CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms

July 8, 2019    |   By: Tina Hilmas, RN, BSN, CPPS

Issue:

  • A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status
  • Examples include:
    • Patient with suspect TB transferred to floor without making staff aware.
    • Patient transferred to ICU from the ED without sharing information that patient was positive for MRSA.
    • Patient directly admitted without informing receiving personnel that swab testing for influenza had come back positive.

Actionable Items to Mitigate Risk

  • Standardize communication during handoffs.
  • Include in the standardized handoffs a summary of the patient’s infectious disease status, including need for precautions.
  • Identify any outstanding testing during handoff.

The Culture Connection

  • Effective handoffs and clear communication among staff members, within and between units, are important components of a strong safety culture.
  • In addition to investigating the clinical components of these events, the organizations should examine any culture factors that impede full and appropriate communication at handoffs.

Resources

BLOG:

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

CPS Safety Alert/Watch – Culture can Improve the Control of Multi-Drug Resistant Organisms:

ISSUE:A number of events reported to CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status.Examples include:~Patient with s

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RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.