Patient Safety

Indiana Patient Safety Center

Introduction to the Culture of Patient Safety

With a job in health care, a mistake can have very serious consequences. A pretty heavy responsibility that Pulaski Memorial Hospital does not take lightly-- patients trust us with their lives...family members trust us with their loved ones.

At Pulaski Memorial, we must never let "good enough" be good enough. We are relentless in our pursuit of finding ways to improve our processes and systems in the delivery of healthcare we provide.

We believe one patient harmed is too many!

While we have always been very safety conscious, Pulaski Memorial is intensifying its focus on patient safety in cooperation with our state government. Indiana is at the forefront of serious medical error reporting in the nation, and we are proud to be a part of this process.

The State Government's Patient Safety Initiatives

On his inauguration day in January of 2005, Governor Mitch Daniels signed an executive order mandating public reporting of serious medical errors. This reporting program was the first step in identifying and improving systems and processes in healthcare to help protect patients.

The governor's executive order, in effect, followed the recommendations of the Institute of Medicine's (IOM) landmark report, "To Err Is Human," issued in 2000. The report helped to confirm that most medical errors result from system failures of processes inadequately designed to prevent a highly educated and dedicated workforce from inadvertently causing harm.

The IOM report recommended mandatory reporting of the most serious events. In response, the National Quality Forum (NQF) (www.qualityforum.org) and its panel of experts representing a wide variety of healthcare stakeholders developed a consensus list of specific highly preventable events. Indiana's new reporting rule focuses on the NQF's list of 27 serious adverse events.

The Indiana Patient Safety Center (IPSC) was formed and works in partnership with:

Indiana Hospital & Health Association (IHHA)
Indiana State Medical Association (ISMA)
Health Care Excel (Indiana's federal contractor for Medicare quality improvement)
Indiana University School of Medicine Regenstrief Institute Center for Health Services and Outcomes Research (IU/CHSOR)
Purdue University Regenstrief Center for Healthcare Engineering (PU/RCHE).

The above groups are providing education and support to Indiana hospitals with respect to the new rule for mandatory reporting of serious medical errors.

Indiana is the second state in the US, behind Minnesota, to publish hospital-specific events.

What are serious adverse events?

Some examples of serious adverse events include but are not limited to:

Surgery performed on the wrong body part, or patient, wrong procedure performed; foreign object left in patient after surgery; death during or immediately following a surgery in a normal, healthy patient.
Product or device involving death or serious disability associated with the use of contaminated drugs or devices; use of a device other than as intended.
Patient protection such as infant discharged to the wrong person; suicide or attempted suicide resulting in serious disability while a patient is in the hospital.
Care management to avoid death or serious disability associated with a medication error; incompatible blood transfusions; maternal death in-low risk labor/delivery; development of serious pressure ulcers acquired after admission to the facility.
Environmental events such as death or serious disability associated with restraints, an electric shock, burn, or fall while being cared for in the hospital.
Criminal events meaning care provided by someone impersonating a physician, nurse, pharmacists or other licensed professional; abduction of a patient; death or physical injury resulting from physical assault on hospital property.

Regional Patient Safety Initiatives

Thirteen hospitals from Pulaski, Starke, Marshall, Elkhart, Porter, St. Joseph, LaPorte, and three Michigan counties are involved in the organization of Michiana Patient Safety Coalition (MPSC).

The group is committed to investigating the cause of a medical adverse event. By determining the root cause for the medical error and changing the process by which it happened, hopefully a repeat of the mistake will not reoccur in the future.

This regional cooperation is especially important because of referrals and transfer of patients from smaller to larger hospitals within the area.

The following fictitious scenario illustrates a heart patient being transferred from small hospital A to the larger hospital B.

At small hospital A, the yellow wrist band is placed on the patient because he has an allergic reaction to certain heart medicines. Later the patient is transferred to the larger hospital B still wearing the yellow wrist band.

At hospital B, a yellow wrist band indicates a "Do Not Resuscitate" patient. Shortly after the patient's arrival, he goes into cardiac arrest. Because he is wearing a yellow "Do Not Resuscitate" wrist band, no efforts are made to shock his heart and the man dies.

With no standardization between regional, referring hospitals, a tragic death like this could take place.

MPSC has already successfully focused on improvements such as:

Patient identification
Medication safety
Reducing risks of injury from slips and falls
Standardizing communication between nurses and doctors

Another approach to protecting patients includes learning from other hospital's mistakes. Whenever an adverse event arises in other healthcare facilities, the MPSC carefully reviews their member hospital's procedures. By doing this and making any needed changes in the systems, the hope is that medical error will be avoided here.

What are we doing at Pulaski Memorial

There are many safety initiatives and actions going on at the hospital. The following are some examples of the process taking place at PMH.

The Medication Safety Committee involves Pulaski Memorial staff from Nursing Administration, Quality Management, Pharmacy, and other front-line Nursing staff.

When we talk about patient safety concerns, we mean anything that might impact the well being of a patient. Patient safety concerns include but are not limited to the following.

Hazards that could lead to falls
Dangerous use of materials, equipment, supplies, or waste
Fire hazards
Security issues
Medication events

A common misconception is that patient safety is about reminding people to be more careful. But in fact, healthcare workers are some of the most careful people. Improving patient safety is about changing the culture in the healthcare from one of blame to one where we examine our systems from beginning to end to reduce the opportunities for mistakes.

A separate Safety Committee oversees the building, equipment, medical gases, and property for safety issues for patients, visitors, staff and volunteers.

You are our partner in medication safety at Pulaski Memorial

Medication safety is the top priority for the Pharmacy department and Nursing. Much of a pharmacist's job revolves around ensuring medications are used safely and effectively.

We have systems in place to make sure medication errors do not occur while you are in the hospital. However, this is a partnership and we need your help!

As a patient, the most important thing you can do is to bring a complete list of your current medications. That list should include:

Prescription drugs and dosage
Any non-prescription or over-the-counter medicines such as aspirin, antacids or laxatives that you use on a regular basis
Any herbal or dietary supplements you may take
Any allergies to medications; include any problems and reactions you encountered and be specific

Your physician will review your medication list and determine which medicines you should continue while a patient in the hospital.

The best patient safety comes when you, the hospital, and the pharmacy department work as partners regarding your medications. Thanks for helping us out!

For more information about patient safety, contact Linda Webb at 574-946-2165 or Vickie Bridge at 574-946-2168.