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QUALITY AND SAFETY COMMITTEE
Overview | Quality and Safety Champions

Collaborative Governance
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Quality and Safety

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Current work:

  1. The Center for Quality and Safety is reviewing the current process for staff to receive feedback when filing a safety report. Quality and Safety champions were asked a series of questions related to the current effectiveness of the feedback loop. Also, if anyone has filed a safety report and would like to provide additional information they should send an email to the MGH Safety Reporting mailbox.
  2. The process for drawing a Blood Bank Sample will change in September 5, 2017 to include a second signature. This signature will validate that it is the correct patient. Education will take place during the month of August. Staff are encouraged to begin implementing this safety practice.
  3. Nurses are reminded that their responsibility in caring for patients at risk for suicide includes detailed communication to the patient observer of the specific plan in place for the patient. Staff should consider using the new Suicide checklists as a tool when delegating care to the observer.
  4. The committee has initiated a “Safety Moment” segment. Members are encouraged to speak up about issues, concerns, and ideas they may have (related to Quality and Safety). They are also encouraged to recognize best practice they have witnessed and provide positive feedback where deserved.
  5. Nurses had positive feedback about the double signature required for all BBS. They also endorsed being champions on their home units by initiating the practice prior to the official rollout date.
  6. Nurses stressed the importance of a verbal handoff, even to procedure areas were a verbal handoff is not always required (e.g. dialysis unit). Please consider giving a verbal handoff whenever sending your patient to all procedure areas.
  7. A nurse recognized a mislabeled medication and avoided administering the wrong medication. The label on the light protecting bag covering the IV medication did not match up with the medication inside. The label on the outside bag could scan appropriately but due to their thorough assessment potential harm was avoided.
  8. To ensure patient safety and correct medication administration, it is important to scan all medication prior to administration (including all IV infusions). For all continuous infusions, please remember to scan and rate/dose verify the infusion per your unit policy.

Accomplishments 2017:

  • Completion of the Speak Up for Safety Video where MGH nurses shared how they speak up for safety and ensure safe patient care. The video was showcased at the SAFER fair and committee members continue to share with their colleagues.

  • Creation of a new Wound Care Product Selection Guide which was shared with clinicians at the SAFER Fair to gather feedback. That feedback will be included in the guide which will shared with clinicians in early 2018 be.

  • Committee champions served as invaluable resources to their colleagues in preparation for Joint Commission and Magnet visits.

2018 Goals:

Advance Safety Culture by:

  • Promoting components of a safety culture—reporting culture, just culture and learning culture —and its value to patient care.

  • Identifying staff and patient safety priorities related to Disruptive patients (including substance-abuse patients) as well as Nursing risk points in the EMR(Epic)

Sustain and/or Improve Nursing Quality Indicator Outcomes by:

  • Exploring unit based efforts to address highest concerning performance indicator (share and learn)

  • Leaning from Shared Experiences and Wisdom Narratives

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Meets:
4th Tuesday of the month
1:00-3:00pm
Sweet Conference Room, Gray / Bigelow 4

Committee Contacts

Co-chairs: Michael Tady, RN, Medicine, Blake 7
MTady@Partners.org

Coach: Karen Miguel, RN
KMiguel@Partners.org

Advisor: Colleen Snydeman, RN
Director, PCS Quality and Safety
CSnydeman@Partners.org

Recorder: Sandra Thomas
PCS Quality and Safety

Quality and Safety Champions

 

 

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