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QUALITY AND SAFETY COMMITTEE
Overview | Quality and Safety Champions

Collaborative Governance
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Committee on Diversity and Inclusion

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Clinical Practice Committee

Quality and Safety

Research and Evidence-Based Practice

 

 

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.

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

 

 

 

 

 

 

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

Elzbieta Gilbride, RN
EGilbride@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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