System, ZList

Safety First Column: Introducing the SAFE System

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Kettering Health is excited to announce changes to the Midas system. First, we heard you and understand it can be time-consuming to enter a safety event in the Midas system. Changes are underway to make it easier for staff to enter events. Changes will go live in early 2023.

Secondly, Midas is being rebranded to, “SAFE” to better align with Kettering Health’s commitment to a culture of safety and transparency around safety events. Staff have shared that “Midas” has gotten the reputation of being a system used for “tattling or reporting people.” Events reported in SAFE are not used to blame or punish staff. Instead, they are used to improve our process and system to keep our patients safe. The network can’t improve unless we know about safety concerns and events.    

The Ask: Please report events. Events typically occur 10 times before harm reaches the patient. The sooner we know about an event, the higher the likelihood that changes can be made to improve our systems and processes before harm reaches the patient. Staff have also shared that instead of “Midas‑ing” someone, they coach them. While we encourage teamwork and coaching, it’s important to note if it can happen to one person on one unit, it can happen to another person on another unit or campus.     

Events can still be entered on the Intranet under the Quality and Safety tab.

Great Catches

  • Thank you, Miranda Weist, from MS4 at Soin Medical Center for your Great Catch. Miranda’s patient had an order for Vancomycin IV once. Miranda questioned this order because the patient was admitted for stroke rule out. Miranda escalated her concern to the Charge RN and together they determined there was no reasonable cause for this patient to receive Vancomycin. Miranda called the PA and was told the Vancomycin was ordered for the wrong patient. The order was discontinued. Thank you, Miranda, for having a questioning attitude.
  • Thank you, Lauren Trevino from the Dayton OR. Lauren spoke up for safety when she noticed the Ophthalmology provider wanted an epi 1mg/1ml vial injected into the patient’s eye. However, the vial in the kit said, “do not use in eye.” Lauren contacted Pharmacy after doing research and found a “pf” amp that could be used in eye injections. Surgery has been using the “non-pf item tied to the kit,” as no one had ever noticed that the current product is not to be used in the eye. Due to this Great Catch, Pharmacy is in the process of fixing the kit list and will start stocking the “pf” product.
  • Thank you, Jamie Oglesbee and Cassandra Nier from the Dayton OR. Jamie and Cassandra were paying attention to detail when they noticed a hair entwined in a lap sponge inside the Medline custom total knee pack.

Medication Safety: Importance of Medication Communication During Patient Hand-off and Transitions of Care

Medication errors commonly occur during patient hand-offs and transitions of care. Numerous causes for breakdowns in hand-off communication have been identified, including differences in training, differences in expectations, interruptions, and lack of time, just to name a few.

 At Kettering Health, we have trends of reports where this communication breakdown resulted in variances in medication management. One example is where there was a significant delay in initiating an insulin infusion, and another resulted in continuing a heparin drip for a much longer period which placed the patient at risk for bleeding.

Governing organizations and researchers have identified several opportunities to improve these important transitions. Almost without exception the recommendations include the use of a standardized handoff tool. By using a standardized tool both the “sender” and “receiver” of information know what is expected, thereby decreasing the opportunities for vital information to get missed.

Within Kettering Health, our standardized communication technique is Situation, Background, Assessment, and Recommendation (SBAR).

While the fields listed in this example of the tool are by no means comprehensive, they provide a great starting point. This assures that much of the most critical information is given to your teammate, allowing them a strong foundation to continue caring for the patient. Utilizing this communication tool will ensure pertinent information is shared amongst healthcare providers to continually provide safe care.

September 20, 2022