More than a month after Duke University Hospital pledged to improve patient safety, the Pediatric Patient Safety Program is fully underway.
The formally structured program, instituted in September following a review of DUH by the Centers for Medicare and Medicaid Services, includes dedicated resources to allow staff the time and human resources to focus on specific issues of safety and incorporate systems improvements that will be implemented throughout the entire hospital.
"The patient safety efforts in general across the hospital and [Duke University Health System] were focused on after the transplant in the spring," said Dr. Karen Frush, chief medical director for Children's Services, referring to the mismatched heart and lung transplant of Jésica Santillán. "We've obviously done a lot of work prior to that time, but after the transplant event there was an effort to develop some more focused and structured approaches to patient safety." Different risks and safety issues exist for the varying units that comprise the pediatrics department.
The program incorporates the three clinical service units as well as the Intensive Care Nursery, the Full Term Care Unit and the Pediatric Intensive Care Unit. Each unit's teams were formed a month ago and have begun to discuss patient safety issues from a broad spectrum of perspectives, especially focusing on bedside-care providers, Frush said. The multidisciplinary team--comprised of physicians, nurses, pharmacists, house staff and patients' family members, in addition to others--will lead 'walk rounds' of the units weekly to talk to patients, family and other hospital staff members, she added.
The structure of the program also calls for one pediatrics safety core team that will oversee the CSU teams and participate in some of their discussions. The core team will also be multidisciplinary and will include industry representatives. The formation of these teams is 'patient safety in action,' Frush said.
"A lot of conversations have been on the systems, but what we've begun to do is start those conversations at the bedside, from the people who provide care day in and day out," Frush said.
Dr. Marlene Miller, director of quality and safety initiatives at Johns Hopkins Children's Center and a consultant to the safety program, said that instilling front-line caregivers was a necessary step because they know better than anyone else where safety could potentially fall through the cracks.
"We need to empower them to think of solutions and have the resources, be it time, money, or space, to change the whole system," she said. Teams have already found concerns regarding medication safety, chemotherapy and sedation of children.
Although the topic of patient safety has always been present, the way in which issues are being tackled is new. Frush said that as issues continue to be identified, creative solutions will be put in place to improve safety.
"It requires a new way of thinking," she said. "There are different challenges for different teams because the everyday care they provide [is different]."
Frush said innovative thinking may be able to resolve many of these issues, but eventually monetary resources will be necessary to fully address them.
Dr. Ronald Goldberg, director of the Intensive Care Nursery, said that the nursing shortage is a significant problem that could have substantial ramifications on patient safety. Goldberg also cited the recently-implemented 80-hour work week for residents as another safety issue.
"There is a concern of experience for physicians," he said. "I worry about long-term consequences of [residents] seeing fewer patients and doing fewer operations."
The ICN unit safety team will strive to regularize the approach to specific safety issues and deliver statistics on trends for near misses, as well as to examine problems with the current information systems.
"What we're in the process [of doing] right now with the safety committee is trying to get all the data streams focused and localized so they can start to evaluate patterns of problems," he said.
Although the ICN has historically had a multidisciplinary team investigating safety issues, this new team is meant to look at issues more broadly and incisively.
Miller said she was encouraged because Duke was in an "incredibly good position" to start.
The program will also incorporate hospital-wide systems improvements, including Computerized Physician Order Entry, to be implemented January 2004. CPOE will allow physicians to electronically submit medication orders to prevent errors due to misinterpretation of handwritten prescriptions.
Although DUHS will also implement a patient safety officer soon, Frush said pediatric medicine could not wait for a greater organization to be formed before their program could be instituted. Care of children is significantly different from care of adults for many reasons, including the fact that children are administered medication based on weight.
One of the most pressing challenges, and a longer term concern, is the issue of training health care providers to be even more mindful of safety, changing the culture of the education, Miller said.
"The biggest success is that you never have an event that harms a patient," Frush said. "We're trying to measure the absence of something."
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