Patient Safety Meeting Minutes – March 2017

Present: Deborah Sax – UU, Dillan Nelson – Brigham City, Dorothy Watson – Ogden Regional

Dawna Nielson – Coral Desert Surgical Center, Edward Decker – St. Marks, Elaine Hoagland – Mountain View, Grant Bearclough – Castleview, Jean Bigelow – IHC, Kathy Andrus – Dixie, Kendell Nelson – IHC, Kim Harrison – IHC, Laurie Schafer – San Juan, Marie Prothero – HCA, Michele Rojas – Utah Surgical Center, Missi Roeber – McKay Dee, Paula Strasburg – Timpanogas, Raelynn Fredrickson – UU, Rob Marshall – Promise, Stephanie Seuell - HCA

I.  Review of history of Utah Patient Safety efforts

  1. Team discussed goal for 2016 to include more sharing and presentation of effective safety practices by member organizations.

II.  Review of Utah Patient Safety 2002-2016 Report

  1. Discussion included the following
  2. Placing Interpretive Guidelines on WEB site
  3. these can be found as 2016 Patient Safety Surveillance and Improvement Program R380-200 – Definitions on http://health.utah.gov/psi/
  4. Top 3 events by number were:
  5. Retained Foreign Objects (210)
  6. Wrong Body Parts (147)
  7. Falls (86)
  8. Requests included location of Retained Foreign Objects and over time
  9. Requests included seeing what other states or Joint Commission had related to event types

ACTION: Jean Bigelow to send state based information

ACTION: More information was requested on communication and education from the narratives.

ACTION: Jean will look at ‘education’ actions and share some work IHC has done.

  1. A quick review of ‘deaths’ found only 6 cases. The new database has the harm categories and the old data does not.
ACTION: Reporters were requested to go into the database and if possible assign a harm scale to the outcomes for the past 5 years of events.
III.  Anesthesia Amendment
  1. Recommendation for Harm scale to be mapped to rule language on reported adverse event for harm.

ACTION: Jean Bigelow will send Iona the TJC RCA Square tool.

  1. Count number of deaths.

ACTION: Marie Prothero will prepare examples of ‘outcomes’ for Harm Scale.

  1. Recommended that advisory committee define adequacy of sedation and anesthesia requirements.

ACTION: need list of ‘sedation drugs’

  1. Recommendations for data to collect include:
  2. age
  3. gender
  4. procedure (CPT codes)
  5. whether procedure was consented
  6. list of relevant co-morbidities
  7. weight in kilos or lbs
  8. current medications
  9. drug name from pick list

ACTON: Marie to send list

  1. total dosage,
  2. concentration
  3. allergies
  4. cardiac or respiratory issues
  5. training and identity of person performing procedure
  6. training and identity of person administering sedation
  7. List of responsibilities
  8. Definition of patient monitoring –
  9. SPo2
  10. Vitals
  11. Cardiac life support - American Heart Association, American Hospital Association

xv.  The H&P should include at least the following information:

xvi.  chief complaint;

xvii.  (present illness;

xviii.  relevant medical/surgical history

xix.  medications/allergies;

xx.  social and family histories;

xxi.  review of body systems;

xxii.  a comprehensive physical assessment;

xxiii.  impression;

xxiv.  plan.

  1. Recommendations for advisory committee
  2. Anesthesia groups or association
  3. Surgical Center association
  4. UMA – Plastic Surgeons, Fertility, OB, Pain clinics
  5. Nurse Anesthesia groups
  6. Risk Managers – Corporate
  7. Podiatry Association
  8. Dentist Association
  9. Legislative sponsors
  10. Medical Staff Credentialing representatives
  11. Pharmacist
  12. Physician Leadership

ACTION: Marie to follow up with Dr.Mark Shockey