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Nursing's Top Priority: Patient Safety

RN crafts exceptional culture of safety at Seattle hospital.

Patients at Virginia Mason Medical Center (VM), a 336-bed acute care facility in Seattle, founded in 1920, are among the safest in the nation.

For the second year in a row, HealthGrades, a leading independent healthcare ratings organization, has ranked VM among the top 5 percent of U.S. hospitals in terms of patient safety.

HealthGrades analyzed 40 million hospitalization records from nearly 5,000 hospitals to document the frequency of 13 safety "events" among surgical inpatients. The events ranged from bed sores to catheter-related bloodstream infections to migrating blood clots to death.

Medicare patients treated at VM and the other top 5 percent of hospitals were, on average, 46 percent less likely to experience these kinds of setbacks, according to HealthGrades.

Asked how it felt to be honored for safety excellence 2 years running, VM's top safety officer was ecstatic. "It feels great!" said Joan Ching, MN, RN, CPHQ, administrative director of hospital quality and safety. "Protecting our patients from preventable harm is our top priority. We want patients to receive only what they need to improve their health - nothing that will slow their recovery or threaten their present or future well-being."

Pressure Ulcer Protocol

Ching shared how nurses can recognize and respond to several imminent threats to inpatients, beginning with the common, creeping menace known as pressure ulcers.

"First and foremost, nurses must accept that no other clinician 'owns' the well-being of the patient's skin more than a nurse," she said. "No one will look at the patient's skin more frequently than a nurse or reliably assist the patient with pressure-ulcer preventing actions like off-loading pressure-prone areas."

VM teaches its nurses to do a head-to-toe, back-to-front skin assessment over bony prominences and under nasal cannula tubing, NG tubes, sequential compression devices and other medical equipment, according to Ching, who has received extensive training in applying the Toyota Production System (Lean Management) to healthcare, including two study missions to Japan.

"We use the acronym SKIN as our 'bundle' to check that we meet a patient's unique needs for pressure ulcer prevention," she said. SKIN stands for the following:

  • Surface: Match the surface to the patient's risk factors.

  • Keep turning: Some patients can get by with turning every 1 or 2 hours; some need turning every 15 minutes.

  • Incontinence: Manage moisture, as it accelerates skin breakdown.

  • Nutrition: Proper diet promotes wound healing.

Infection Control

To prevent catheter-related bloodstream infections, VM nurses assist physicians with following a standard protocol for insertion that includes a checklist and a cart with BioPatch and all other needed supplies.

"Our IV therapy nurses change all central-line dressings using standard work and sterile procedure," Ching said. "They use a new Clave cap whenever the catheter has been accessed. And they do a daily assessment of ongoing need. Is the catheter still needed? Or can we remove it today?"

To protect patients' lungs against ventilator-associated pneumonia, VM's critical care nurses follow every step of the Institute of Healthcare Improvement's ventilator bundle, introduced during the IHI's 100K Lives Campaign in 2005, Ching said.

These steps include elevating head-of-bed a minimum 30 degrees; meticulous and frequent oral care; Dobhoff tube in the small intestine and peptic ulcer prophylaxis, daily "vacation from sedation" protocol and early mobility - even while patients are intubated.

Early mobility can also help ward off deep vein thrombosis and pulmonary embolism (DVT/PE), Ching added. When VM nurses suspect DVT, they ask physicians to consider ordering lower extremity Doppler studies, which can be easily done at the bedside by radiology, she pointed out.

VM also employs the American College of Surgeons' DVT/PE prophylaxes to identify patients at risk and deliver prompt, medically appropriate pharmacological and mechanical intervention. "We have hard-wired prophylaxes through the use of computerized physician order entry and multidisciplinary rounds, so more than one set of eyes are checking for appropriate intervention," Ching said.

Involve Patient & Family

Whenever possible, patient handoffs should be done at the bedside and in front of the patient and family members "so they have the opportunity to participate in crafting or revising the plan of care and can correct information before it's erroneously passed on to the next set of care providers," Ching said.

In fact, always striving to include patients and families "can only improve the delivery of safe, appropriate and patient-centric care," she stressed. "At VM, we use the phrase 'patient at the top' rather than 'patient-centered.' That's because our mission, vision and values statements are placed in the shape of a pyramid with the patient at the top. All decisions we make are with the patient in mind."

Finally, to further improve their culture of safety, VM nurses (and all nurses) should not shy away from speaking up when something is wrong, Ching concluded. "We are all on the same team," she said. "We can confront difficult issues or behaviors by reminding ourselves that patient safety is our No. 1 priority."

That includes helping to inculcate the habit of hand-washing - "the single, most important action you can do to prevent the spread of infection," Ching said. "It's totally underestimated but it's the right thing to do."

Michael Gibbons is an editor at ADVANCE.

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  Last Post: June 15, 2011 | View Comments(1)


We are undertaking a significant amount of lean work in our province but my question is, how have staffing levels changed (if at all) during this process. What would your nurse:patient ratio be on a general medical or surgical unit?

I think many believe these improvements can happen by adding more staff. Can anyone comment on this?


Kyla Avis,  Program DirectorJune 15, 2011


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