Actionable Patient Safety Solutions #6: Hand-off Communications

and 22 collaborators
Executive Summary Checklist
- Hospital governance must become aware of this major performance gap as it exists in their own organization and must participate in and support the following actions.
- Establish a HOC core team that includes a strong sponsor (senior clinical and administrative leadership is strongly encouraged for this role), physician champion, nursing champion and project leader. Other members include practicing physicians, nurses, therapists, technicians, and information technology experts.
- Define the exact roles of the sender and receiver in each category of HOC in order to make them effective and reliable.
- Educate all hospital staff on the following principles and requirements for effective HOC:
- HOC occur when patient care is transferred to a different caregiver, care team, hospital unit, or patient care site. Each HOC involves a “sender” and “receiver.”
- HOC failures occur when (1) the “sender” omits vital patient information from his/her report, (2) the “receiver” fails to understand or properly record vital information given by the sender or (3) the "sender" and/or "receiver" fails to manage the subject in formation in a complete accurate and/or timely manner."
- A systematic complete HOC process is similar to the pre-takeoff and pre-landing procedures used by aircraft crew. Aviation has made great progress in Quality Improvement in these procedures through the use of checklists. We will use a similar approach here.
- PSMF has identified nineteen different categories of HOC that commonly occur in hospitals or other care units. Each of these categories requires a specific HOC checklist. PSMF has developed 10 to date:
- Emergency Department to Operating Room (Appendix A);
- Hospital Unit to Home (discharge) (Appendix B);
- Hospital Unit Shift Change (Appendix C);
- Operating Room to Hospital Unit (Appendix D);
- Operating Room to Home (Appendix E);
- Hospital to Outside Care Unit (Appendix F);
- Emergency Department to Surgery (Appendix G);
- Hospital Unit to Outside Care Unit (Appendix H);
- I-PASS Handoff Mnemonic (Appendix I);
- Emergency Department to Critical Care Unit (Appendix J);
- Paramedics to Emergency Department (Appendix K)
- Measure the effectiveness of current HOC processes and build into performance goals
The Performance Gap
Leadership Plan
- Hospital governance and senior administrative leadership must commit to becoming aware of this major performance gap in their own organization.
- Hospital governance, senior administrative leadership, and clinical/safety leadership must close this performance gap by implementing a comprehensive approach to addressing hand-off communication.
- Healthcare leadership must reinforce their commitment by taking an active role in championing process improvement, giving their time and attention, removing barriers, and providing necessary resources.
- Leadership must demonstrate their commitment and support by shaping a vision of the future, clearly defining goals, supporting staff as they work through improvement initiatives, measuring results, and communicating progress towards goals. Actions speak louder than words. As role models, leadership must ‘walk the walk’ when it comes to supporting process improvement across an organization.
- There are many types of leaders within a healthcare organization and in order for process improvement to be successful, leadership commitment and action are required at all levels. The Board, the C-Suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and must be engaged.
- Build a strong foundation for change by assessing the culture for change, defining the change, building a strategy, engaging the right people, and painting a vision of the future. This should be done at the outset of the project.
Actionable Patient Safety Solutions #14: Falls and Fall Prevention

and 10 collaborators
Executive Summary Checklist
- Assess the existing fall prevention and protection from injury policies, procedures, protocols, and educational programs in relation to current evidence and emerging research.
- Identify existing needs or gaps in the fall prevention and protection from injury policies, procedures, protocols, and knowledge application for employees.
- Identifying Opportunities for Improvement and Set Aims \cite{Goodwin_2014,Mion2012,mccurley2014new,Waters_2015}.
- Collect fall and injury data to assist in advancing precision performance of fall prevention and protection from injury program.
- Debrief all falls, including non-injury falls. Analyze for trends or patterns that assist in advancing performance of the fall prevention and protection from injury strategy.
- Consider bundling evidence-based recommendations to achieve greater outcomes.
- Consider provider training on how to partner with patients and their loved ones on safety strategies to prevent falls and protect from injuries.
- Consider technological advancements to advance performance and reduce injuries.
- Develop a multidisciplinary team to create, implement, and sustain fall prevention and protection from injury initiatives. This team should include, but is not limited to, Executive sponsor, Environmental Manager, Risk Manager, Physical Therapist, Occupational Therapist, Medical Doctor, Unit Manager, frontline nursing staff, or Certified Nursing Assistant. Efforts should be made to get as many representatives from all shifts.
- Develop fall champions throughout all departments who further drive organizational knowledge and action in the healthcare setting.
- Provide clear and concise communication regarding the champion's role and responsibilites.
- Develop feedback mechanisms to learn what is workign and what can be improved upon in the fall prevention and protection from injury plan from the champion's perspective.
Performance Gap
Actionable Patient Safety Solutions #16: Person & Family Engagement
and 19 collaborators
Executive Summary Checklist
The Performance Gap
Actionable Patient Safety Solutions #11A: Postpartum Hemorrhage (PPH)

and 15 collaborators
Executive Summary Checklist
Prevention of PPH-related maternal mortality
- Commitment from hospital governance and senior administrative leadership to support maternal safety initiatives like PPH in their healthcare system.
Readiness in Every Unit
- Create a hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches based on the recommendations referenced \cite{2006,safemotherhood,ob3,american2014preparing,collaborative2013florida,postpartum18hemorrhage,bingham2010cmqcc}
- Ensure teams have immediate access to hemorrhage medications (kit or equivalent) \cite{world2014recommendations,evanson2014postpartum,warningguidelines}
- Establish a response team - who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services)\cite{joint2010sentinel}
- Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)
- Unit education on protocols, unit-based drills (with post-drill debriefs)
Recognition & Prevention in Every Patient
- Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)
- Assessment of:
- Retained placenta
- Failure to progress during the second stage
- Lacerations
- Morbidly adherent placenta
- Instrumental delivery
- Large for gestational age newborn (>4000 gm)
- Hypertensive disorders
- Induction of labor
- Prolonged 1st or second stage of labor
- Measurement of cumulative blood loss (formal, as quantitative as possible)
- Weigh the pads for quantitative measurement
- Active management of the 3rd stage of labor (department-wide protocol)
Response
- Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists
- Obstetric rapid response teams, Team Stepps.
- Support program for patients, families, and staff for all significant hemorrhages
Reporting
- Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities
- Multidisciplinary review of serious hemorrhages for systems issues
- Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
The Performance Gap
Postpartum Hemorrhage (PPH)
- Retained Placenta
- Failure to Progress During the Second Stage Of Labor
- Placenta Accreta, Increta, and Percreta
- Lacerations
- Instrumental Delivery
- Large Gestational Age (LGA) Newborns
- Hypertensive Disorders
- Induced Labor
- Augmentation of Labor With Oxytocin \cite{16272036}
Leadership Plan
- Individual practices, hospitals, and hospital systems should develop systems of care that deliver risk-appropriate care to women pre- and post-delivery.
- Managing PPH requires a comprehensive and interdisciplinary commitment from administrative and medical leaders.
- While there are prescriptive clinical interventions, highlighted in the practice plan, engaging expectant mothers and those supporting them is critical to the holistic improvement of an institution's obstetric safety including PPH.
- Women with risk factors for PPH should be identified and counseled as appropriate for their level of risk and gestational age.
- It is important that leaders ensure availability of resources such as personnel, equipment, blood products and trained personnel.
- Establishing PPH protocols, creation of PPH kits, and appropriate training and simulation drills reduces the risk of PPH.
Practice Plan
Technology Plan
- Electronic Health Record (EHR)
- Web-based/EHR predictive algorithms that elicit specific data as but not limited to vital signs (BP, temp, HR, RR and SpO2), lab values, nurses notes and event reports.
- Close monitoring of hemodynamics such as heart rate and blood pressure.
- Ultrasound technology for assessment of retained products, retained placenta or abruption.
Metrics
Severe Maternal Morbidity among Hemorrhage Cases
Outcome Measure Formula
- Presence of an abruption, previa or antepartum hemorrhage diagnosis code
- Presence of transfusion procedure code without a sick cell crisis diagnosis code
- Presence of a postpartum hemorrhage diagnosis code
Metric Recommendations
Actionable Patient Safety Solutions #4: Failure to Rescue: Monitoring for Opioid-induced Respiratory Depression

and 13 collaborators
Executive Summary Checklist
- Implement continuous electronic monitoring on all floors where patients are receiving opioid medications.
- Make continuous (not spot-check) monitoring of oxygenation the care standard. At a minimum, monitoring should include continuous measure through motion and low perfusion pulse oximetry (i.e. SET, until another technology is proven to be equivalent) with a central monitoring station with direct, immediate communication to the nurse on a mobile device.
- Monitor ventilation in patients receiving supplemental oxygen with either continuous capnography or acoustic respiration rate monitoring are technologies that can achieve this.
- Set appropriate respiratory rate (RR) alarms and apnea alarms to minimize alarm fatigue based on the patient population and individual risk of respiratory compromise. For example, RR between 6 and 30 breaths per minute, pulse rate (PR) between 40 and 100 for adults, PR between 70-120 for pediatric patients and a lower limit of 84% for SpO2)\cite{McGrath_2016}.
- Institute a rapid response notification system, which will alert staff if the patient is deteriorating. A plan for escalation of rapid response alarm to another staff member should also be in place.
- Hospital governance should commit to a plan that includes:
- Reviewing all reported patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the event. A review of all previous closed malpractice claims related to opioid induced respiratory depression should also be undertaken.
- Monitor and review all patients where naloxone was administered.
- Identifying and prioritizing common contributing factors from those serious preventable events.
- Identify and institute continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition, and ensure appropriate interventions are initiated in a timely manner.
- Providing the resources necessary to implement the action plan.
- Identifying a hospital “champion” who will be accountable for successful implementation, education and evaluation of the chosen plan.
- Developing an educational plan for all staff, patients and family members that shares common contributing factors leading to opioid induced respiratory depression.
- Implementation of a plan that eliminates current risks associated with opioids.
- Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.
- Develop a multimodal analgesic pain management program utilizing non-opioid adjuncts.
- Patients and caregivers should be educated to recognize potential side effects of opioids and sedatives, and notify caregivers immediately if they occur.
The Performance Gap
Leadership Plan
- The plan should include fundamentals of change outlined in the National Quality Forum safe practices, including awareness, accountability, ability, and action \cite{APSS4Cite23}.
- Hospital governance and senior administrative leadership must commit to become aware of this major performance gap in their own healthcare system.
- Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach to addressing the performance gap.
- A goal date should be set to implement the plan to address the gap with measurable quality indicators.
- “Some is not a number. Soon is not a time."\cite{APSS4Cite24}.
- Specific budget allocations for the plan should be evaluated by governance boards and senior administrative leaders.
- Clinical/safety leadership should endorse the plan and drive implementation across all providers and systems.
Practice Plan
- Formally address opportunities to improve electronic detection of deteriorating patients and the early notification of the caregivers. This includes the prevention of adverse events due to respiratory depression from pain medications.
- Implement systematic protocols to assess pain management protocols and unify order sets where possible.
- Implement multi-modality pain strategies \cite{_NA__2012}.
- Implement an effective system to accomplish continuous electronic monitoring and notification and escalation.
- Continuous oxygenation and/or respiratory monitoring (not spot check monitoring) with pulse oximetry through an adhesive sensor. Pulse Oximetry with measure through motion and low perfusion technology is preferred.
- Remote notification system that provides alarm notification to the care provider.
- A system of alarm escalation if the primary nurse does not respond in a timely manner.
- Set SpO2 alarms to reduce non-actionable alarms
- Depending on the institution and patient populations within that institution, lower alarm limits may be set to be conscious of alarm fatigue. Each institution should set limits to fit their specific patient population.
- Continuous ventilation monitoring (e.g. capnography or respiratory acoustic rate monitoring) for reduced respiratory rate in patients on supplemental oxygen.
- Set respiration rate alarms to reduce non-actionable alarms (National Quality Forum 2010)
- Depending on the institution and patient populations within that institution, lower alarm limits may be set to be conscious of alarm fatigue. Each institution should set limits to fit their specific patient population.
- Continuous electronic monitoring systems should integrate multiple physiologic parameters in the form of an index to identify clinically significant changes earlier and more reliability.
- Formalize transfer protocols from surgery and intensive care unit to postoperative general floor unit.
- Formalize workflows for patient admits and discharges from continuous monitoring.
- Rapid response team
- Identify the opportunities for implementation of rapid response teams and protocol for initiating a rapid response call for postoperative respiratory depression.(Alam 2014)
- Since family members are often highly sensitive to changes in a patient’s condition, it is advisable to allow families to ask the nurse to activate the rapid response system. Families should be educated regarding this option \cite{Brady_2014}.
- Consider proactive rounding on high-risk patients by resource nurses with critical care training \cite{Hueckel_2006}.
Technology Plan
- Continuous pulse oximetry
- Adhesive pulse oximetry sensor connected with pulse oximetry technology proven to measure through motion and low perfusion to avoid false alarms and detect true physiologic events, with added importance in care areas without minimal direct surveillance of patients (ie: Masimo SET® pulse oximetry, in a standalone bedside device or integrated in one of over 100 multi-parameter bedside monitors, until another technology is proven to be equivalent) \cite{Shah_2012}.
- Continuous respiratory rate monitoring
- Ability to accurately measure changes in respiratory rate and cessation of breathing with optimal patient tolerance and staff ease of use in order to avoid false alarms, with added importance in care areas without minimal direct surveillance of patients (e.g. Masimo rainbow® Acoustic Monitoring \cite{Mimoz_2012}, EarlySense Contact Free Monitoring System, or sidestream end-tidal carbon dioxide monitoring such as Oridion®, Masimo® or Respironics®).
- Remote monitoring and notification system
- Remote monitoring with direct clinician alert capability compatible with recommended pulse oximetry technology or other respiratory rate monitoring technologies (Masimo Patient SafetyNet™, EarlySense Contact Free Monitoring System or comparable multi-parameter monitoring system).
- Direct clinician alert through dedicated paging systems or existing hospital mobile device notification system.
- Network
- Medical-grade wireless network suitable to permit reliable, continuous remote monitoring and documentation during ambulation and/or transport.
- Alternatively, a wired network can be used which allows surveillance of patients while they are in bed but not while they are ambulating.
Metrics
Topic
Outcome Measure Formula
- any secondary ICD-9-CM or ICD-10-CM diagnosis code for acute respiratory failure; or
- any-listed ICD-9-CM or ICD-10-PCS procedure codes for a mechanical ventilation for 96 consecutive hours or more that occurs zero or more days after the first major operating room procedure code (based on days from admission to procedure); or
- any-listed ICD-9-CM or ICD-10-PCS procedure codes for a mechanical ventilation for less than 96 consecutive hours (or undetermined) that occurs two or more days after the first major operating room procedure code (based on days from admission to procedure); or
- any-listed ICD-9-CM or ICD-10-PCS procedure codes for a reintubation that occurs one or more days after the first major operating room procedure code (based on days from admission to procedure)
- with a principal ICD-9-CM or ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for acute respiratory failure (see above)
- where the only operating room procedure is tracheostomy
- where a procedure for tracheostomy occurs before the first operating room procedure†
- with any-listed ICD-9-CM or ICD-10-CM diagnosis codes for neuromuscular disorder
- with any-listed ICD-9-CM or ICD-10-PCS procedure codes for laryngeal or pharyngeal, nose, mouth or pharynx surgery
- with any-listed ICD-9-CM or ICD-10-PCS [if appropriate] procedure codes involving the face and any-listed ICD-9-CM or ICD-10-CM diagnosis codes for craniofacial anomalies
- with any-listed ICD-9-CM or ICD-10-PCS procedure codes for esophageal resection
- with any-listed ICD-9-CM or ICD-10-PCS procedure codes for lung cancer
- any-listed ICD-9-CM or ICD-10-CM diagnosis codes for degenerative neurological disorder
- MDC 4 (diseases/disorders of respiratory system)
- MDC 5 (diseases/disorders of circulatory system)
- MDC 14 (pregnancy, childbirth, and puerperium)
- with missing gender, age, quarter, year, or principal diagnosis
Metric Recommendations
Actionable Patient Safety Solutions #9A: Early Detection & Treatment of Sepsis (For High-income Countries)

and 25 collaborators
Executive Summary Checklist
- Commitment from hospital governance and senior administrative leadership to support early detection and appropriate management of sepsis in their healthcare system.
- Develop a team approach to implement a protocol for early sepsis identification and treatment.
- Create a sepsis dashboard for your organization’s leadership.
- Implement a Sepsis Rapid Response Team or incorporate early detection of sepsis into your existing medical emergency teams (e.g. rapid response teams).
- Formalize processes to screen patients for signs of sepsis throughout the entire institution.
- Implement an effective monitoring system to accomplish continuous monitoring and early detection, based on existing data (SIRS criteria, MEWS or any other warning system being used).
- Select an EHR or leverage the existing EHR to serve as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool and allows for continuous analysis and surveillance will be most beneficial.
- Implementation of automated electronic screening and documentation of process of care based on existing data (SIRS criteria, MEWS or any other warning system being used).
Actionable Patient Safety Solutions #9B: Early Detection & Treatment of Sepsis (For Low and Middle-Income Countries)

and 13 collaborators
Executive Summary Checklist
- Commitment from hospital administrators, leaders and senior clinicians to support early detection and appropriate management of sepsis in their healthcare system.
- Develop a team approach to implement a protocol for early sepsis identification and treatment. Identify key stakeholders and a team leader.
- What is the current "reality of sepsis care" in your organization? Create a list of data and collect data to assess processes and outcomes of care for sepsis.
- Create a clear vision of where you want to be and what you would like to improve.
- Be systematic in your approach to quality improvement - Plan, Do, Study and then Act.
- Implement a system for improving recording of vital signs and use of early warning scores to identify severely ill patients such as patients with sepsis.
- Implement a system for early detection of sepsis such as screening and response throughout the hospital or in specific areas, e.g. emergency department, maternity wards, intensive care unit, pediatrics, surgical wards.
- Develop bundles and systems to improve implementation:
- For sepsis, implement processes for rapid assessment and intervention at the bedside and initiate sepsis bundle (surviving sepsis campaign 3-hour element).
- For septic shock, implement processes for rapid assessment, intervention, and need for higher level of care and initiate septic shock bundle (surviving sepsis campaign 6-hour elements).
- For those who can acquire electronic systems:
- Acquire electronic systems to facilitate data collection and screening for sepsis.
- Implement an automated system for electronic screening and documentation of the process of care based on existing data. This may involve using SIRS criteria, MEWS, qSOFA, or any other warning system being used.
- Implement a process for continuous monitoring of electronic systems and protocols.
- Compliance, efficacy and outcome measures.
- Design a workflow specific to level of alert.
- Screening: SIRS/Sepsis/Septic shock workflow.
- Mortality prediction: Early Warning Score e.g. Universal Vital Assessment, MEWS or qSOFA (or "Level of Risk") .
- Implement case reviews when cases are not managed well or when outcomes are poor e.g. mortality, intensive care admission, prolonged stay in the hospital.
The Sepsis Improvement Gap
- What is sepsis and why is it important?
- How to use a quality improvement approach to improve sepsis management?
- How to use resources and tools to support sepsis improvement programs?
What is sepsis and why is it important to you?
What is sepsis?
What is burden of sepsis?
Actionable Patient Safety Solutions #2D: Ventilator-associated Pneumonia (VAP)

and 30 collaborators
Executive Summary Checklist
- Commitment from hospital leadership to support a program to eliminate VAP.
- Implement evidence-based guidelines to prevent the occurrence of VAP.
- Prevent aspiration of secretions
- Maintain elevation of head of bed (HOB) (30-45 degrees)
- Avoid gastric over-distention
- Avoid unplanned extubation and re-intubation
- Use cuffed endotracheal tube with subglottic suctioning
- Maintain the endotracheal tube cuff pressure at greater than 20 cmH20
- Encourage early mobilization of patients with physical/occupational therapy
- Ensure that patient is conscious and responsive prior to extubation.
- Reduce duration of ventilation
- Conduct “ sedation vacations”
- Assess readiness to wean from ventilator daily
- Conduct spontaneous breathing trials
- Reduce colonization of aero-digestive tract
- Use non-invasive ventilation methods when possible (i.e. CPAP, BiPap)
- Use oro-tracheal over naso-tracheal intubation
- Use cuffed Endotracheal Tube (ETT) with subglottic suctioning
- Perform regular oral care with an antiseptic agent
- Reduce opportunities to introduce pathogens into the airway
- Prevent exposure to contaminated equipment
- Use sterile water to rinse reusable respiratory equipment
- Remove condensation from ventilator circuits
- Change ventilator circuit only when malfunctioning or visibly soiled
- Store and disinfect respiratory equipment effectively
- Measure adherence to VAP prevention practices and consider monitoring compliance
- Hand Hygiene
- Daily sedation vacation/interruption and assessment of readiness to wean
- Regular antiseptic oral care
- Semi-recumbent position of all eligible patients
- Monitor ventilated patients for: positive cultures, temperature chart/log, pharmacy reports of antimicrobial use, and change in respiratory secretions
- When complications exist, raise them on top of the patient’s EHR problem list.
- Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention of VAP.
- Encourage continuous process improvement through the implementation of quality process measures and metrics and a monthly display through a dashboard
The Performance Gap
Leadership Plan
- Hospital governance and senior administrative leadership must champion efforts in raising awareness to prevent and manage VAP infections safely.
- Healthcare leadership should support the design and implementation of an antimicrobial stewardship program.
- Senior leadership will need to integrate surveillance and metrics to ensure prevention measures are being followed.
- Leadership commitment and action are required at all levels for successful process improvement.
Actionable Patient Safety Solutions #3E: Standardizing and Safeguarding Medication Administration
and 5 collaborators