Patient safety: Questions and answers
1. What is the adverse health care event report?
2. What are Allina's patient safety priorities?
3. Who are Allina's patient safety partners?
4. How do I find out more about national safety work?
1. What is the adverse health care event report?
Minnesota consumers have information on how safe hospitals are when it comes to the 28 adverse health care events that should not occur, as established by the National Quality Forum (NQF). The Minnesota adverse health care events reporting law mandates that hospitals disclose to the Minnesota Department of Health when any of these 28 events occur.
As part of the law, the Minnesota Department of Health is required to produce a report for the legislature and for the public, which includes counts of events across the state and hospital-specific event counts. The hospital-specific reports include each type of event that was reported by the hospital in a 12-month period. The report also includes the total number of surgeries and the total number of adjusted patient days.
2. What are Allina's patient safety priorities?
Falls prevention in the hospital
When patients are in the hospital, they often feel weaker than usual or more confused due to their medical condition. This change can sometimes result in a patient falling and getting hurt while they are trying to move around in the new environment of their hospital room.
Allina's hospitals have been participating in a system-wide collaborative to prevent patient falls since 2003. Overall, we have started to see a decrease in falls in the hospital and an increased awareness by hospital staff of the importance of preventing falls and thus the long-term safety consequences they have for patients.
- A falls prevention group, with participation from all Allina hospitals, determined a new plan to prevent patient falls by implementing the Hendrich II Fall Risk Prevention Model© and new interventions to protect patients. Staff from all of the Allina hospitals participated in a two-day collaborative in early 2004 to learn how to implement the Hendrich II assessment model, which detects patients at high risk of falling. All Allina hospitals have now implemented this assessment tool for all inpatients.
- The hospitals have also been sharing new and innovative ideas on how to help patients prevent falls. For example, patients at United Hospital in St. Paul are assisted to the bathroom on a consistent basis, to avoid having delays in getting to the bathroom when they call nurses on an as-needed basis.
Teamwork between nurses and physicians
In the medical field, doctors, nurses, pharmacists, and other professionals are trained in separate schools and then put together in the hospitals to work as a team. The lack of training on how to work as an effective team has been identified as a nation-wide safety issue in medicine.
Five Allina hospitals have been participating in an innovative initiative on developing improved teamwork skills for nurses, physicians, and other hospital staff. These five hospitals identified a potential problem area and have been learning from a physician from Kaiser Permanente Health System on how to use a set of skills to improve teamwork and thus improve safety in the hospital.
Adverse drug event prevention
Mistakes or errors with medications can occur at home, in the clinic, and in the hospital. Allina is leading an effort to identify the types of medication problems that most frequently occur to hospitalized patients.
We are using a tool developed by the Institute of Healthcare Improvement (IHI) to detect adverse drug events in a sample of hospital patients. The Allina hospitals are using this information to design and implement improvements to make our medication systems safer.
Reporting and learning from safety events
In the current, complex health care environment, learning about safety concerns and fixing systems to prevent safety events are important aspects of a hospital safety program. Allina's hospitals encourage staff and physicians to voluntarily report any safety concerns or events they are aware of through a reporting system. The data that is collected in this system is protected and can only be used for quality improvement efforts in the hospitals. The hospitals have been leaders in the nation in collecting information and using it to help identify areas we need to improve, such as the falls prevention work discussed above.
3. Who are Allina's patient safety partners?
Safest in America
Allina's Abbott Northwestern Hospital, Mercy & Unity Hospitals, and United Hospital are working with other Twin Cities hospitals to make the area the safest place in the country to receive hospital care. Learn more at mnhospitals.org...
National Patient Safety Foundation
Allina has joined the nationwide campaign called "Stand Up for Patient Safety" which brings together leading hospitals and health systems committed to developing a hospital-driven, patient-focused safety agenda. Learn more at npsf.org...
Institute for Healthcare Improvement
Allina hospitals collaborate with the Institute for Healthcare Improvement (IHI) to improve care in intensive care units by reducing infections and complications for patients. Learn more at ihi.org...
Allina supports IHI initiatives to save lives by improving care for hospital patients in six areas:
- using rapid response teams
- improving care for heart attack patients
- preventing adverse drug events
- preventing central line-associated bloodstream infections
- preventing of surgical site infections
- preventing of ventilator-associated pneumonia
Minnesota Alliance for Patient Safety
Allina has been a member of the Minnesota Alliance for Patient Safety (MAPS) since it began in 2000 and has had active involvement in all of the initiatives and committees. Recent efforts have included improvements focused on health literacy, pressure ulcer prevention, improved communication among caregivers, creating a just culture to encourage voluntary reporting of safety event, and planning a state-wide conference to share patient safety improvement ideas. Learn more at mnpatientsafety.org...
4. How do I find out more about national safety work?
Learn more about national patient safety efforts through these resources:
- Patient Falls Prevention (Hendrich II Model)
- National Quality Forum
- Institute for Safe Medication Practices
- Partnership for Patient Safety
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