Click the links in the Treatment Area column to view the survey results for a specific treatment.
Open Heart Surgery |
We have a very low volume of cases. Most case are referred to the larger affilates within St. John Health System. We have access to risk-adjusted data in Care Science through Ascension Health. We are currently revising our surgical pre-operative assessment to address cardiac risk facotrs to allow us to identify patients that are at increased risk and require pre-op and perioperative beta blockade as recommended by NQF. |
Abdominal Aortic Aneurysm Repair |
Most of our AAA cases are emergent in nature. We do review all cases and report to Department of Surgery. We conduct 100% review of all mortalities at St John Oakland through our local Morbidity and Mortality Committee. The Morbidity & Mortality Committee supports the pre-operative and peri-operative beta blockade for patients identifed at increased cardiac risk. The Surgery and Anesthesia Departments have developed an assessment tool and policy. |
Carotid Endarterectomy Surgery |
All carotid endarterectomy cases are reviewed for mortality and morbidity ( post-procedure stroke). As of FY06 review (cases from July 1, 2005-June 30, 2006) there were 0 mortalities identified. Cases are also reviewed to determine if Interqual criteria was met for the procedure. We also review for complications. Pre-operative assessment tools have been updated to identify patients at increased cardiac risk to allow for administration of pre and peri-operative beta blockade to those identified at risk. |
Intensive Care Unit Physician Staffing (IPS) |
Involved in Keystone ICU project through MHA since onset. Projects include prevention of central line BSI (rates have been at 0 the past 6 consecutive quarters); prevention of ventilator-associated pneumonia utilizing VENT BUNDLE ( our rates have been below NNIS rate). Tight glycemic control. Sepsis identification and management. Data is collected and reported as required. Daily goal sheets are utilized. Multidisciplinary rounds are conducted daily in the ICU by the intensivist. |
Healthcare Failure Mode and Effect Analysis |
Post-improvement remeasurement /findings will drive our decision to re-evaulate the risk reduction activity. |
Root Cause Analisys |
RCA involves a multi-disciplinary approach. We identify a problem statement based on assessment of the situation. We flow-chart out the process to identify areas in the process that may be problem prone and work as a team to identify solutions. |
General Comments on Patient Safety Activities |
Dedicated Patient Safety Officer
Patient Safety Executive Walking Rounds 3 times monthly.
Monthly Executive Patient Safety Review Committee-review of cases when patient is transferred to a higher level of care and other issues referred as potential patient safety issues.
Implemented Rapid Response Team with debriefing sessions.
Trach/ventilator rounding.
Surgical time out-Patient Identification in Surgery- Side sensitive surgery monitors
Root Cause Analysis- look for opportunities in near-miss situations
Keystone ICU Safety
Keystone Hospital Associated Infection Project
Participation in Ascension Health Nosocomial Pressure Ulcer Prevention Project
Implemented system-wide falls risk assessment
Sepsis identification and treatment education
Adoption of interventions recommended through Surgical Complications Improvement Project (SCIP)
Patient Safety Week to educate all staff related to Patient Safety issues |
