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Pages From BOM-02!23!10

Pages From BOM-02!23!10

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Published by Ryan McNeill

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Published by: Ryan McNeill on Nov 12, 2010
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11/12/2010

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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
 
to
 
the
 
following
 
departments
 
for
 
their
 
contributions
 
of 
 
data
 
to
 
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.
2
 
 Part 1:Safe Outcomes
3

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