Timmins programs encourage safety

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Patient safety has taken on a whole new dimension at the Timmins and District Hospital.

Jennifer Plant, organizational, quality and patient-safety lead, has been co-ordinating patient safety projects to create a safer environment for both staff and patients.

Plant and the 19-person patient safety committee have received recognition by Accreditation Canada for a program called Search for the Stars and were chosen to host a booth at the Celebrating Innovations in Health Care Expo in Toronto, November 18th.

The program involves one of Accreditation Canada's required organizational practices whereby a health-care provider must use at least two patient identifiers before the provision of any service or procedure.

Search for the Stars

The Search for the Stars initiative was designed to reinforce the hospital's new patient identification policy, encourage dialogue and review the practice. 

Verifying patient IDs could be a simple matter of confirming their names and birth dates by checking the hospital wristband. Previously, it may have been done verbally, but if a patient doesn't hear well, a mistake is possible.

"It is about making sure we don't give medication to, or perform an invasive test or intervention on the wrong patient," Plant said. 

Search for the Stars occurred over a two-day period, requiring a unit co-ordinator to place a star on a patient's wristband. When staff members verified the patient's identity and noticed the star, they could fill out a ballot with their name and the patient's ID and enter it into a draw. During the initiative, stars were identified 251 times. The success rate was 90 per cent.

The ten patients who were not "star" identified were distributed across different units, indicating it wasn't one specific area of the hospital not participating or identifying patients.

Five names were drawn randomly from the ballots and awarded a gold-trimmed safety star pin, indicating their contribution to patient safety.

Plant said it generated a lot of dialogue among hospital staff about patient identification standards and expectations.

 "Staff thought it was fun and felt it was a good way to promote the practice and involve patients in their care." 

She plans to implement the program about four times a year to engage staff and encourage a culture of patient safety.

The Good Catch program is another patient safety initiative created to promote reporting "near misses," or "good catches."

The goal is to avoid adverse events and overall incidents. Adverse events have been defined as unintended injuries or complications resulting in death, disability or prolonged hospital stay, according to a G.R. Baker 2004 study.

This study determined the incidence of adverse events in Canadian acute care hospitals to be 7.5 per cent, which translates to about 185,000 adverse events for just under 2.5 million annual hospital admissions in Canada. Approximately 70,000 adverse events could have been prevented, according to the study.

An overall incident is a negative or unfavourable action or result that may not harm the patient, but is inconsistent with their routine of care.
Typically, the culture has been that people don't report near misses for fear of getting in trouble," Plant said. "We're saying a lot of times the error isn't necessarily with an individual, it is with a process. We really want those things reported, so we can look at it and ask how we can change it."

Timmins and District Hospital has defined a "good catch" or "near miss" as recognition of an event or circumstance having the potential to cause an incident which did not occur due to corrective action and/or timely intervention following recognition.

The program recognizes staff and physicians for identifying "good catches" and is designed to share that information to learn from the incident and avoid potential errors.

"It is a proactive attempt to implement risk reduction strategies, not to point fingers or report on job performance," Plant said.

The method of reporting near misses has changed to a simple form requiring the name of the person, department, date, a description of the situation and suggestions for improvement.

"Front-line staff have the best knowledge base for identifying how their own work flow can be improved," Plant said. "We've asked them to review (near misses) with their manager to elicit team brainstorming. At that point, the form will come to me."

All submissions are reviewed by the Quality Improvement Committee and studied through a matrix weighing the risk factor, potential impact on patient safety, quality of care and service, and the potential of recurrence. An action plan is then developed to address the issues of concern.

On a monthly basis, the committee will select and recognize two submissions that best impact on patient safety, quality of patient care and service. Recognition will be in the form of a safety star pin, a letter signed by the CEO, chief of staff and the board chair, and a thank you card signed by Plant and the employee's manager or director. Recipients will also be acknowledged at the quarterly Employee Recognition Awards.

All near misses will be published in the newsletter and logged in the "Good Catch" area on the hospital's Intranet in a generic, anonymous manner, without any patient identifiers. The intent is to be proactive, not punitive.

The "Good Catch" reporting system will be permanent to empower people to be part of the solution.  n

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