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Patient Safety

How do we define Patient Safety?

• Patient Safety - freedom from unintended injury associated with the provision of healthcare services
• Ensuring patient safety involves the establishment of operation systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them, so patient harm will not occur.

 

Who is responsible for Patient Safety?

 

EVERYONE who enters our organization, including:

• Employees
• Students
• Patients
• Visitors
• YOU!

 

What is an Event?

An event can be due to Unsafe Conditions, an Unsafe Act, or a Near Miss event.

• In these cases, not harm has happened. This is what we call "Good Catch" events. We want to learn from Good Catch Events to prevent future harm. 
• But sometimes, accidents do happen. These are the unexpected outcomes we want to avoid. Often, accidents occur because of system failures - either there is no process in place to prevent the accident, or the current process in place does not work. These processes can be fixed to prevent future accidents. 

 

What should be reported? 

The following should be reported as an I CARE Report: 

• Unexpected outcomes in care
• Unsafe conditions
• Patient safety issues
• Near miss events
• Good catch events
• Behavioral events
• Work place violence
• Abuse, neglect & exploitation
• Visitor events

How to make an I CARE Report:

• On the Intranet homepage, click the "I CARE Report" under the Clinical Section.
• Timely Reporting is Essential!

 

What is a System Failure?

Events do not happen as the result of a single source of failure, but from many sources.
When they all line up, an event can occur.
An example of a system failure: A patient passes away because... 

• The doctor opens up a wrong patient's chart and orders the wrong medicines.
• The pharmacy is behind because the tube system is not working tonight, so they skip the verification process that is normally used for high risk medication.
• The RN treating the patient is new graduate and unsure if the medication is correct, but trusts the MD & pharmacy knows best.
• and the Preceptor is busy with another patient

Examples of Patient Safety Events:

The below youtube videos are examples of patient safety events:

• Near Fatal: A Patient Safety Story
• Misplaced Feeding Tube

 

UMMC High Reliability Journey: Chasing Zero

Chasing Zero is UMMC's safety campaign that aims to zero preventable harm to patients.

For more information about Chasing Zero, visit the Chasing Zero page: Chasing Zero.

 

Good Catch Program

• The Good Catch Award is a program that developed from the Patient Quality and Safety group during the 100-Day Workout.
• It is the discovery of a potential event that was caught before a patient was harmed. In our effort to Chase Zero, we would like to recognize our employees when they make a Good Catch!
• Risk Management will identify these events through I-CARE reports, or you can call them at 601-815-1996.
• When a Good Catch is discovered, the employee will be notified and presented with the Good Catch Award, which is a mounted baseball glove signed by the Mississippi Braves.
• The employee will then have his/her picture taken with the award, and their picture plus the award will be put on view in the display case in the cafeteria. In addition, the picture will also be placed on the intranet for all to see.

Abuse, Neglect, or Exploitation

• To comply with Mississippi Laws, we must report all possible abuse, neglect, and exploitation of patients at UMMC. 
• If you, or a staff member, or concerned that a patient is experiencing abuse, neglect, or exploitation on UMMC's campus, please file an I CARE Report. 
• Remember, all patients at UMMC, regardless of age, are vulnerable to abuse, neglect. and exploitation.

 

What should I do if I see abuse?

Report immediately to one of the following:

• Charge Nurse 
• Immediate Supervisor 
• Adminstrative House Supervisor 
• Risk Management: (601) 815-1994

Remember: ALWAYS complete an I CARE Report. 

Risk Management will lead the investigation

 

What do our patients want?

• To be treated Kindly
• To be Healed 
• To be Safe

 

Team Safety Training

• Everyone makes a personal commitment to safety. 
• Everyone is accountable for clear and complete communication.
• Everyone supports a questioning attitude.

Safety belongs to all of us!

 

Contact Information

 

Tina Gelston, MSN, RN-BC