National Patient Safety Week March 7 - 13Patient safety requires continuous dedicationby Michael BakerPublic Relations Upon entering a hospital, patients expect to receive treatment in a safe environment. For this reason, the National Patient Safety Foundation (NPSF) sets aside a week each year to remind both patients and health care professionals that ensuring patients’ safety is a continuous effort. This year, MUSC recognizes National Patient Safety Awareness Week from March 7 to 13. John Heffner, M.D., MUSC’s medical director, reinforced the fact that although patients expect a safe health care environment, maintaining such a safety standard requires constant vigilance. Although he believes that MUSC’s medical center employees are highly trained and extremely competent, Heffner asserted that the “factory” of MUSC’s hospitals—the step-by-step process of health care at the medical center—needs constant attention. “In a sense, we’re where the aviation industry used to be,” he explained. “You can train the pilots and the mechanics to be the best, but if you don’t train the flight controllers, you’ll have planes crashing into each other.” To that end, MUSC takes a systems approach to patient safety, examining the processes through which health care professionals care for patients. The goal, according to Heffner, is to analyze every aspect of patient safety, enabling health care professionals to respond to or prevent safety issues in any location—from the ER, to the hospital room, to the elevator. Rosemary Ellis, R.N., director of quality and patient safety, whom Heffner calls “a devoted, talented person who has carried the banner of patient safety at MUSC,” explained that MUSC encourages its employees to remain vigilant in their pursuit of patient safety by reporting safety concerns before events occur. According to Ellis, employees can use a new online system anonymously to report potential safety hazards before they reach the patient. “The system provides the hospital with immediate feedback, identifying patient safety concerns,” she explained, “Not just prior occurrences, but also those that could occur if not addressed.” Heffner added that the electronic filing system is part of the hospital’s goal to move away from a culture of blame and towards a culture of safety. “If a nurse administers the wrong pill to a patient, we don’t want simply to blame the nurse,” he said. “We want to examine the series of events that led to the occurrence. Most commonly, errors result from problems with the system of care delivery rather than with the care providers. Ideally, we’d like to make it impossible for our employees to make a mistake,” he concluded. And Heffner and Ellis believe that MUSC is headed in the right direction. As a testament to their confidence, the international medical journal Lancet will publish a five-part series on patient safety in mid-March. MUSC provided oversight for the series and developed the lead article. Another important example of the hospital’s dedication to patient safety involves an online repository of preprinted order forms for physicians. To minimize the potential for error, physicians can use the Clinician Order Form site, which stores order sets developed by physicians using evidence-based practice. Rather than repeatedly writing similar orders by hand, physicians can input data into a prearranged form on a computer. The order sets also eliminate problems related to handwriting legibility. “It’s like completing your income tax forms online,” Heffner said. “Who would want to write not only the tax information but also the printed words on each form? We’re taking the busy work away from our clinicians, giving them more a chance to focus on more important tasks.” “It’s a real time-saver,” Ellis added, “and it’s definitely one of our larger impacts with regard to patient safety.” MUSC hopes that this year’s Patient Safety Awareness Week will remind medical center employees of their excellent track record. In 2003, MUSC’s Main and Children’s hospitals met each of the NPSF’s goals (see accompanying box) and passed the Joint Commission’s triennial survey. In 2004, quality management has taken a direct route to spreading awareness of NPSF goals, placing information sheets in all public areas of the medical center. The sheet includes a list of the seven goals, as well as tips for patients and visitors on how to ensure their safety while visiting a health care facility. “We want the public to be aware of Patient Safety Awareness Week,” said Mary Allen, R.N., quality management. “Our patients need to be actively involved in their own care.” One of the week’s more interesting events, Allen said, is infection control’s glitterbug demonstration, which uses a special lotion and unique lighting to demonstrate the effectiveness, or lack thereof, of an individual’s handwashing technique. “We’ll ask two volunteers to cover their hands with a special lotion,” Allen explained. “Then, they’ll wash their hands as usual. Finally, the volunteers will hold their hands underneath a special light that will display any germs left after regular handwashing.” The demonstration underscores the ease with which germs spread due to lackadaisical hygienic practices. More importantly, it represents a microcosm of the processes and health practices that define MUSC’s continuing focus on patient safety. “There’s a huge national trend, that health care isn’t as safe as it should be,” Heffner and Ellis agreed, “but we feel that our patient safety program is a model for the rest of the state.” Seven major goals for 2004
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