DL Patient Safety Initiative

Seton Family of Hospitals Patient Safety Initiatives

Overview for Physicians

Seton Family of Hospitals has partnered with the Medical Staff and Seton associates to make promoting Patient Safety a primary focus since 2003. It is part of Healthcare That is Safe, one of the three core Calls For Action of Ascension Health.

In conjunction with Ascension Health, we participated in a five-year effort to eliminate preventable injury and death. As a result, our severity-adjusted mortality is ranked in the “select category” (i.e., the best 15% of hospitals nationally for mortality rate as measured by Care Science methodology).

Current Seton Family Safety Initiatives

Ascension projects include:

VAP Reduction
BSI Reduction
Perinatal Safety
Patient Falls Reduction
Pressure Ulcer Reduction
Medication Safety
Code Reduction and Rapid Responses Team (CRT) Introduction
Ascension Health Children’s Healthcare Initiative

In addition, we have made great progress in other areas of Patient Safety, including:

1. Improved Core Measures Compliance

a. AMI Performance Measures

b. CHF Performance Measures

c. Pneumonia Performance Measures

d. Surgical Site Infection Performance Measures

2. Other Areas of Infection Reduction

a. MRSA Program

b. UTI Program

c. SSI Prevention in Non-Core Measure Settings

3. Patient and Associate Handling Injuries

4. Universal Protocol Introduction

5. Unit-based Patient Safety Team

6. Simulation / Team Training

7. CLEAR (Closed Loop Ensures Accuracy and Reliability) Program

Network Pain Team
Anticoagulation Team
Insulin Protocol Effort

8. JCAHO Tracer Reviews

9. Network Nutrition Support Team

10. Network Sepsis Team

All Facilities are also pursuing other site-based, tailored Patient Safety efforts, including the following examples:

DVT Prophylaxis Efforts
Heparin Induced Thrombocytopenia Team
Dilaudid Dose Optimization Team
Alcohol Withdrawal Team
Sickle Cell Anemia “Closed Loop” Team
“SWAT” Reviews of Adverse Events
“Just Culture” for Peer Review
Handwashing
Pediatric Medication Error R>eduction
Pediatric Early Warning Scoring System>

What’s Next

FY09 safety objectives for the Seton Family include:

Limit significant events to 4.5 or fewer events per 100,000 patient days (expanded definition includes Stage 3 and Stage 4 pressure ulcers)
Limit potentially preventable injuries to 22 per 10,000 patient days (expanded definition includes VAP, CVL-BSI, falls with injury, potentially preventable codes, birth trauma and Stage 2-4 pressure ulcers).
Reduce pressure ulcer prevalence to 2.1% or less for patients with Stage 2-4 hospital acquired pressure ulcers.
Comply with sequenced initiatives at least 90% of the time.
Provide all of the core measures appropriate care to at least 80% of eligible patients at each site.
Develop a new metric for serious events.
Mortality target to be set.

If you would like more information on any of the Seton Family safety initiatives, please contact the Medical Chief of Staff at your site or you VPMA.

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