Unplanned Returns to OR

2. Trends Neurosurgery: There were a total of 7 Neurosurgical returns to surgery. 5 were due to hematoma of which 3 was 1 surgeon. The other Neurosurgical returns included 1 loose hardware & 1 recurrent subdural hematoma. No cardiovascular returns to surgery. Actions The neurosurgical cases have been sent to CE/PI for further review. Unplanned Returns to OR Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

3. Trends 3 major injuries Toileting 14% Behavioral Health 35% Found on floor 12% Assisted to floor 13% Ambulating 2 - 4 p.m. and 9 p.m. – Midnight 40% Age 60 years or greater Patient Falls Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

4. Actions Designed a door sign which enhances visualization of fall risk and prevention measures in place. The sign was designed by Tower 7B unit council as an action item from a Root Cause Analysis & approved through Patient Safety Improvement Council & Systemwide Evidenced Based Practice Council. Advanced Practice Partners assisting in enforcing hourly rounding. Monitoring of face to face handoff between transportation and nursing indicates compliance. Trending & analysis is submitted to systemwide falls committee for performance improvement opportunities. Risk Management participating in IHI falls collaborative. Patient Falls Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

5. Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

6. Trends 4 general surgery 2 orthopedic – post op infections 1 gynecological Wound infection after breast surgery Return to hospital with superficial wound infection FY2010 40% of infections were MRSA Unplanned Returns to OR/Post Operative Surgical Site Infection Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

7. Actions All cases have been reviewed by Quality Management, care appropriate Screen preoperative orthopedic (as of May 2010) & nursing homes & ICU admits Nursing providing gloves to physicians at dressing change Inservice provided to nursing May 2010 focusing on isolation precautions &MRSA screening. Contact physicians to discuss findings and assess office practices Unplanned Returns to OR/Post Operative Surgical Site Infection Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

8. Trends Computer entry – orders entered incorrectly by RN Misreading of electronic order by nursing One Near miss Actions Reviewed handoff tool for Emergency Department to include pre-operative antibiotics Medication Variances Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

9. Trends 50% while toileting 5 minor injuries Confusion, loss of balance 33% had been designated as high risk for falls Actions Ensure falls are documented in medical record to enable analysis. Director is ensuring hourly rounds & post fall huddles. Risk Management is participating in the IHI Falls Collaborative. Patient Falls Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11

10. ATTENTION ALL STAFF: FALL RATES ARE EXTREMELY HIGH! OUR UNIT ACTION PLAN EFFECTIVE IMMEDIATELY Hourly Rounds: Added to chart reviews Post fall “Kuddles:” Included in report sheet to Director Charge RN/ANM Monitoring: Fall risk assessments Safety initiatives Sitter case needs Charge RN/ANM To Notify Director of all falls (24/7) Ensure Consistency/Education Lead ACP –Train all new ACP’s ACP’s to offer toileting especially, (prior to and after meal times) *Strict compliance and monitoring Patient Falls Confidential Patient Safety Work Product.  Protected under the Patient Safety and Quality Improvement Act.  Do not disclose unless authorized by BH Risk Management or Legal Department. PSWP collected on: 1/12/11