish or exceed the tasks outlined in published infection control guidelines to prevent infections.”

Extra attention will also be paid to pain management.

“More medication is not always the answer,” says subgroup leader Dr. Joseph Civetta, professor and vice chairman of the Department of Surgery.

Caregivers need to understand and learn more about how to measure pain and pain levels in order to provide maximum safe care, he says. Seventy percent of a half-million dying cancer patients have pain – about 85 percent of which is easily controllable; and 60 percent of post-operative patients have pain that can be controlled, he notes.

“Physicians may be reluctant to prescribe medications because of addiction concerns or concerns about medication levels that might be dangerous, or because they under appreciate the patient’s pain,” says Civetta. “We must create what I call ‘the tension to learn.’”

With the use of a computer-based pain management test for caregivers created by Civetta, caregivers who select a wrong treatment answer can immediately link to an in-depth explanation of the right answer.

“Caregivers become more aware of what they don’t know and are drawn to learn more – the tension,” he says. “When retested later, they score significantly higher.”

Underpinning all the efforts of C4I are education and culture change, says Nicholas Warren, assistant professor of medicine, director of the Ergonomic Technology Center, and leader of the culture change subgroup.

“Our research demonstrates that quality and safety of patient care are closely tied to employee working conditions and organizational culture,” Warren says. “We need to establish a more complete understanding and dialogue between management and line workers. We need to be a learning organization – and learn about how we work, support each other, deal with changes, manage work and family, and deal the many other aspects of our work and our culture. Then we need to create systems that examine this information, adjust, track progress, and continually improve working conditions and patient care.”

The ultimate goal, according to hospital director Strongwater, is to become a “high reliability” organization, on a par with nuclear power plants, for example, and air traffic control centers. These organizations focus on the ability of their staff to adapt to new situations, quickly pass control to experts, recognize and accept human variability, and develop a preoccupation with the possibility of failure and prepare for it.

“The vision for John Dempsey Hospital is to be the safest hospital in the state,” Strongwater says. “It’s all about the patient.”