Building a culture of patient safety

Courtenay Lutz, BSN, RN, CPNP-PC, CPHON and Caitlyn Francis, BSN, RN do a safety cross-check as they access five-year-old Alexander Brown’s central line.
Courtenay Lutz, BSN, RN, CPNP-PC, CPHON and Caitlyn Francis, BSN, RN do a safety cross-check as they access five-year-old Alexander Brown’s central line. “Staff is incredibly caring and conscientious,” said Alexander’s mom Christina. “My husband and I have never once worried about Alexander’s safety while he has been in the hospital.”

Do no harm.

Patient safety, the heart of the Hippocratic Oath, encompasses our mission to protect every youngster admitted to Comer Children’s Hospital from preventable, hospital-acquired adverse events.

Yet warding off falls, pressure injuries, unplanned extubations, and surgical-site infections is only one part of our strategy to achieve zero harm. The challenge is to develop a culture of safety where every frontline clinical staff member focuses on making patient safety a top priority.

“We want safety to be a core value and interwoven into all of the decisions we make,” said Associate Chief Nursing Officer Jeff Murphy, DNP, RN, Vice President, Women’s Children’s and Emergency Services and Vice President of Comer Children's.

UChicago Medicine has a dedicated risk and safety department that investigates safety events and works with leaders and frontline teams to address opportunities to improve patient safety. But Comer leaders want to change staff’s focus from reacting to a safety event after the fact to proactively identifying and mitigating potentially harmful situations.

“We want to take safety to the next level and to accelerate changes that were already happening in individual units and extend those measures institution-wide,” said Allison Bartlett, MD, MS, Professor of Pediatrics and Chief Quality Officer.

“This is where we are going to see the biggest impact for our patients,” added Murphy.

To that end, Comer Children’s has joined the Children’s Hospitals’ Solutions for Patient Safety (SPS), a consortium of more than 145 pediatric hospitals committed to improving safety for their patients and staff. Since 2012, SPS’ efforts have spared 25,834 U.S. children from serious harm. The SPS estimates this achievement has also resulted in savings of $533 million in healthcare cost.

Each SPS member-hospital is required to openly share its safety data as well as successes and failures so clinicians can learn from each other. Regular Zoom and in-person meetings among member hospitals give clinicians the opportunity to share the safety initiatives underway. There are also discussion boards and listservs hosted by content experts where members can seek advice on specific safety issues they’ve encountered and their experiences remedying them.

“Viewing each other as collaborators rather than competitors allows us to learn from each other so we can all make faster progress in sparing more children from harm,” said Murphy, spearheading Comer’s safety initiative with Bartlett.

People aren't simply following the safety initiatives because we are asking them to. People are actually starting to change the way they think about patient safety, which changes behavior in the long term.

Comer Children’s benefits from UChicago Medicine’s efforts to decrease hospital-acquired conditions, such as central line-associated blood stream infections and pressure injuries. But interventions that are effective in preventing these events in adults may not have the same impact in children, or the safety concerns of hospitalized children can be vastly different from adults in acute-care hospitals.

“We need different strategies to prevent hospital-acquired harm in kids,” said Murphy. “In addition, because of our smaller size and cohesive community, we can focus on interventions relevant to our specific patient population.”

For example, blood samples from hospitalized children are generally obtained from a central line to reduce the trauma of daily peripheral blood draws on a child, said Camille Graham, RN, Infection Preventionist. “But drawing blood from a central line increases the risk of bloodstream infections,” she said. “The midlines we use in adults for infusion of antibiotics are safer, but they may not be feasible for a child’s anatomy.”

It’s essential to safely access central lines in children to avoid the risk of infection, so Comer nurses now receive real-time coaching from a veteran nurse trained as a “qualified observer.”

The nurse-coach watches as a nurse performs the central line procedure, and provides feedback to ensure that the blood draw is done safely and correctly every time.

“We’ve been very strategic in educating Comer staff on accessing and maintaining central lines,” said Graham. “We’re also promoting a culture of safety by encouraging coaches to speak up and show their peers a safer way to access a child’s central line.”

Comer’s PICU staff piloted the coaching initiative, and qualified nurse observers are now available to provide feedback on every unit. Nurses are also encouraged to advocate for the discontinuation of a central line when the line becomes unnecessary.

An Extensive Training Effort

Building a culture of safety involves a tremendous commitment from leaders and frontline staff, all of whom are undergoing training for safe patient care.

“The hospital is a complex system and humans make errors,” said Murphy. “Having awareness of situations that carry an increased risk of errors, having tools to decrease the chance of an error, and collaborating as a team to check processes can all help improve safety.”

Since joining SPS, Comer has committed to training every clinical staff member who works at least 50% of the time at the pediatric hospital. All faculty, residents and staff will participate in a three-hour, in-person training session on error prevention techniques. Sessions include how to voice safety concerns and assessing measures applied during previous events. A core group of leaders from inpatient units each received a two-day, intensive error-prevention training session and will train their peers in turn.

Comer has also enhanced its patient safety and risk management process. For example, a multidisciplinary team conducts safety briefs on all inpatient and procedural units five days a week to identify root causes of adverse events and to detect trends that may lead to serious harm.

“We focus on immediate safety issues and strive to resolve them in real time before they escalate to bigger problems,” said Martina Buttilgero, MSN, RN, Senior Patient Safety Specialist. “We want staff to report anything they perceive as an unsafe condition or that prevents them from delivering safe care.”

The safety oversight committee also extends a unit’s successful safety strategies and lessons learned to other units to proactively prevent hospital-acquired adverse events.

The new safety initiative at Comer also includes preventing staff harms, such as needle-sticks or lifting injuries. “We take employee safety as seriously as reports of harms to patients,” said Buttilgero. “If we see a trend in lifting injuries, for example, we will examine whether we have the right equipment and protocols in place to prevent future injuries.”

When patient safety is everyone’s priority, the entire hospital benefits, said Bartlett.

“It’s been wonderful to see the transformation as we relate all our actions to safety. Instead of each unit working alone to solve a safety issue, we are now focused on bringing safety solutions to all the units,” she said. “Everyone is starting to speak the same language and realizing that an issue in one area is likely occurring in another area of the hospital.”

Examples of safety issues tackled by staff include labeling medication orders as adult or pediatric to ensure correct dosing, updating continuous-infusion protocols, and proactively calling for safety huddles when support services are short-staffed.

To keep safety high on the agenda, “all of our large group meetings include a discussion of a safety event that we could have prevented,” said Bartlett. “We discuss what we’ve learned, what we could have done differently, and the fixes we’ve implemented to prevent it from occurring again.”

Learning also comes from the exemplary care of patients. “Our emergency room now debriefs all of our resuscitation cases, including those that go exceedingly well,” said Bartlett. “There are lessons to be learned in identifying what went better than expected and how we can continue to implement those practices.”

Comer’s culture of safety is already taking hold. “People are more comfortable speaking up when they see something that makes them a bit concerned, we’re celebrating our good catches and studying our near misses, and we have a patient-safety focus to the work that we do,” said Bartlett.

“People aren't simply following the safety initiatives because we are asking them to,” said Murphy. “People are actually starting to change the way they think about patient safety, which changes behavior in the long term.”