Safety and Systems

The numbers tell all, especially when it comes to reviewing patient safety outcome data and system operations with Clinical Performance Improvement statistics. Through reports, team meetings and publications, we keep our most-revealing figures front and center, sometimes even on a daily basis, so each nurse can gauge progress — whether in protecting patients’ safety or improving quick access to care — individually, as a unit and as a facility team. Here we share our recent progress: 

Hospital-Acquired Pressure Injuries prevention

Our year started with our patients experiencing more hospital-acquired pressure injuries (HAPIs) than we anticipated. These injuries, once known as bedsores, cause discomfort and longer hospital stays and can sometimes require lifelong treatment. Preventing them is paramount to patient care.

After analyzing our system numbers when spotting an upward trend, our HAPI practice forum took immediate action, creating our first-ever HAPI systemwide summit in the spring. Through WebEx seminars, on-site facilitators and hands-on education, our number of HAPIs fell — but we can never become complacent: In the fall, the HAPI forum was back at it again, hosting a similar summit.

Month in and month out, the forum looks at our numbers. Each member  — from a wound ostomy and continence (WOC) nurse to a nursing care partner to a nurse leader — offers his or her perspective:

  • How could a particular PI have been avoided?
  • Would further education have helped?
  • Was another resource needed?
  • Were new products available for prevention or treatment?

Fall prevention

“Do no harm” is an adage embraced by healthcare professionals — and especially so by Sentara hospital nurses: Patients trust you’ll return them home closer to good health. You do all you can to earn that trust, including protecting them as they recover.
Sometimes that protection is simple: Provide the right equipment in the right place. When it comes to preventing falls with injuries, we call this the Gold Standard Approach and the way to ensure needed equipment is nearby.
This year, Sentara nurses and leaders ensured that vital supplies — such as walkers, gait belts, soft mats, non-skid socks – were readily accessible in patient rooms and not stored in a supply room.

Nurse units conduct huddles whenever, despite our best efforts, a fall with injury does occur. Our nursing teams meet at the beginning of each of the next six shifts and review the fall – what happened and what should be done differently. This way, every nurse, no matter his or her schedule, learns from the fall. That learning is extended to other units and hospitals as our nurse executives hold similar huddles weekly.

We keep input from other members of the multidisciplinary teams — such as a physical therapist with details on a patient’s limitations or a pharmacist with concerns about a medicine causing dizziness — top of mind, and remember to look for visual cues in our units. The bright yellow socks given to at-risk patients, the flags outside their rooms and the light above the door remind all staffers to jump to action if needed.

All of this teamwork propelled us to success in 2017: For the first time in several years, we met our overall system goal limit of .39 falls with injuries per 1,000 patient days.

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