Safety Wednesday Update

As most of you know, every Wednesday, we are asked to stop and evaluate all safety issues on the units.  This is done by the nurse manager who performs and audit of standard items like medication refrigerators, locked med rooms, HIPPA concerns, blocked corridors, etc.  If any issues are found, I will follow up with the appropriate staff and charge RN and get them corrected.

I wanted to start taking this one step further and post a weekly Safety Wednesday Update on the blog.  I will include any recent issues found and give a summary of the week's PSNs.  We are all human and if one person can make an error, so can someone else.  I want to be better at bringing you information in real time so we can correct issues in a more timely manner and continue to keep our patients safe.  Please let me know if you find this information helpful.

Safety Wins for the Week:
1. Compliance with change of shift safety checks has been great.  A mom (who is an RN) of a patient on 7C commented today how reassuring it was to watch the nurses do the safety check and to take the practice so seriously!
2.  Kudos to Brooke Nitterhouse in PICU for realizing that pharmacy had stocked the wrong fluids in the Acudose.  She prevented a potential error from reaching the patient!
3.  High five to Nicole Daigle for doing a thorough shift change safety check and catching a medication error early in the PICU.  She helped the patient and proved how important this practice is every shift!
4.  Thanks to our NDNQI auditors who check each month for PIV infiltration and quarterly for pressure ulcers:  Philip Schlabs from 7C and Karen Gilbert and Lisa O'Reilly for PICU.
5.  Melinda is working on a plan with dietary to keep a floor stock of the pediatric enteral formulas so our RNs are selecting the correct enteral feed bag and we can eliminate the multiple errors and the wasted time when dietary sends the wrong enteral formula bag.  Let me know if you have ideas for where we could store the formula bags!


Safety Opportunities for the Week:
1.  Specimen Labeling:  Please label at the bedside and have all specimens double checked with another staff member to ensure it is the right request and the correctly labeled tube.
2.  Please remember when starting any high alert infusion, you must double check EVERYTHING with another RN.  This includes the standard 5 Rights of medication administration:  right patient, right drug, right dose, right time, and right route.  In addition:  you need to physically go to the pump for the double check and check the patient's weight (if wt based dosing), concentration, rate, and usage of guardrail against the MD order.  Patient's weights may change so we need to be sure they are updated and accurate in the pump.
3.  Please ensure your patient has written or electronic transfer orders before sending them to another floor.  We had someone get transferred who was very ready to go, but the residents failed to write the orders.
4.  Please remember to do your Fall Assessment each shift...and then comply with our Fall protocol if your patient is a Fall Risk.  This includes putting the Fall Risk bracelet on the patient and the Fall Risk Sticker on the chart.

Finally, PICU has gone 37 months CLABSI free and has had no VAP or CAUTI this fiscal year!  Unbelieveable!

7C has had no VAP for 2 years and one CAUTI in two years of being open!

Great job putting patient safety first!!!  I am so proud of the dedication of each of you!

Melinda