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Overview | Quality and Safety Champions

Collaborative Governance

Advisory Committees

Committee on Diversity and Inclusion

Ethics in Clinical Practice


Patient Education

Patient Experience

Clinical Practice Committee

Quality and Safety

Research and Evidence-Based Practice



Current work:

1. Joint Commission Lab Survey Preparation

  • Please remember to “Stop” your blood transfusions in Epic. During nursing handoff consider reviewing your Blood Flowsheet to ensure that all transfusion documentation is completed.
  • Please remember to document the provider notification of a critical lab value. This may be done in the Complex Assessment Flowsheet in the Provider Notification row.

2. Pressure Injury Survey

  • 822 patients surveyed, 29 Stage 2 or greater Pressure Injuries identified, 15 Stage 2 (51.72%), 0 Stage 3, 0 Stage 4, 9 DTI (31.04%), and 5 unstageable (17.24%).
  • Rate increased to 2% (Stage 2 or greater), 2.5% (all stages).
  • Now reporting Mucosal Membrane Pressure Injuries, 4 identified on this survey.
  • The committee reviewed staging of pressure ulcers and Braden Scale based interventions.

3. Fall Prevention

  • Review of data surrounding incidents of falls and discussion about patient populations who are at high risk for falling.
  • Every unit takes precautions specific to their patient populations, sharing these techniques proved to be insightful.
  • The committee will explore ideas to promote fall prevention throughout the hospital.

4. According to the American Nurses Credentialing Center, “The peer review process stimulates professionalism through increased accountability and promotes self-regulation of the practice.” Please remember to complete your Nursing Peer Review Health Stream. Think about ways you may champion this on your home units.

5. Champions have begun planning for the SAFER Fair and decided on 4 subgroups; Fall Prevention, Pressure Injury Prevention, Safety Culture, and Suicide Prevention.  We continue to think quality and safety improvement ideas for each topic and ways to disseminate the already wonderful work that takes place throughout MGH.


Practice Alert Transfusion Documentation in EPIC final.6.23.17

Practice Alert HEAT THERAPY 6.23.17

Practice Alert MAR BPA Student View 6.23.17

Practice Alert Suicide-Communications 6.23.17

PRACTICE ALERT Adult Hydromorphone 6.23.17

Practice Alert Bolus from Infusion Converting Units of Measure final 6.23.17

suicide checklist 2-17 final 6.23.17

Suicide-SelfharmPractice Alert 2_ 6.23.17

Highlights/Accomplishments in 2016:

  • stablished the committee’s goals and areas of focus
  • Presented a Safety culture overview for Champions
  • Presented a Journal Club with contact hours
  • Invited guest speakers to talk on: transgender patients, Epic, Suicide Checklist, Police and Security, CAUTI and the RN driven catheter removal protocol.
  • Identify Epic related issues post roll out, including: safety concerns, patient experience during roll-out, blood transfusion
  • Participated in visiting scholar events – pressure ulcers & missed nursing care
  • Reviewed and gave feedback on Practice Alerts
  • Activities during the SAFER Fair included: Patient Safety, Fall and CAUTI Prevention Staff Safety, MOAB Training and Injury Prevention, Medication Safety, Safety Jeopardy Game and Weight Based Dosing contest.
  • Speak Up for Safety Video (in production).

2017 Goals:

  • Creating a “Safety Culture”
    • Just Culture
    • Promoting safe and evidenced-based practice
    • Encourage feed back
  • Fall Prevention and promotion of the LEAF Program
  • Further review of qualaity and safety data
  • Safe patienthandling
  • Suacide prevention
  • Participation in Patient Safety Week
  • Pressure Ulcer prevention and training
  • Staff Safety
    • MOAB Training
    • Preventing exposures
    • FInjury prevention







4th Tuesday of the month
Sweet Conference Room, Gray / Bigelow 4

Committee Contacts

Co-chairs: Michael Tady, RN, Medicine, Blake 7

Coach: Patricia Shanteler, RN, Surgery, Neurosciences

Advisor: Colleen Snydeman, RN
Director, PCS Quality and Safety

Recorder: Sandra Thomas
PCS Quality and Safety

Quality and Safety Champions


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