Making Medication Administration Safer: A Resilience Approach
|
|
- Delphia Barnett
- 5 years ago
- Views:
Transcription
1 Making Medication Administration Safer: A Resilience Approach C Alice Oborne PhD, Consultant Pharmacist in Medication Safety and Trust Medication Safety Officer Amelia Samuel, Senior QIPS Manager for Medical Specialties Resilience in Healthcare Masterclass 7-8 May Guy s
2 Objectives Outline application of principles of resilience in understanding medication safety to prevent dose omissions Illustrate with work around timely medication doses for inpatients (provisional data) 2
3 Traditional Approach to Quality Improvement and Safety Reactive learning from local, national data 1. Investigation of reported incidents Including Root Cause Analysis 2. Trends in incidents, compare with similar sites 3. Complaints 4. Claims 5. Inquests, Coroner s reports 6. Patient feedback (PALs) 7. Clinical audit Prospective 8. Risk assessments (potential to cause harm) 9. Failure Mode and Effects Analysis Learning when things go wrong locally and externally Action planning, test interventions Spread 3
4 Omitted or Delayed Medication Doses Nationally: 16% medication incidents reported due to omission or delay 1 Locally: 23% due to omission or delay (901/4003) Greater risk with specific medicines Insulins, antimicrobials, anti-epileptic drugs, Parkinson s disease drugs 2 Omissions/delays All medication incidents Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 1 Reducing harm from omitted and delayed medicines in hospital NPSA/2010/RRR Trust Omitted or delayed doses: Critical drugs list
5 Protected data Incident data shows that antimicrobial and insulins omissions were most common drugs classes omitted 5
6 Protected data Drug administration was more common stage of reported incident, than prescribing and dispensing of medicines 6
7 Trust Omitted Doses Working Group Reviewed incident and audit data Multiple contributing factors: Complex and changing environment No drug in stock on the ward Unable to get hold of prescriber Incorrect documentation No drug in stock in pharmacy Lack of staff knowledge Distractions / interruptions 7
8 8
9 Safety-I versus Safety-II Traditional Approach: Safety-I Resilience Approach: Safety-II A Blue Cheese Model? 9
10 New Safety Model Capacity Work as Imagined System / Organisation of work Standards Staffing Skill Mix Equipment Drug storage Demand (Variation in the environment) Low staffing levels Lack of equipment Interruptions Prescription omission Patient acuities and co-morbidities Work as Done Normal Performance Adjustments Physical cues / reminders Workarounds Escalation Patient prompts Acceptable Outcomes (successes) Administration of insulins and antimicrobials within 2 hours of time due Administration of antimicrobials within 1 hour during sepsis Adapted from Hollnagel, E (2012). A Tale of Two Safeties. Retrieved from http// see also DNM Safety (2014) From Safety-I to Safety-II: A White Paper. Available at: Adapted from Anderson, J (2014). CARe Resilience Model, Centre for Applied Resilience in Healthcare (CARe). Available at: 10
11 Methodology 1. Two wards: surgical and medical 2. Understand normal medicines procedures Interview ward manager and staff 3. Patients with insulin or antimicrobial due 4. Observation: changes in the environment (environmental variation) and how staff respond (performance adjustments) Discussion of observations with staff 11
12 Methodology (2) 5. Qualitative data analysis 6. Analysis iterative with data collection 7. Decide interventions by learning from the successes 8. Test changes 12
13 Pilot to date 1 Medical Ward at GSTT 1 afternoon (pilot) and 1 morning drug round 13
14 14
15 Findings: Observation of Drug Rounds Work as Imagined Work as Done Capacity 6 beds per nurse Work in order of bed number Start drug round at dedicated time Protected time, no interruptions (red apron) Work independently Ask a member of the team for help (check IV & CD) Drugs & equipment stored in dedicated places Demand (Variation in the Environment) Dealing with other patient requests / needs Busyness / multitasking Drugs not stored in the usual place Unable to find equipment Helping another member of the team (e.g. checks) Broken equipment Mixed model of electronic and paper prescribing Fluctuation in staffing levels Performance Adjustments Previous shift administering meds Asking for help Well labelled alternative storage space for drugs Dedicated member of the nursing team with no patient load Mental note Visual cues (computer on wheels) Success Failure Lack of adjustments to higher patient acuities and heavy workload 15
16 Learning Some systems improvements were in place Heavy mental workload from interruptions Looking for medicines and equipment time consuming Teamwork Failures were seen when workload was not assessed and adjusted (2 hourly dressings, multiple drugs prescribed) 16
17 17
18 Questions
SPSP Medicines. Prepared by: NHS Ayrshire and Arran
SPSP Medicines Prepared by: NHS Ayrshire and Arran Medication Reconciliation: Story so far MR happening in primary care, acute adult, paediatrics and mental health Started in acute then mental health,
More informationChange Management at Orbost Regional Health
Change Management at Orbost Regional Health Our change management journey 1 Medication Change System Meds at Beds 2 The slightly exaggerated before process 3 Project Goals The purpose of the Meds at Beds
More informationPharmaceutical Services Report to Joint Conference Committee September 2010
Pharmaceutical Services Report to Joint Conference Committee September 21 Background: Pharmaceutical Services staffing has increased by 31 FTE from 26 due to program changes and to comply with regulatory
More informationIdentifying Errors: A Case for Medication Reconciliation Technicians
Organization: Solution Title: Calvert Memorial Hospital Identifying Errors: A Case for Medication Reconciliation Technicians Program/Project Description and Goals: What was the problem to be solved? To
More informationInfluence of Patient Flow on Quality Care
Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District
More informationRoyal Cornwall s implementation plan: A Chief Pharmacist s perspective
Royal Cornwall s implementation plan: A Chief Pharmacist s perspective Iain Davidson, Chief Clinical Information Officer and Chief Pharmacist, Royal Cornwall Hospitals NHS Trust 13 April 2016 GS1 at The
More informationBoard Briefing. Board Briefing of Nursing and Midwifery Staffing Levels. Date of Briefing January 2018 (December 2017 data)
Board Briefing Board Briefing of Nursing and Midwifery Staffing Levels Date of Briefing January 2018 (December 2017 data) This paper is for: Sponsor: Chief Nurse- Dame Eileen Sills (DBE) Decision Author:
More informationNorthern Health - Acute Services. Evidence Based Practice Venous Thromboembolism Prevention
Northern Health - Acute Services Evidence Based Practice Venous Thromboembolism Prevention (VTE) Jeannette Kamar Christine Lamotte, Liam Carter Improving Patient Safety Preventing and Managing Venous Thromboembolism
More informationDevelopment and assessment of a Patient Safety Culture Dr Alice Oborne
Development and assessment of a Patient Safety Culture Dr Alice Oborne Consultant pharmacist safe medication use March 2014 Outline 1.Definitions 2.Concept of a safe culture 3.Assessment of patient safety
More informationSTATISTICAL PRESS NOTICE MONTHLY CRITICAL CARE BEDS AND CANCELLED URGENT OPERATIONS DATA, ENGLAND March 2018
STATISTICAL PRESS NOTICE MONTHLY CRITICAL CARE BEDS AND CANCELLED URGENT OPERATIONS DATA, ENGLAND March 2018 Main Findings March 2018: Critical Care Beds There were 4,064 adult critical care beds available
More informationInfluence of Patient Flow on Quality Care
Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District
More informationUsing MEDMARX for Reporting and Benchmarking. Anne Skinner, RHIA Katherine Jones, PhD, PT
Using MEDMARX for Reporting and Benchmarking Anne Skinner, RHIA Katherine Jones, PhD, PT Purpose of the Grant: Assist small rural hospitals to Voluntarily report and analyze medication errors Identify
More informationCorporate Services Employment Report: January Employment by Staff Group. Jan 2018 (Jan 2017 figure: 1,462) Overall 1,
Corporate Services Employment Report: January Employment by Staff Group Jan (Jan 20 figure: 1,462) Jan % Overall 1,520 +58 +4.0% 8 Management (VIII+) 403 +52 4.8% Clerical & Supervisory (III to VII) 907
More informationConstant Pursuit of Medication Safety. Geraldine Koh Chief Pharmacist
Constant Pursuit of Medication Safety Geraldine Koh Chief Pharmacist 1 Alexandra Hospital 400 beds Multi discipline except Paeds & ObGyn Restructured in Oct 2000 Transformation Creating A Safety Culture
More informationSHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS MEETING HELD MAY 2011
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST K EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS MEETING HELD MAY 2011 Subject Supporting TEG Member Author Status 1 Pharmacy and medicines management
More informationBoard Briefing. Board Briefing of Nursing and Midwifery Staffing Levels. Date of Briefing August 2017 (July 2017 data)
Board Briefing Board Briefing of Nursing and Midwifery Staffing Levels Date of Briefing August 2017 (July 2017 data) This paper is for: Sponsor: Chief Nurse- Dame Eileen Sills (DBE) Decision Author: Workforce
More informationSheffield Teaching Hospitals NHS Foundation Trust
Sheffield Teaching Hospitals NHS Foundation Trust @seamlesssurgery Seamless Surgery Team Sheffield Teaching Hospitals NHS Foundation Trust July 2017 PROUD TO MAKE A DIFFERENCE PROUD TO MAKE A DIFFERENCE
More informationFrom Big Data to Big Knowledge Optimizing Medication Management
From Big Data to Big Knowledge Optimizing Medication Management Session 157, March 7, 2018 Dave Webster, RPh MSBA, Associate Director of Pharmacy Operations, URMC Strong Maria Schutt, EdD, Director Education
More informationEnlisted Professional Military Education FY 18 Academic Calendar. Table of Contents COLLEGE OF DISTANCE EDUCATION AND TRAINING (CDET):
Enlisted Professional Military Education FY 18 Academic Calendar Table of Contents STAFF NON-COMMISSIONED OFFICER ACADEMIES: SNCO Academy Quantico SNCO Academy Camp Pendleton SNCO Academy Camp Lejeune
More informationNorth Carolina Division of Medical Assistance
North Carolina Division of Medical Assistance Medicaid Clinical Policy and Programs Update on Medicaid In-Home Personal Care Services (PCS) Presented Larry Nason, Ed.D. Chief, Medicaid Facility by: and
More informationPharmacy Technician led model to reduce the rate of omitted medicines
Pharmacy Technician led model to reduce the rate of omitted medicines By Fleur Baylis Lead Pharmacist Patient Safety Brighton and Sussex University Hospitals NHS Trust Outline NPSA alert Missed doses Trust
More informationImproving HCAHPS with a Culture of Quiet St. Francis Hospital (Puget Sound)
Improving HCAHPS with a Culture of Quiet St. Francis Hospital (Puget Sound) Problem: Surveys showed that the noise level made it difficult for patients to rest. Innovation: Implemented a culture of quiet.
More informationBOARD OF DIRECTORS PAPER COVER SHEET. Meeting Date: 1 st December 2010
BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 1 st December 2010 Agenda Item: 9 Paper No: E Title: Management of Pressure Ulcers Purpose: For Information Summary: This paper provides a report on the
More informationRapid Assessment and Treatment (R.A.T.) Team to the Rescue. The Development and Implementation of a Rapid Response Program at a Regional Facility
Rapid Assessment and Treatment (R.A.T.) Team to the Rescue The Development and Implementation of a Rapid Response Program at a Regional Facility Dynamics 2013 Lethbridge Chinook Regional Hospital 276 Bed
More informationSafer Nursing and Midwifery Staffing Recommendation The Board is asked to: NOTE the report
To: Board of Directors Date of Meeting: 26 th July 20 Title Safer Nursing and Midwifery Staffing Responsible Executive Director Nicola Ranger, Chief Nurse Prepared by Helen O Dell, Deputy Chief Nurse Workforce
More informationPATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, August 2016
Report Contents: PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, August By: Terry Dentoni, MSN, RN, CNL, SFGH Chief Nursing Officer 1. Professional Nursing..1 2. Emergency Department
More informationGillan Belfon-Johnson Critical Care Matron North Middlesex Hospital
* Gillan Belfon-Johnson Critical Care Matron North Middlesex Hospital *What was the issue *Managing the issue * Education and Training * Giving nurses a platform * Managing diversity *Outcome * Threatened
More informationHard Truths Public Board 29th September, 2016
Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland
More informationElaine Andrews, Assistant Director of Nursing & Safety and Caroline Booton Quality Analyst Jill Asbury, Acting Director of Nursing
Report to: Board of Directors Date of Meeting: 26 th October 2016 Report Title: Inpatient Falls Report Status: Mark relevant box with X Prepared by: Executive Sponsor (presenting): For information x Discussion
More informationPATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, May 2010 Sharon McCole-Wicher, RN, MS, Chief Nursing Officer
PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, May 2010 Sharon McCole-Wicher, RN, MS, Chief Nursing Officer 1. April 2010 2320 RN VACANCY RATE: Overall 2320 RN vacancy rate for
More informationPPI Deprescribing: Ascension
PPI Deprescribing: Ascension Tonya Thomas, PharmD Clinical Pharmacist Saint Thomas West Hospital Nashville, TN, USA #derx2018 Session resources will be available at deprescribing.org/resources Learning
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT
Agenda item A5(iv) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT EXECUTIVE SUMMARY The Tissue Viability Team assists wards and departments to reduce
More information1. November RN VACANCY RATE: Overall 2320 RN vacancy rate for areas reported is 12.5%
PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, December 2013 Terry Dentoni, RN, MSN, CNL, Interim Chief Nursing Officer 1. November 2013-2320 RN VACANCY RATE: Overall 2320 RN
More informationQuality and Efficiency Support Team (QuEST) Directorate for Health Workforce and Performance
Quality and Efficiency Support Team (QuEST) Directorate for Health Workforce and Performance A Whole System Approach to Patient Flow for Scotland Our Quality Improvement Approach Jane Murkin Programme
More informationExperiential Education
Experiential Education Experiential Education Page 1 Experiential Education Contents Introduction to Experiential Education... 3 Experiential Education Calendar... 4 Selected ACPE Standards 2007... 5 Standard
More informationSafety in Mental Health Collaborative
NHS Tayside Safety in Mental Health Collaborative Improving Safety in Mental Health Programme Aims supported by an Improvement Advisor: Dr Noeleen Devaney Support 4 UK organisations to: reduce harm improving
More informationBOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013
Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health
More informationStatement 2: Patients/carers are offered verbal and written information on VTE prevention as part of the admission process.
THROMBOSIS GROUP Venous thromboembolism (VTE) is a collective term referring to deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is defined by the following ICD-10 codes: I80.0-I80.3, I80.8-I80.9,
More informationPatient Care: Case Study in EHR Implementation. With Help From Monkeys, Mice, and Penguins. Tom Goodwin, MHA MIT Medical Cambridge, MA March 2007
Using Information Technology to Drive Patient Care: Case Study in EHR Implementation With Help From Monkeys, Mice, and Penguins Tom Goodwin, MHA MIT Medical Cambridge, MA March 2007 MIT Medical Staff 122
More informationReadmission Reduction: Patient Interviews. KHA Quality Conference March, 2018
Readmission Reduction: Patient Interviews KHA Quality Conference March, 2018 Initial Driver Diagram Use Data and Root Cause Analysis to drive Continuous Improvement Analyze data to inform targeting approach
More informationTAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 29 th June 2017 Agenda Item 7b Title Sponsoring Executive Director Author (s) Purpose Previously considered
More informationJANUARY 2018 (21 work days) FEBRUARY 2018 (19 work days)
AND CORRESPONDING DATES FOR JANUARY AND FEBRUARY 2018 JANUARY 2018 ( work days) Deadline* 12-27 12-28 12-29 1-2 1-3 1-4 1-5 1-8 1-9 1-10 Benefit Hold ** 12-28 12-29 1-2 1-3 1-4 1-5 1-8 1-9 1-10 1-11 Mailing
More informationThe Royal Wolverhampton NHS Trust
Title: Safe Staffing; Planned Versus Actual Staffing by Ward September 2016 data The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 31 st October 2016 Title: Nursing Workforce Report Executive
More informationCase study: how reliable are our healthcare systems?
Case study: how reliable are our healthcare systems? CMSSQ Centre for Medication Safety & Service Quality Professor Bryony Dean Franklin Centre for Medication Safety and Service Quality Imperial College
More informationQuality Management Report 2017 Q2
Quality Management Report 2017 Q2 Quality Management Program CMS STAR Ratings Member Satisfaction (CAHPS & HOS) HEDIS Risk Adjustment DHS Member Incident Reporting Member Satisfaction Surveys Pay for Performance
More informationNational Trends Winter 2016
National Trends Winter 216 About the National Trends data This report presents a unique and real-time view of trends within temporary nursing including bank and agency usage. The data used has been drawn
More informationBOROUGH OF ROSELLE PUBLIC NOTICE ANNUAL NOTICE OF CALENDAR YEAR 2018 WORKSHOP SESSIONS, PRE-AGENDA MEETINGS AND REGULAR MEETINGS
BOROUGH OF ROSELLE PUBLIC NOTICE ANNUAL NOTICE OF CALENDAR YEAR 2018 WORKSHOP SESSIONS, PRE-AGENDA MEETINGS AND REGULAR MEETINGS BE IT RESOLVED, by the Mayor and Borough Council of the Borough of Roselle,
More informationDelivering a joined up approach to dementia care, medicines and medicines administration
Delivering a joined up approach to dementia care, medicines and medicines administration Anne Child MBE MRPharmS, PHwSI, I.P, Director Of Pharmacy and Dementia Care Avante Care and Support. First Steps
More informationdiabetes care and quality improvement in our practice
The Multidisciplinary Team: The key to successful planned diabetes care and quality improvement in our practice Robb Malone, PharmD UNC General Internal Medicine January 20, 2009 Objectives Review the
More informationPATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, February 2013 Terry Dentoni, RN, MSN, CNL, Interim Chief Nursing Officer
PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, February 2013 Terry Dentoni, RN, MSN, CNL, Interim Chief Nursing Officer 1. 2320 RN Vacancy Rates for the Month of January 2013
More informationPATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, November 2017
Report Contents: PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, November By: Terry Dentoni, MSN, RN, CNL - ZSFG Chief Nursing Officer 1. Professional Nursing.....1 2. Emergency
More informationNHS Awards 2013 Endoscopy Unit
NHS Awards 201 Endoscopy Unit 1. Storyboard Title Improving the quality of the patients experience of the endoscopy service: achieving full JAG accreditation in Bronglais District General Hospital utilising
More informationDrug Distribution Services for Long Term Care Facilities. Susan L. Lakey, PharmD 1/11/06
Drug Distribution Services for Long Term Care Facilities Susan L. Lakey, PharmD 1/11/06 Drug distribution The process: Receipt / transcription of order Interpretation / evaluation of order Filling and
More informationCompliance Division Staff Report
Compliance Division Staff Report Polygraph Advisory Board Meeting Tuesday, September 26, 2017 Public Outreach Compliance Division routinely attends annual industry meetings held by TALEPI (Texas Association
More informationNHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011)
NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with
More informationThe Royal Wolverhampton NHS Trust
The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 24 June 2013 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private:
More informationLearning from Deaths; Mortality Review Policy
Learning from Deaths; Mortality Review Policy Version: 4.0 New or Replacement: Replacement Policy number: CESC/2012/066 (Version 4) Document author(s): Executive Sponsor: Non-Executive Sponsor: Title of
More informationWorkflow. Optimisation. hereweare.org.uk. hereweare.org.uk
Workflow Optimisation Dr. Paul Deffley & Jaivir Pall Clinical Lead & Commercial Lead About Here Not-for-profit social enterprise Membership organisation (our members are local GPs, Practice Managers, Practice
More informationThe Reduction of Seclusion & Restraint in the University of Michigan Psychiatric Emergency Services with the Introduction of 24/7 Nurse Staffing
The Reduction of Seclusion & Restraint in the University of Michigan Psychiatric Emergency Services with the Introduction of 24/7 Nurse Staffing Sharon P. Stetz MSN Marvella M. Muzik, MS PMHNP, BC Objectives
More informationWorking in partnership to improve the identification and treatment of sepsis
Identifying and Tackling Sepsis in Healthcare Tuesday 25 th April 2017 Working in partnership to improve the identification and treatment of sepsis Tracy Broom Associate Director Wessex Patient Safety
More informationA Million Little Pieces: Developing a Controlled Substance Diversion Program. Tanya Y. Barnhart, PharmD, BCPS
A Million Little Pieces: Developing a Controlled Substance Diversion Program Tanya Y. Barnhart, PharmD, BCPS I have no conflicts of interest to disclose Objectives Explain the importance of building a
More informationHigh Returns Pharming COWS
High Returns Pharming COWS HIC 2009 The Frontiers of Health Informatics * IM&TD, + Concord Repatriation General Hospital, Sydney South West Area Health Service, Sydney, NSW. Design & implementation of
More informationEnhancing Patient Quality and Safety with Compliance
Enhancing Patient Quality and Safety with Compliance April 23, 2013 John Kalb, JD, CCEP, CHPC Operational Excellence Executive/ Compliance Officer Kootenai Health Content A successful compliance program
More informationLet Hospital Workforce Data Talk
Let Hospital Workforce Data Talk A Data Visualisation Exercise Health & Biosecurity Yang Xie yang.xie@csiro.au HIC, 08-Aug-2017 THE AUSTRALIAN E-HEALTH RESEARCH CENTRE Healthcare Marketplace: the big picture
More informationManagement of Reported Medication Errors Policy
Management of Reported Medication Errors Policy Approved By: Policy & Guideline Committee Date of Original 6 October 2008 Approval: Trust Reference: B45/2008 Version: 4 Supersedes: 3 February 2015 Trust
More informationHAI Prevention. Beyond the Bundle. March 18, 2016
HAI Prevention Beyond the Bundle March 18, 2016 Krystyna Strozewski Director of Quality Lake Health System Karen Mrazik Infection Preventionist Tripoint Medical Center Elizabeth Reed Infection Preventionist
More informationCHC-A Continuity Dashboard. All Sites Continuity - Asthma. 2nd Qtr-03. 2nd Qtr-04. 2nd Qtr-06. 4th Qtr-03. 4th Qtr-06. 3rd Qtr-04.
PPC1: ACCESS AND COMMUNICATION Element B: Access and Communication Results Item 1: Visits with assigned PCP Continuity data is reviewed each month at our Office Redesign Committee (ORDC). The data is collected
More informationLeveraging the Accountable Care Unit Model to create a culture of Shared Accountability
Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability How we improved Patient Safety and Quality Outcomes at Northwest Hospital Our Journey to Shared Accountability Implementation
More informationMaimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology
Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology Healthcare Information and Management Systems Society Electronic Poster Session CPR System Planning The
More informationHIQA s Medication Safety Monitoring Programme in Public Acute Hospitals. One Year Later
HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals One Year Later Sean Egan Head of Healthcare Regulation Health Information and Quality Authority Presentation outline Recap on the
More informationNHS Borders Feedback and Complaints Annual Report
NHS Borders Feedback and Complaints Annual Report 2016-17 1 Introduction NHS Borders Feedback and Complaints Annual Report 2016-17 is a summary of the feedback provided by the complaints, comments, concerns
More informationBoard of Director s Meeting
Board of Director s Meeting Meeting Date: 15 November 212 Agenda item: 6.1 Title: Purpose: Summary: Recommendation: Author: Presented by: QUALITY AND PATIENT SAFETY ASSURANCE COMMITTEE To provide an exception
More informationNational Readmissions Summit Safe and Reliable Transitions: An Integrated Approach Reducing Heart Failure Readmissions
National Readmissions Summit Safe and Reliable Transitions: An Integrated Approach Reducing Heart Failure Readmissions Michael Kanter, MD, Medical Director Quality and Clinical Analysis Patti Harvey, RN,
More informationBrent Treichler, M.D., FACEP Assistant Professor, UT Southwestern Department of Surgery, Division of Emergency Medicine Chief of Emergency Services,
Brent Treichler, M.D., FACEP Assistant Professor, UT Southwestern Department of Surgery, Division of Emergency Medicine Chief of Emergency Services, Parkland Health and Hospital System September 13, 2010
More informationStandardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017
Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017 Background Theme 3 builds upon previous key strategic commissioning
More information4/12/2016. High Reliability and Microsystem Stress. We have no financial, professional or personal conflict of interest to disclose.
High Reliability and Microsystem Stress Helping leaders identify and mitigate unit level stress: Next steps towards the journey of high reliability Whittney Brady RN, DNP Jackie Hausfeld, RN, MSN, NEA-BC
More informationImproving Pain Center Processes utilizing a Lean Team Approach
Improving Pain Center Processes utilizing a Lean Team Approach Organization Name: St. Joseph Medical Center Type: Acute Care Hospital Contact Person: Sue Mitchell Title: Nurse Mgr Pain Mgmt Center E-Mail:
More informationCase Study BACKGROUND. Recovering Ambulance Linen. Larry J Haddad, CLLM Textile Management Consultant. Midwest Region
Title: Facility: Author: Recovering Ambulance Linen Midwest Region Larry J Haddad, CLLM Textile Management Consultant Midwest Region BACKGROUND A 294-bed, not-for-profit community hospital in the Midwest
More informationShine 2012 final report
Shine 2012 final report Supporting Patients to be Active Participants in Anticoagulant Medication Safety UCLH NHS Hospitals NHS Foundation Trust March 2014 The Health Foundation Tel 020 7257 8000 www.health.org.uk
More informationUrgent Care Short Term Actions to Improve Performance
To: Trust Board From: Chief Operating Officer Date: March 2017 Healthcare standard Title: Urgent Care Short Term Actions to Improve Performance Author/Responsible Director: Michael Woods / Andrew Prydderch
More informationQuality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 4/1/2014 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop
More informationCriteria Led Discharge Pilot NHS Ayrshire and Arran Lorna Loudon, Linsey Stobo, Fraser Doris Implementing CLD in Scotland
Criteria Led Discharge Pilot NHS Ayrshire and Arran Lorna Loudon, Linsey Stobo, Fraser Doris Implementing CLD in Scotland 18.3.15 Whole System Patient Flow Improvement Programme 1 Background Project Team
More informationTranslating Evidence to Safer Care
Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins Bloomberg
More informationQuality Improvement Scorecard March 2018
Mortality: HSMR Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Performance further improved in October. November data not yet available. Mortality:
More informationPRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management
PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication
More informationColumbus Regional Hospital Pressure Ulcer Prevention
Columbus Regional Hospital Pressure Ulcer Prevention Kathryn Jackson RN, MSN, CRRN Pressure Ulcer Prevention Columbus Regional Hospital, Columbus, IN Objectives & About Us Describe current pressure ulcer
More informationSafe medication practice what can we learn from root cause analysis and related methods?
Safe medication practice what can we learn from root cause analysis and related methods? Dr David Gerrett, Senior Pharmacist Patient Safety NHS Improvement Information Day on Medication Errors 20 October
More informationFrom Implementation to Optimization: Moving Beyond Operations
From Implementation to Optimization: Moving Beyond Operations Session 260, March 8, 2018 Scott Aikey, Sr. Director, Core Clinical Applications Children s Hospital of Philadelphia 1 Conflict of Interest
More informationAgenda Item The report triangulates staffing levels against appropriate quality measures. The Report is provided to the Board for:
To: Trust Board From: Michelle Rhodes, Director of Nursing Date: 2 nd May 2017 Essential Standards: Health and Social Care Act 2008 (Regulated Activities) Regulation 18: Staffing Title: Monthly Nursing/Midwifery
More informationIntergovernmental Working Group of Experts on International Standards of Accounting and Reporting (ISAR) Sustainability Reporting
Intergovernmental Working Group of Experts on International Standards of Accounting and Reporting (ISAR) 29th SESSION 31 October 2 November 2012 Room XIX, Palais des Nations, Geneva Friday, 2 November
More informationLaguna Honda Lean Transformation. Laguna Honda Strategic Performance Management November 2017
Laguna Honda Lean Transformation Laguna Honda Strategic Performance Management November 2017 Background MAKE IT BETTER 4. 1. Performance Improvement FIX IT Do the work and make it happen 3. Create best
More information1. March RN VACANCY RATE: Overall 2320 RN vacancy rate for areas reported is 13.8%
PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, April 2014 Terry Dentoni, RN, MSN, CNL, Interim Chief Nursing Officer 1. March 2014-2320 RN VACANCY RATE: Overall 2320 RN vacancy
More informationAdministrative Update: How to Implement Discharge Pharmacy Services (DPS) Objectives
Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health Objectives Evaluate the need
More informationPatient Safety in Ambulatory Care: Why Reporting Counts. August 11, 2010 Diane Schultz, RPh and Sheila Yates, MPH
Patient Safety in Ambulatory Care: Why Reporting Counts August 11, 2010 Diane Schultz, RPh and Sheila Yates, MPH Group Health Group Health provides medical coverage and care to more than 628,000 residents
More informationIain Patterson. Associate Workforce Director Homerton University Hospital NHS Foundation Trust
Iain Patterson Associate Workforce Director Homerton University Hospital NHS Foundation Trust Who we are? Who we are? North East London Sector 3,800 staff spread across Hackney and beyond c. 3,000 acute
More informationAyrshire and Arran NHS Board
Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz
More informationPERFORMANCE IMPROVEMENT REPORT
PERFORMANCE IMPROVEMENT REPORT First Quarter Fiscal Year 214 October-December, 213 Daniel Coffey, CEO 1 Executive Summary The Quarterly Performance Improvement Report summarizes the measures used to monitor
More informationPatient safety in the NHS in England and the development of the Healthcare Safety Investigation Branch (HSIB)
Patient safety in the NHS in England and the development of the Healthcare Safety Investigation Branch (HSIB) Dr Mike Durkin NHS National Director of Patient Safety 11 May 2016 The NHS is big! Great potential
More informationPSYCHIATRY SERVICES UPDATE
PSYCHIATRY SERVICES UPDATE Mark Leary MD, Interim Chief Kathy Ballou RN, Director of Nursing Anton Nigusse Bland MD, PES Medical Director Emily Lee MD, Inpatient Psychiatry Medical Director TRUE NORTH
More informationLearning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 2018
Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 218 Purpose The purpose of this paper is to update the Trust Board on progress with implementing the mandatory
More information