Safety Award Research Articles

Rowan Hillson Insulin Safety Award ‘best in class’ insulin prescription chart competition

The National Diabetes Inpatient Audit for 2013 described insulin-related prescription errors in over 21% of patients each year from the beginning of data collection in 2010. Error rates have fallen year on year but remain unacceptably high, with significant variation between hospitals. Many of these issues were related to insulin prescribing. In 2014, the Joint British Diabetes Societies for Inpatient Care (JBDS) organised a competition for the ‘best in class’ current insulin prescription chart from hospitals in the UK. The aim was to identify safe and effective insulin charts, and make them available to the other clinical teams. A total of 41 Trusts submitted their insulin prescription charts, which were considered by an expert panel of independent judges against predefined criteria based on guidelines on the safe prescription of insulin from the UK National Patient Safety Agency. The charts from Nottingham University Hospitals won this competition, with East Sussex Healthcare, Worcestershire Royal Hospital and Western Sussex Hospitals as runners up. The competition identified areas of particular strength in the winning charts, which are available online (see Box 1).

Evelina pharmacy team scoops Patient Safety and Care Award

Evelina pharmacy team scoops Patient Safety and Care Award

The Readmission Reduction Program of Kaiser Permanente Southern California—Knowledge Transfer and Performance Improvement

In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region's "transitional care" bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team. The 6 KPNW bundle elements were risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, and a special transition phone number on discharge instructions. The 2 additional bundle elements added by KPSC were palliative care consult if indicated and a complex-case conference. KPSC has implemented most of the KPNW and KPSC bundle elements during the first quarter of 2012 for our Medicare risk population at all of our 13 medical centers. Each year, KPSC discharges approximately 40,000 Medicare risk patients. After implementation of bundle elements, KPSC Medicare risk all-cause 30-day Healthcare Effectiveness Data and Information Set readmissions observed-over-expected ratio and readmission rates from December 2010 to November 2012 decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively.

CSX honors Dow with Chemical Safety Award

CSX honors Dow with Chemical Safety Award

Tips from the top on implementing a patient safety initiative

Helen Jaques receives some advice from the shortlisted candidates for the Improvement in Patient Safety award

Toolkit to improve prescribing by doctors wins patient safety award

Toolkit to improve prescribing by doctors wins patient safety award

BMJ safety award for pharmacy-led project

BMJ safety award for pharmacy-led project

Interview with a Quality Leader: Carol Wagner on Washington State Hospital Association (WSHA) and their Statewide Improvement

Carol Wagner, RN, MBA is the Vice President for Patient Safety at the Washington State Hospital Association (WSHA). She is recognized nationally as an innovative patient safety leader. She led the development of WSHA's Patient Safety Program and Rural Healthcare Quality Network. Under Carol's leadership, the WSHA received the 2010 John Eisenberg Patient Safety and Quality Award for national innovation given by The Joint Commission and the National Quality Forum. The association also received the 2011 Dick Davidson Award for Allied Association Leadership. These national awards are two of the highest honors an organization can receive for patient safety and quality. Through close working relationships with national and state regulatory bodies and professional organizations, Carol designs programs to improve quality and safety in every hospital in Washington State. Under Carol's leadership, all hospitals in Washington participated in the Institute for Healthcare Improvement's (IHI) 5 Million Lives Campaign. The effort led to implementation of the largest number of rapid response teams in a geographic area. Carol also created the first statewide learning collaborative to reduce hospital-acquired infections. Carol is a registered nurse with an MBA focusing on finance and operations. She worked clinically in a variety of settings, provided leadership as a nursing administrator, and transitioned to lead hospital strategic planning, budgeting, and cost accounting. She studied management and system change at The Wharton School at the University of Pennsylvania. Her quality training was with Dr. W. Edwards Deming and at Intermountain Health Care with Dr. Brent James. Her experience includes work in for-profit and not-for-profit environments and supporting community, tertiary, and academic medical centers. This includes Huntington Hospital in Pasadena, California and a national for-profit hospital system with more than 100 hospitals.

Interview with a Quality Leader: Paul Uhlig on Transforming Healthcare

Paul N. Uhlig, MD, MPA, FACS, a cardiothoracic surgeon who lives in Wichita, KS, is associate professor of preventive medicine and public health at the University of Kansas School of Medicine-Wichita. In 2002 Dr. Uhlig and the cardiac surgery team he led at Concord Hospital, Concord, NH, received the John M. Eisenberg Patient Safety Award from the National Quality Forum and the Joint Commission. Dr. Uhlig has received international recognition for research concerning patient safety, teamwork, and healthcare culture, including a 2007-2008 King James IV Professorship of the Royal College of Surgeons of Edinburgh, Scotland.

Implementation of a High-Alert Medication Program

Greater than 500,000 doses of high-alert medications are administered throughout the Kaiser Permanente Northern California (KPNC) Program on an annual basis. High-alert medications (HAM) carry a higher risk of harm than other medications and errors in the administration of HAM can have catastrophic clinical outcomes. The purpose of this project is to ensure safe medication practices and to eliminate medication errors that cause harm to our patients.The Program: KPNC leadership, physicians, nurses, pharmacists, quality leaders, and labor unions worked with regional and local medication safety committees to: 1) standardize high-alert medication-handling practices; 2) enhance education programs related to medication practices, embedding these into annual core competencies of all staff who handle high-alert medications; 3) develop monitoring functions at both the regional and local levels to ensure sustainability and ongoing systems improvements. Begun in December 2005, this program covers the delivery of high-alert medications across the continuum of care and affects all patients receiving HAM. The initial phase of the monitoring process was put in place to measure compliance with implementation. Over the first few months of the program the 90% minimal threshold was surpassed with regional overall compliance of 95%. Following this initial process, the Regional Medication Safety Committee developed monitoring tools. Department managers carry out these concurrent observational audits at the medical centers with oversight by the Assistant Administrators for Quality and Service. These audits are designed to measure whether or not all medications on the HAM list are handled specifically to policy requirements, eg, independent double-checks, HAM stickers, etc. Audit specifications are provided for each audit tool. Medical Center audit results from the third quarter of 2006 through the third quarter of 2007 have shown a regional aggregate of 97.7% compliance. As the high percentages of compliance have held constant over time, more actionable metrics are being put in place for 2008.To determine whether or not the program is reducing HAM errors, data from the regional Quality and Risk database (MIDAS) related to all high-alert medication errors was reviewed. Two interventions were of note: in July of 2005, there was a renewed effort to educate leaders, managers, physicians, and staff on responsible reporting in a "just culture" and the introduction of the new Responsible Reporting Form. An increase in reporting was noted at this time. In December 2005, the HAM program was introduced. There is a statistically significant drop in errors reported for 23 consecutive months following this program. These findings were similar for all phases of the delivery process. A powerful indicator of improvement is the average days between major injury and death. As of November 30, 2007, it has been 232 days since the last significant negative event was reported due to a HAM. This program has been implemented in all of the KPNC Medical Centers and is in the process of being implemented in all KP regions. This spread has been endorsed by the Medical Directors Quality Committee and by the KP Boards of Directors. The Interregional Medication Safety Committee is overseeing the spread process. A toolkit containing all of the required tools plus additional materials and information has been developed and made available throughout KP. The program is the recipient of the 2007 Lawrence Patient Safety Award.

Quality through Sustainability and Transferability

Is an innovative practice that improves quality sustainable? Can it be transferred to other sites in a whole system of care for a large population? The future of American medicine depends on affirmative answers. This issue's four Original Articles answer these more difficult questions about quality innovation through successful demonstrations. A good idea is not enough, and as noted by Arthur Huberman, MD, who chaired the Transfer of Successful Practices Workgroup of the Kaiser Permanente (KP) Care Experience Council: “The complexity involved in transferring successful practices is often underestimated. It involves much more than knowledge of the technical aspects involved. In fact, cultural issues usually present the most significant challenges.”1 The organizational process that lifts the most successful of these practices into view and recognizes them includes the Vohs Award for Quality and the Lawrence Patient Safety Award. With this issue, The Permanente Journal has published 23 Vohs Award projects over a seven-year period, and five Lawrence Award projects over three years, representing many KP regions and most major medical specialties.

Rough set theory for distilling construction safety measures

There are numerous construction safety measures adopted by the local construction industry in Hong Kong. The purpose of this study is to distil the more significant measures from all these practices. To achieve this, the rough set theory, a data mining technique by applying the rule induction method, is proposed to distil the rules that determine the safety performance of construction firms. Rough sets represent a different mathematical approach to vagueness and uncertainty. It is based on the assumption that lowering the degree of precision in the data makes the data pattern more visible. Under such an assumption, the rough set theory can provide the ability of classifying vague and uncertain data. A practical example is used to illustrate its application to distil these safety measures and highlight those which are most effective and important in combating site accidents. There are three decision rules identified; the best one is companies with a comprehensive safety orientation programme and good safety award campaigns for senior management staff which give the lowest accident rate and the best safety performance. Safety management rules can be successfully reduced, facilitating contractors to direct their limited recourses effectively.

The Evolution and Future of the Highway Safety Field Through the Eyes of Multiple Generations of Lauer Awardees

Relatively little driver behavior research was conducted prior to the founding of HFES and it only really began to accelerate in the 1960's. Some highway safety pioneers remain active in HFES and their careers illustrate the trajectory of the field itself, from emergence to maturation as a human factors domain. These early leaders mentored a subsequent generation of today's leaders. This panel brings together six of the most respected researchers in the field and spans multiple generations of human factors study. All have been honored with the Lauer Safety Award, the Society's premier recognition of career contributions to traffic safety. The more senior panelists describe the state of the field as they entered it, highlighting specific major accomplishments or changes over their careers. Their protégés then focus on how things have evolved into major issues we face now. The presentations are followed by an open discussion period.

The Third David M Lawrence, MD, Chairman's Patient Safety Award

In 2005, the Southern California Region had the honor of winning both the New and Transfer Projects Lawrence Patient Safety Awards: “Patient Safety Executive Walkarounds” won in the new project category; “Perinatal Patient Safety Project” won in the transfer category. These winning projects were honored at the annual Lawrence Patient Safety Award Recognition dinner on December 6, 2005. We are pleased to publish the Executive Walkarounds project and a brief overview of the previously published Perinatal Safety Project. Walkarounds are a gloriously low-tech and relatively informal intervention encouraging staff to discuss safety concerns that might not otherwise get reported …

The Second David M Lawrence, MD, Chairman's Patient Safety Award.

The Second David M Lawrence, MD, Chairman's Patient Safety Award.

CASCO CEO Mike Farge receives MRO Safety Award

CASCO CEO Mike Farge receives MRO Safety Award

Aftermath of the contact lens experience: food for thought: Excerpts: Howard Fawcett Chemical Health & Safety Award Address, Chicago, August 27, 2001

Aftermath of the contact lens experience: food for thought: Excerpts: Howard Fawcett Chemical Health & Safety Award Address, Chicago, August 27, 2001

Milliken Chemical receives safety award

Milliken Chemical receives safety award

Hoeganaes plant receives safety award

Hoeganaes plant receives safety award

Laboratory Safety Program at Francis Marion University

The chemistry program at Francis Marion University (FMU) received the 1999 University Safety Award from the Division of Chemical Health and Safety. Although there is no formal course in safety at FMU, the Laboratory Safety Training Program is extensive and well organized. The safety training program begins in General Chemistry and continues throughout the entire program. Proper safety equipment, regular review of all laboratory procedures, safety inspections, and continuous safety training provide the students and faculty with a safe laboratory experience.