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Grand Rounds Thursday, February 28, 2013

Grand Rounds Thursday, February 28, 2013. Patient Safety – No Problem Here. http://www.youtube.com/watch?v=hJbYwL2vfJE Silent Killer , Josie King Story. Answer = Zero The correct question is: Mizzou’s trips to the Final Four? The number of children harmed in our MRI?

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Grand Rounds Thursday, February 28, 2013

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  1. Grand RoundsThursday, February 28, 2013 Patient Safety – No Problem Here

  2. http://www.youtube.com/watch?v=hJbYwL2vfJE • Silent Killer , Josie King Story

  3. Answer = Zero The correct question is: • Mizzou’s trips to the Final Four? • The number of children harmed in our MRI? • CMH’s strategic plan harm goal? • The chance that nobody in the Auditorium or off site spots isn’t currently on their smart phone or tablet?

  4. 2017 Goals and Strategies Demonstrate Quality Outcomes Demonstrate Quality Outcomes Demonstrate Quality Outcomes Goals B1. Effectively allocate staffing and other resources to meet needs D1. Enhance and grow the Pediatric Care Network (PCN) E1. Enhance the research enterprise with cohesive oversight/ guidance, broad-based funding, and a focused research portfolio C1. Assertively act to retain current regional position and take proactive steps to secure and grow complex patient referrals in Southwest Missouri and Eastern Kansas A1. Eliminate harm B2. Increase transparency and accountability D2. Work with commercial payers and/or adult Accountable Care Organizations to be their pediatric network A2. Improve the outcomes of the care provided B3. Build upon a culture which is agile/nimble and engaged in innovation at all levels E2. Increase the caliber of CMH’s educational programs ensuring leading-edge teaching approaches C2. Grow inpatient and specialty outpatient services at CM-South Strategies D3. Leverage system expertise to build business opportunities outside of traditional market areas (e.g., international) B4. Enhance team behaviors to promote service excellence for internal & external customers C3. Improve the relationship with and connection to primary care physicians C4. Enhance access across our system

  5. Answer = Ten What is the best question: • Years since I completed my residency? • Number of HACs being tracked by the Children’s Hospitals Solution for Patient Safety Consortium? • Number of central line infections (CLA-BSIs) at CMH last year? • Mike Artman’s golf handicap?

  6. Safety Event Classification Near Miss Safety Event Serious Safety Event Precursor Safety Event

  7. Near Miss Safety Event • Does not reach the patient. • Error found by detection barrier or luck.

  8. http://www.youtube.com/watch?v=KNqWPswYYaA • Amazing near miss car crash

  9. Precursor Safety Event • Reaches the patient. • Minimal or no detectable harm.

  10. http://www.youtube.com/watch?v=CKkXQxQyYpU • 4 yr old Turkish Boy's Amazing Escape

  11. Serious Safety Event • Reaches the patient. • Causes moderate or severe harm, • Or causes death.

  12. http://www.youtube.com/watch?v=RPBlEE3xIE0 • A closer look at a medication error

  13. Answer = Too numerous to count What is the best question: • Days since Burry retired? • Near miss safety events in our MRI? • Surgical site infections in the past academic year? • Losses by the KU football team in past 10 years?

  14. http://www.youtube.com/watch?v=plvIEf7JsKo • Dangers of MRI

  15. Answer = Four What is the best question: • Number of times Jason Newland has competed in the Hawaii Ironman? • Number of people who have given Jason a hard time this week? • Number of near miss wrong site surgery events since Jason has been the Medical Director of Safety?

  16. http://www.youtube.com/watch?v=SxDx2DlL0UY • Tom Shillue's Wrong Side Surgery

  17. http://www.youtube.com/watch?v=t6mr3gxXx64 • Jess’s story

  18. Jess’s Story “The Holter monitor test was never looked at until after I died, more than a year after I had the test.”

  19. “Zero”

  20. 2012 PICU Quality Improvement Report Chris Hubble, MD Kathy Baharaeen, RN

  21. 2012 PICU Quality Improvement Report • CLA-BSI 20122011 Total Number 15 23 Total CVL days 5611 5484 Rate 2.67/1000 days 4.19/1000 days • 36% reduction

  22. 2012 PICU Quality Improvement Report Unplanned Extubations 20122011 Totals 12 38

  23. 2012 PICU Quality Improvement Report PICU – Catheter Associated UTIs (CA-UTI) Nurse driven removal algorithm • Rate before algorithm (July – Dec 2011) = 5.83 • Rate after algorithm (July – Dec 2012) = 2.24 • 60% reduction

  24. 2012 PICU Quality Improvement Report 20122011 Total Patient Days 8154 7885 Deaths 45 65 • patient mix equal • 20 lives saved

  25. http://www.youtube.com/watch?feature=player_embedded&v=GPOQ8pzY0kYhttp://www.youtube.com/watch?feature=player_embedded&v=GPOQ8pzY0kY • Labels Out

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