National Patient Safety Awareness Week (PSAW) is March 10-16, 2024. This year’s theme, “Safer Together,” emphasizes the importance of safety among the entire team, including care providers, support staff, patients, and families. The Tennessee Center for Patient Safety at THA collected recent stories of teams from Tennessee hospitals that worked together to improve patient safety. We celebrate the remarkable achievements of each of these Tennessee hospitals and extend our gratitude to them for generously sharing their stories. It’s through collective effort and collaboration that we ensure the highest standards of safety for all.
Ballad Health – Perioperative Services: Assessing Safety and Culture in Ballad Health Operating Rooms
“A perioperative rounding initiative was launched in March 2023 with a goal of optimizing patient care by ensuring a Safety Culture in which all team members feel empowered to voice any safety concerns as they occur. Additionally, identifying areas of opportunity to better serve patients and achieve zero harm for both our patients as well as our caregivers is vital in becoming a high reliability organization (HRO).
OR leadership, quality, and risk management team members partnered together to assess potentially high-risk areas such as team member communication, fire safety, time-out, and more. Success highlights include:
- Facility and team willingness to participate in rounding initiative – Rounding teams reported they felt welcome during their visits and perioperative teams were seemingly gracious and receptive to feedback.
- Perioperative team communication and handoff – Teams demonstrated respect in interactions throughout phases of care. There was opportunity to ask questions and request assistance when needed.
- Patient satisfaction – Patients were treated with dignity and respect. Multiple instances of team members going above and beyond to ensure patients were as comfortable as possible were witnessed.”
Submitted by: Alisha Westmoreland, BSN RN CPHQ, Corporate Director, Process Improvement & Clinical Outcomes Optimization, Ballad Health
Cookeville Regional Medical Center – Heroes for Zero Infections
“Cookeville Regional Medical Center’s “Heroes for Zero Infections” program is a new initiative from the Infection Prevention Committee to recognize and promote CRMC staff’s hard work to protect patients and prevent hospital-acquired infections (HAIs).
Patient care units are rewarded for reaching the goal of zero infections for one year in any one of the following categories:
- CLABSI (Central Line-Associated Bloodstream Infection)
- CAUTI (Catheter-Associated Urinary Tract Infection)
- C. diff (Clostridioides difficile)
- MRSA bloodstream infections (Methicillin-resistant Staphylococcus aureus)
Our “heroes” were 6East and ICU. 6East (pulmonary stepdown) had an impressive improvement to zero infections for CLABSI, CAUTI and C. diff in 2023. They have made a significant impact by decreasing their central line and foley days to reduce the risk of HAIs related to indwelling catheters. ICU (medical/surgical) achieved one year without a CLABSI or C. diff. Both units are high acuity units and have made a significant impact by decreasing their central line and foley days to reduce the risk of HAIs related to indwelling catheters.
“They have been significantly impacted by decreasing their central line and foley days by more than 40% to reduce the risk of HAIs related to indwelling catheters,” said Stephanie Etter, Infection Prevention Manager at Cookeville Regional Medical Center.
This program recognizes the value of prevention and serves as a reminder that we can get to zero by consistently applying the basic principles of infection prevention and removing lines when no longer necessary.”
Submitted by: Logen Borie, Communications, Cookeville Regional Medical Center
East Tennessee Children’s Hospital – Unplanned Extubation Team
“East Tennessee Children’s Hospital would like to take the time to celebrate and share the incredible work that our Unplanned Extubation Team is doing to help emphasize the importance of safe, quality care to our patient populations. The journey began seven years ago as the NICU and PICU teams embarked on discussions to help mitigate strategies to prevent unplanned extubations (UE) within their units. Data and causal analysis demonstrated gaps with communication, education, and true understanding of UEs among the disciplines participating in bedside care. Then, ETCH joined the Solutions for Patient Safety (SPS) UE pilot to discuss, share, and learn from other children’s hospitals across the nation through participation in a nationwide quality collaborative.
Several change concepts were implemented that involved standardized taping method, development of a protocol for touching and handling of intubated infants, standardized documentation of ETT depth, standardized chest x-ray positioning to reduce ETT adjustments, development of extubation criteria, and clear competencies. Apparent Cause Analysis was done with each UE and reviewed with a multidisciplinary care team at monthly meetings. Over the course of this project, interventions were introduced, educated, monitored, and later re-educated so that unplanned extubations within the hospital are below the benchmarking rate for the SPS national collaborative. As we continue this journey, we recognize and believe that a multicomponent approach is necessary to reduce the rates of unplanned extubations among patients.
We included a picture of some members of the team who continue to work diligently each day to help prevent patient harm and keep patients safe. We applaud and want to say ‘Thank You’ to this team as we celebrate their continued efforts and successes.”
Submitted by: Dawn P. Jeffers, RN, Quality Improvement Analyst, East Tennessee Children’s Hospital
Hardin Medical Center – Inaugural Quality Casino
Hardin Medical Center hosted an inaugural Quality Casino event in March 2024. Hardin leadership put together a wonderful day of learning, games, and prizes for staff to continue to promote excellent patient care and go “Rollin’ for 10s” for patient satisfaction. Kudos to Hardin Medical Center for nurturing a vibrant workplace culture while ensuring that fun remains an integral part of the journey!
Games included:
- Fall Jenga
- Teach Back Black Jack
- C-Diff Craps
- Foundational 5 Fold ‘Em
- Glove Toss
Regional One Health – Reduction of Hospital-Acquired Pressure Injuries (HAPIs)
“Regional One Health staff focused on the reduction of hospital-acquired pressure injuries (HAPIs) this year by taking a process that first saw success in the emergency department to house-wide. That’s right, it started in the emergency department. HAPIs are not something that are typically focused on in the emergency setting. But what if pressure injuries present on admission were caught on arrival? What if interventions were put in place earlier? This was the genesis of the project to reduce HAPIs in the emergency department.
The staff created ‘bundles’ of preventative measures to implement, including an increased effort to document present-on-admission HAPIs and ensuring preventative pads were in place for patients at risk. Fast forward to the spring of 2023, and these harm prevention bundles became a system-wide initiative. Since then, HAPIs across the hospital have steadily declined. In February 2024, there were zero HAPIs.
The bundle for HAPIs includes items such as specialty bed use, placement of preventatives on heels, sacrum and occipital, patient turning, wound care and nutrition consults. Items are stocked in every department to ensure staff have quick access. Compliance of the bundles is reported on the organization’s daily safety call, and barriers are addressed before they become a bigger problem.”