Kettering Health is committed to patient safety. In 2020, we adopted a Zero Harm strategy which taps into the concepts of Just Culture. One way we share updates and information on safety is through this monthly column.
We appreciate you reading our final Safety Column of 2022. This has been a busy, yet successful, year for our Safety and Infection Prevention team. We are excited to highlight some of the system’s accomplishments in 2022.
2022 Results
A Serious Reportable Event (SRE) occurs when a patient experiences death or serious harm due to an error or deviation from best practice. With the Kettering Health Zero Harm initiative, we are committed to reducing patient harm 80% by 2025.
As part of our commitment to that goal, we want to provide a year-over-year update. In 2021, the Kettering Health SRE rate was 0.51 per 1,000 patient days. We set a target goal to reduce that rate by 20%.
In 2022, Kettering Health reached our target with a 20% reduction in SRE rate to 0.41 per 1,000 patient days.
The SRE rate reduction represents 49 fewer patients seriously harmed while receiving care at Kettering Health as compared to 2021.
There were 56% fewer oxygen events, 28% fewer HAPI (stage 3, 4, and unstageable) in 2022 and the below SRE categories were eliminated in 2022:
- Failure to follow up on tests
- Lost specimens
- Restraint death
- Physical/sexual abuse
- Wrong procedures
2022 Accomplishments
- Lindsay Sanders, RCA Analyst, joined the safety team.
- Jordan McLeland, Clinical Pharmacy Medical Safety, joined the safety team.
- An automated submission for Great Catches was developed and resulted in an increase of 123 Great Catch submissions in 2022 as compared to 2021. Celebrating and sharing Great Catches are key to spreading a culture of safety and identifying potential safety issues before harm reaches the patient.
- The Press Ganey 3-Meeting Model has been spread across Kettering Health (Soin/Greene go live in Q1 2023).
- RCA learnings at each campus are shared across the system through the RCA Final Case Summary document.
Medication safety
Kettering Health is committed to patient safety which requires a collaborative effort from all individuals within our organization. Together, we ensure patient safety is embedded in our daily workflows. The Medication Safety team applauds our employees’ commitment to reporting medication events, as these reports bring attention to where our systems are not working as intended.
In 2022, we had over 1,300 medication events voluntarily reported through the SAFE reporting system. Due to the review of reported medication events, we were able to make many system enhancements within Epic, Alaris, BCMA, and other systems that played a role in the reported medication events.
Below are some of the major system enhancements completed in 2022:
- Standardized ED Omnicells Override Medications.
- Standardized KBMC Omnicells Override Medications.
- Standardized Cardiac Alert Kit.
- Updated labeling to highlight Warning of Paralytic Agents contained in the RSI kits.
- Enhanced Heparin MAR calculators to specify exact volume to draw up for bolus doses.
- Implemented medication critical dose warnings and limits in Epic to prevent errors in high or low doses when prescribing.
- Methylene Blue BPAs developed and implemented in Epic.
- Reviewed and updated oncology infusion medications within Alaris to optimize guardrail settings.
- Optimized Alaris guardrails to ensure accurate dosing parameters for many IV medications.
These are just a fraction of all the enhancements that were implemented, and each required collaboration and approval from multiple teams. These enhancements were made to prevent medication events from reoccurring and to enhance system safety.
We encourage each of you to take an active role in reporting medication events, which include near misses. When you report via the SAFE system, you give us the opportunity to review the cause of the event and identify corrective measures to enhance procedures–all with the goal of reinforcing a culture of safety at Kettering Health.
Infection prevention
Overall, 2022 was a very successful year for infection prevention as Kettering Health saw improvement in performance for most of the different healthcare-associated infection types that we monitor. The most significant improvements were seen in the reductions of MRSA bacteremia infections and hysterectomy surgical site infections. Comparing 2022 to 2021, we saw
- 16.3% reduction in central line associated bloodstream infections
- 26.7% reduction in catheter associated urinary tract infections
- 17.5% increase in C. diff infections
- 55.2% decrease in MRSA bacteremia infections
- 9.8% increase in colon surgical site infections
- 43.8% reduction in abdominal hysterectomy surgical site infections
We are looking forward to continued collaboration to achieve even more reductions in HAIs in 2023!