# NCPS TIPS -- March/April 2002

### Contents: 1. Escorts Improving Patient Safety

> 2\. Final Patient Safety Handbook Now on Web
>
> 3\. In Memoriam
>
> 4\. Safety Spotlight
>
> 5\. Tips on Reducing Falls

### 

### 1. ESCORTS IMPROVING PATIENT SAFETY

##### From the VA National Center for Patient Safety

Hospitals are all too familiar with the potential risks in transporting
oxygen-dependent patients:

**•** Patients may be transported without their ordered oxygen

**•** Patients may be transported with ordered oxygen, but the tank has
inadequate capacity for transport

**•** Transport may take longer than expected and the patient's portable
oxygen tank runs out

To address these issues, Eileen Hagarty, a pulmonary clinical nurse at
Hines VA Medical Center, and Barbara Springer, the patient safety
manager, worked together to develop and implement an O2 transport
program with various components, including the *Oxygen Patient Transport
Communication Tool*. The tool was designed to ensure that sufficient
oxygen is available when a patient is transported with a portable E
cylinder.

Nursing staff use the tool to indicate the approximate minutes of E
cylinder capacity. This is determined from a neatly constructed table
that compares flow in liters/minute with tank pressure in pounds per
square inch (psig). The tool is handed off to an escort who rechecks the
approximate minutes of operation and transports the patient to the
appropriate destination within the available time. As of February 2000,
oxygen patient transport practices at Hines mandated the use of this
tool.

Escorts are an essential part of the team because they are responsible
for rechecking the amount of O2 available and assuring that the patient
arrives at the destination with sufficient oxygen. As part of their
orientation process, all escorts must demonstrate competency on using
the tool. This includes the ability to read E cylinder flow meters and
tank pressure gauges as well as demonstrate how to shut off the cylinder
in an emergency situation. To date, 758 staff from 13 different services
are trained in using the tool.

Monthly analyses of the program monitor compliance rates,
education/training competency, and the required flow meter rates being
set. Noteworthy results from this program include:

**•** The lack of standardized regulators led to problems in estimation
of O2 supply duration so now regulators are being standardized.

**•** Escorts and other staff are more aware of other transport-related
safety issues, such as the proper attachment of the E cylinder to the
patient's wheelchair.

**•** Escorts are recognized by clinical care providers as an essential
part of the team for their contributions to the care and safety of
patients.

**•** Oxygen transport adverse events and close calls are much less
likely to occur.

Through their communication tool, Hines has achieved considerable
patient safety success. Reported oxygen transport-related adverse events
have declined to almost zero. Communication gaps between escort, Nursing
Service, and treatment area staff have been bridged. For more
information about Hines' Oxygen Patient Transport Communication Program
and Tool, please contact Eileen Hagarty (708-202-8387 x25016), Barbara
Springer (708-202-8387 x23996), or Dea Mannos at NCPS (734-930-5839).

### 2. FINAL PATIENT SAFETY HANDBOOK NOW ON WEB

##### From the VA National Center for Patient Safety

On January 30, 2002, the VHA National Patient Safety Improvement
Handbook (VHA Handbook 1050.1) was officially adopted and the old 1051.1
was rescinded. The draft version that has been used by direction from
the Under Secretary for Health is also rescinded, so please discard
these drafts. The current version of the Handbook may be accessed on the
NCPS website at http://www.va.gov/ncps/ncps/NCPShb.doc.

The current version of the Handbook has benefited from many questions,
inputs, and other contributions from dedicated VHA personnel at all
levels of the organization. Additional information on aggregate reviews
is provided in this version of the final Handbook along with some minor
editorial changes. Everyone involved in the process of developing the
Handbook should be proud of their efforts and the National Center for
Patient Safety wants to extend our thanks to them for their help.

### 

### 3. IN MEMORIAM

##### From the VA National Center for Patient Safety

We at NCPS are saddened at the recent death of John Eisenberg, M.D.,
M.B.A., after a lengthy illness. Dr. Eisenberg was the Director of the
Agency for Healthcare Research and Quality (AHRQ) and was a
well-respected leader in the field of health services research. His
visionary efforts to improve patient safety and health care quality will
sorely be missed.

### 

### 4. SAFETY SPOTLIGHT

##### From the VA National Center for Patient Safety

(On a regular basis we will feature teaching examples pulled from
medical literature and similar RCAs that we feel are applicable and of
interest to the entire VHA health care system. The following represents
information taken from RCAs; it is presented to spark discussion and
[does not]{.underline} represent NCPS policy. Depending on the specific
circumstances at any given facility, there are various systems-level
solutions that will be most appropriate.)

# Patient Fall From Window

####### Description

This event occurred in a locked second story psychiatric unit that was
constructed to care for psychiatric patients. The unit's windows were 2'
x 3' glazed panels that were installed in a curtain wall system. (The
curtain wall system consists of a series of glass panels held in a
framed metal grid.) A psychiatric patient who had been demanding to go
home was able to kick out a glass panel and crawl out of the opening,
falling to the concrete sidewalk one floor below. The patient was
injured and taken to the emergency room. Even though the unit was very
crowded and busy, no staff members witnessed the patient kicking out the
glass panel or crawling out of the window.

####### Facility Identified Vulnerabilities

The existing VA construction master specifications relied on industry
standards for window systems and these were found to be inadequate to
prevent a patient from dislodging them in a psychiatric unit.

The activity level in the psychiatric unit increased the probability
that staff would not be able to adequately monitor all of the patients.

####### Actions Taken by Facility

Contacted VA Office of Facilities Management to study using glazed
curtain wall window systems in psychiatric buildings and units.

Retrofitted existing curtain wall windows in psychiatric unit by
installing interior windows to block access to the curtain wall windows.

Staff activities are more closely scheduled throughout each shift to
ensure that the patients are more closely monitored.

####### *NCPS Comments*

*As a result of this event, VA has now modified master construction
specifications for curtain wall systems in psychiatric units. These
window systems were initially designed to meet industry standards and
tested to withstand exterior wind load, but not unusual and heavy
interior pressure. VA standards now require curtain wall window systems
in psychiatric units to withstand stronger internal forces and minimizes
their use in psychiatric areas.*

*The actions taken on this event led to VA-wide changes and demonstrate
the power that RCA teams can have.*

*"**Never doubt that a small group of thoughtful committed people can
change the world; indeed it's the only thing that ever has."***

***\-- Margaret Meade***

### 5. TIPS ON REDUCING FALLS

##### From the VA National Center for Patient Safety

(The following was submitted by the VISN 1 Patient Safety Center of
Inquiry \[PSCI\] on lessons learned.)

In July 2001, 40 teams from VA and non-VA hospitals came together to
begin a Collaborative Breakthrough Series on Reducing Falls and Injuries
in both acute care and nursing home care settings. Collectively the
teams have achieved a 45% reduction in their serious injury rate over
the last nine months.

The following program elements were reported as being effective in
mitigating falls:

# Targeted clinical interventions:

**• [Use of a toileting program to prevent falls related to bathroom
use.]{.underline}** A high percentage of falls occurred while patients
were attempting to go to the bathroom.

**• [Use of signage/identification methods to increase all staffs'
awareness that the patient is at risk to fall.]{.underline}** For
example the use of the "falling star" sign on the door and above the
bed.

**• [Methods to ensure patients wear shoes or non-skid
slippers.]{.underline}** Teams that were able to keep appropriate
footwear on patients saw injuries decrease.

**• [Use of Post-Fall debriefing programs.]{.underline}** Teams used a
post-fall debriefing form (available online at
www.patientsafety.gov/FallReport.doc).

**• [Regular environmental assessments to identify fall risk in the
environment]{.underline}**. Don't forget to use your engineering and
maintenance people.

# Staffing and patient interventions:

**• [Use of a falls expert.]{.underline}** Begin to train staff on every
unit to take the lead in reviewing falls and testing new interventions.

**• [Changes in care delivery and staffing patterns:]{.underline}** For
example, one facility identified a high number of falls in their
day-room and reduced falls by placing staff in the day-room.

**• [Educate patients on their fall risk.]{.underline}** Teams that have
included patient education have seen decreases in their fall rates.

**Use of measurement**:

**• [Use simple measurement to be sure your changes are resulting in
improvements]{.underline}**. Be sure to track the injury rate, not just
the number of falls. Use process measures to make sure the interventions
are actually being accomplished. If the staff is unable to do the
interventions, look for the systemic reasons for this result.

**• [Use the Morse Scale to systematically assess patients at risk for
falls ]{.underline}**[(see the VHA Fall Prevention and Management
flipbook).]{.underline} Most facilities are now using this tool to
identify those at risk for falling after developing education programs,
policies/guidelines, and inter-rater reliability systems.

# Organizational aspects of success:

**• [Form a truly multidisciplinary team.]{.underline}** Make sure the
people that will be doing the changes are on your team. Include
physicians, pharmacy, nursing, physical therapy, nurses' aides,
engineering and maintenance.

**• [Establish and maintain good communication with your senior
leaders.]{.underline}** Make sure your facility director and chief of
staff know about your improvement team, and that your improvement goals
are aligned with the goals of senior management. Let them know your team
will demonstrate quality and safety improvement during JCAHO reviews.

**• [Teams have learned to value the use of small, planned change that
is action-oriented.]{.underline}** Before implementing any new
intervention on a large scale, test it on a small scale to "work out the
bugs" and modify the intervention to fit your local environment.

**• [Pilot test new products such as hip protectors and
alarms.]{.underline}** Teams need to find the products that work in
their facilities with their patient populations. Good success has been
experienced with hip protectors.

Also, use the VHA Fall Prevention and Management flipbook. Fifty copies
of these were distributed to each VHA facility in November 2001. To
request additional copies, e-mail NCPScognitiveaids@med.va.gov. More
information on reducing falls and injuries related to falls can be found
on the NCPS intranet (vaww.ncps.med.va.gov/PPt/AggRev.html) and internet
(www.patientsafety.gov) sites.