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 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

CPS Safety Watch/Alert: Elopement

TARGET AUDIENCE

  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

SAFETY WATCH: ELOPEMENT
Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.

THE CULTURE CONNECTION

  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.

RESOURCES

NEXT STEPS

  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

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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

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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.