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Patient Safety Officer2009 Annual Report

Under the direction of the Board of Managers, the Parkland Patient SafetyProgram is designed to identify and manage risks to patient safety with theultimate goal of eliminating preventable deaths and preventable harm that are theresult of medical care.Though the Department of Patient Safety and Risk facilitates the creation of thisannual evaluation, the responsibility of patient safety belongs with everyemployee and every department. Many of the accomplishments outlined are theresult of clinical and operational leadership from across Parkland Health &Hospital System as well as the daily efforts of the clinicians who directly care forthe patients we serve.The 2009 Program Evaluation includes both the results of overarching metricsregarding safe outcomes of care along with metrics associated withimplementation of the processes associated with the National Quality Forum(NQF) Safe Practices.

Acknowledgements

the

following

departments

for

their

contributions

data

this

report:

Clinical

Information

Services,

Data

Management

and

Reporting,

Health

Information

Management,

Infection

Prevention

Control,

Medical

Staff

Services,

Occupational

Health,

Pathology,

Patient

Safety

Risk,

Performance

Improvement,

Pharmacy

Rev: 02/10/2010

Table of Contents

Part 1: Safe Outcomes of Care

NQF Serious Reportable Events ............................................................... 4Agency for Healthcare Research & Quality (AHRQ) – Patient Safety Indicators .................................................................. 6

Part 2: Selected*NQF Safe Practices

Leadership Systems (SP1) ........................................................................ 8Culture Measurement, Feedback, and Intervention (SP2) ........................ 9Identification and Mitigation of Risks and Hazards (SP4) ........................ 10Disclosure (SP7)...................................................................................... 13Care of the Caregiver (SP8) .................................................................... 14Intensive Care Unit Care (SP11) ............................................................. 14Patient Care Information - Critical Results (SP12) .................................. 15Order Read-Back (SP13) ........................................................................ 16Labeling of Diagnostic Studies (SP14) .................................................... 17Computerized Physician Order Entry (SP16) .......................................... 18Pharmacist Leadership Structure & Systems (SP18) .............................. 19Influenza Prevention (SP20) .................................................................... 20Central Line Associated Bloodstream Infection Prevention (SP21) ........ 21Care of the Ventilated Patient (SP23) .................................................... 23Pressure Ulcer Prevention (SP27) .......................................................... 25Venous Thromboembolism Prevention (SP28) ....................................... 26Anticoagulation Therapy (SP29) .............................................................. 27Organ Donation (SP31) ........................................................................... 29Glycemic Control (SP32) ......................................................................... 30Falls Prevention (SP33) ........................................................................... 31

Attachments:1. List of Serious Reportable Events (NQF 2009)2. List of Safe Practices for Better Healthcare (NQF 2009)

*There are 34 NQF Safe Practices. 20 Safe Practices are highlighted in the 2009 Patient Safety ProgramEvaluation. Those selected for inclusion are those in which significant improvement activity occurred this pastyear and data exists to evaluate performance.