Safety First Column: Ticket to Ride and Key Learnings from Case Reviews
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Safety First Column: Ticket to Ride and Key Learnings from Case Reviews

By Jeffrey Weinstein, MD, Kettering Health Patient Safety Officer; D’Anna Stekli, Kettering Health Infection Control Manager; and Lindsay Alexander, Kettering Health Quality and Patient Safety Manager

Thank you to everyone who completed the employee engagement survey, which included questions about safety in our organization. It is through your feedback that we can drive improvement across the network.    

That survey is just one way we check on our safety goals across the network. And soon, we will add another resource that provides transparency on quality and safety performance across the network. The Quality and Safety team is working with Process Excellence and other data teams to develop the Safety First Dashboard. This will allow users to:

  • Find all quality and safety data in one location
  • Filter data by campus and unit, and view network-level info
  • View Quality Key Result Areas, falls, infections, and reported safety events
  • Find graphs, tables, benchmarks, goals, control charts, “days since last,” counts and rates

Stay tuned for more updates coming soon!

Safety learnings

As an organization, we are committed to providing safe, high-quality care, ultimately guiding our patients to their best health. By following the proper processes and continuing to look for ways to improve, we can keep our patients and our teams safe. Here are a few tips to help us ensure we are putting safety first:  

Patient identifiers 

We use two patient identifiers to help us keep the “rights” in mind: Verify it is the right patient, at the right time, going to the right place for the right procedure.

Always use two patient identifiers, rather than assume you have the correct patient. While network policy does not allow for patient identification by room number, you can use characteristics like first name and last name as well as date of birth to safely identify a patient.

Oxygen ticket to ride

In early 2021, we implemented an oxygen ticket to ride process, as oxygen is considered a medication. Since this is still a relatively new process, we wanted to share some important reminders:

  • The ticket to ride should always be used when transporting any patient on oxygen, including room transfers on the same unit.    
  • Two people should be involved with the hand-off. Both people should review the form and patient to ensure the oxygen is correct, and then sign off.    
  • One of the two people involved with the sign-off must be licensed.
  • Nurse assistants and those who have not completed HealthStream competency are not permitted to transport patients on oxygen. This includes moving patients from one room to another on the unit, taking the patient out of their room, or taking the patient off the floor.
  • Nurse assistants are not permitted to handle oxygen in any situation because it is classified as a medication.
  • Remember: Yellow is air and greene is oxygen. Oxygen is considered medication, so it’s vital that these be identified correctly.   

Healthcare-associated infections

When healthcare-associated infections (HAIs) occur that are part of Kettering Health’s Infection Control surveillance plan, a multidisciplinary review and audit of each case takes place to help prevent a similar type of patient harm from occurring to future patients. Below are some of our opportunities for improvement, based on case reviews and audits:

  • Catheter-associated urinary tract infection (CAUTI): Overuse of Foley catheters for accurate monitoring of output and for retention, presence of dependent loop in catheter tubing (not a complete downhill path of the tubing into the drainage bag).
  • Central line-associated bloodstream infection (CLABSI): Keeping peripheral IVs in place after a central line has been inserted, misses in daily CHG baths, not changing central line dressings when they are soiled or any part has lifted.
  • Clostridium difficile (C. diff): Not getting a sample collected within the first 3 days of a patient’s stay when any unexplained loose bowel movements occur, lack of documentation of stool consistency for every bowel movement. Remember: Any patient positive for C. diff within the first three midnights is considered to have a community-associated case, while any patient positive for C. diff after the first three midnights of the patient’s stay is considered to be hospital-associated.
  • MRSA Bacteremia (MRSA BSI): Not getting a set of blood cultures within the first 3 days after a patient is transferred from another facility where they had unresolved MRSA bacteremia, not getting a set of blood cultures upon admission when the sepsis BPA fires. Note: The timeframe for whether or not a MRSA BSI is community onset versus hospital associated is the same as for C diff.
  • Surgical site infection (SSI): Issues with pre- operative antibiotic administration, lack of glucose control during surgery and the first 48 hours afterward, misses in daily CHG bathing.

All nursing staff and providers are encouraged to review these opportunities as they apply for their clinical areas and continue to work together in our mission to utilize best practices to prevent HAIS in our patients.

Just like in our June column, we’ll end on some employee shout-outs. Congratulations to the employees below who had a “Great Catch” and proactively prevented harm from reaching the patient. Thank you for your attention to detail and safety. Your actions keep our patients and each other safe.

  • Denise LaBar, an MRI technician at Grandview Medical Center, removed a metal object from the MRI table while changing the bedding. This prevented a possible patient injury. 
  • Edgar Worrell, a physical therapist at Soin Medical Center, noticed while ambulating that a patient seemed to be in pain, despite a previous X-ray that did not show a fracture. Edgar contacted the physician to request further studies, which revealed a fracture.
  • Beth Hoffman, a nurse at Soin Medical Center, noted new onset atrial fibrillation on the monitor prior to a surgical procedure. Surgery was cancelled, and the patient was sent to the emergency department.
  • Sarah Sparks, a nurse at Kettering Medical Center, worked with anesthesia to get moderate sedation for a patient during a procedure, where Sarah identified tension pneumothorax. 
  • Trish Campbell at Troy Hospital identified a patient on the loose stool report and asked the unit nurse to collect a stool for C. diff. The patient was positive for C. diff, and an HAI was prevented.
July 26, 2021