Grand Rounds Thursday, February 28, 2013

Grand RoundsThursday, February 28,

2013

Grand RoundsThursday, February 28,

2013

Patient Safety – No Patient Safety – No Problem HereProblem Here

http://www.youtube.com/watch?http://www.youtube.com/watch?v=hJbYwL2vfJEv=hJbYwL2vfJE Silent Killer , Josie King StorySilent Killer , Josie King Story

Answer = ZeroAnswer = Zero

The correct question is:The correct question is: Mizzou’s trips to the Final Four?Mizzou’s trips to the Final Four? The number of children harmed in our The number of children harmed in our

MRI?MRI? CMH’s strategic plan harm goal?CMH’s strategic plan harm goal? The chance that nobody in the Auditorium The chance that nobody in the Auditorium

or off site spots isn’t currently on their or off site spots isn’t currently on their smart phone or tablet?smart phone or tablet?

2017 Goals and Strategies2017 Goals and StrategiesDemonstrate Quality

OutcomesDemonstrate Quality

OutcomesDemonstrate Quality

Outcomes

Go

als

Str

ateg

ies

A1. Eliminate harmA1. Eliminate harm

A2. Improve the A2. Improve the outcomes of the care outcomes of the care providedprovided

B1. Effectively allocate B1. Effectively allocate staffing and other staffing and other resources to meet needsresources to meet needs

B2. Increase transparency B2. Increase transparency and accountabilityand accountability

B3. Build upon a culture B3. Build upon a culture which is agile/nimble and which is agile/nimble and engaged in innovation at engaged in innovation at all levelsall levels

B4. Enhance team B4. Enhance team behaviors to promote behaviors to promote service excellence for service excellence for internal & external internal & external customerscustomers

C1. Assertively act to C1. Assertively act to retain current regional retain current regional position and take position and take proactive steps to secure proactive steps to secure and grow complex and grow complex patient referrals in patient referrals in Southwest Missouri and Southwest Missouri and Eastern Kansas Eastern Kansas

C2. Grow inpatient and C2. Grow inpatient and specialty outpatient specialty outpatient services at CM-Southservices at CM-South

C3. Improve the C3. Improve the relationship with and relationship with and connection to primary connection to primary care physicianscare physicians

C4. Enhance access across C4. Enhance access across our systemour system

D1. Enhance and grow D1. Enhance and grow the Pediatric Care the Pediatric Care Network (PCN)Network (PCN)

D2. Work with D2. Work with commercial payers commercial payers and/or adult Accountable and/or adult Accountable Care Organizations to be Care Organizations to be their pediatric networktheir pediatric network

D3. Leverage system D3. Leverage system expertise to build expertise to build business opportunities business opportunities outside of traditional outside of traditional market areas (e.g., market areas (e.g., international)international)

E1. Enhance the research E1. Enhance the research enterprise with cohesive enterprise with cohesive oversight/ guidance, oversight/ guidance, broad-based funding, broad-based funding, and a focused research and a focused research portfolioportfolio

E2. Increase the caliber E2. Increase the caliber of CMH’s educational of CMH’s educational programs ensuring programs ensuring leading-edge teaching leading-edge teaching approachesapproaches

Answer = TenAnswer = Ten

What is the best question:What is the best question: Years since I completed my residency?Years since I completed my residency? Number of HACs being tracked by the Number of HACs being tracked by the

Children’s Hospitals Solution for Patient Children’s Hospitals Solution for Patient Safety Consortium?Safety Consortium?

Number of central line infections (CLA-Number of central line infections (CLA-BSIs) at CMH last year?BSIs) at CMH last year?

Mike Artman’s golf handicap?Mike Artman’s golf handicap?

Safety Event ClassificationSafety Event Classification

Near Miss Safety Event Precursor Safety Event

Near Miss Safety EventNear Miss Safety Event

Does not reach the patient.Does not reach the patient.

Error found by detection barrier Error found by detection barrier or luck.or luck.

http://www.youtube.com/watch?http://www.youtube.com/watch?v=KNqWPswYYaAv=KNqWPswYYaA Amazing near miss car crashAmazing near miss car crash

Precursor Safety EventPrecursor Safety Event

Reaches the patient.Reaches the patient.

Minimal or no detectable harm.Minimal or no detectable harm.

http://www.youtube.com/watch?http://www.youtube.com/watch?v=CKkXQxQyYpUv=CKkXQxQyYpU 4 yr old Turkish Boy's Amazing 4 yr old Turkish Boy's Amazing

EscapeEscape

Serious Safety EventSerious Safety Event

Reaches the patient.Reaches the patient.

Causes moderate or severe Causes moderate or severe harm,harm,

Or causes death.Or causes death.

http://www.youtube.com/watch?http://www.youtube.com/watch?v=RPBlEE3xIE0v=RPBlEE3xIE0 A closer look at a medication errorA closer look at a medication error

Answer = Too numerous to countAnswer = Too numerous to count

What is the best question:What is the best question: Days since Burry retired?Days since Burry retired? Near miss safety events in our MRI?Near miss safety events in our MRI? Surgical site infections in the past Surgical site infections in the past

academic year?academic year? Losses by the KU football team in past Losses by the KU football team in past

10 years?10 years?

http://www.youtube.com/watch?http://www.youtube.com/watch?v=plvIEf7JsKov=plvIEf7JsKo Dangers of MRIDangers of MRI

Answer = FourAnswer = Four

What is the best question:What is the best question: Number of times Jason Newland has Number of times Jason Newland has

competed in the Hawaii Ironman?competed in the Hawaii Ironman? Number of people who have given Number of people who have given

Jason a hard time this week?Jason a hard time this week? Number of near miss wrong site Number of near miss wrong site

surgery events since Jason has been surgery events since Jason has been the Medical Director of Safety?the Medical Director of Safety?

http://www.youtube.com/watch?http://www.youtube.com/watch?v=SxDx2DlL0UYv=SxDx2DlL0UY Tom Shillue's Wrong Side SurgeryTom Shillue's Wrong Side Surgery

http://www.youtube.com/watch?http://www.youtube.com/watch?v=t6mr3gxXx64v=t6mr3gxXx64 Jess’s storyJess’s story

Jess’s StoryJess’s Story

““The Holter monitor test was The Holter monitor test was never looked at until after I died, never looked at until after I died, more than a year after I had the more than a year after I had the test.”test.”

““Zero” Zero”

2012 PICU Quality Improvement Report


Chris Hubble, MDChris Hubble, MD

Kathy Baharaeen, RNKathy Baharaeen, RN





Unplanned ExtubationsUnplanned Extubations

20122012 20112011

TotalsTotals 12 12 38 38



PICU – Catheter Associated UTIs (CA-UTI) PICU – Catheter Associated UTIs (CA-UTI)

Nurse driven removal algorithmNurse driven removal algorithm

Rate before algorithm (July – Dec 2011) = 5.83Rate before algorithm (July – Dec 2011) = 5.83 Rate after algorithm (July – Dec 2012) = 2.24Rate after algorithm (July – Dec 2012) = 2.24

60% reduction60% reduction



http://www.youtube.com/watch?http://www.youtube.com/watch?feature=player_embedded&v=Gfeature=player_embedded&v=GPOQ8pzY0kYPOQ8pzY0kY Labels OutLabels Out

Documents

Grand Rounds Thursday, February 28, 2013