October 29 to November 2 is national Patient Safety Week and Sinai Health is recognizing the work we do every day to ensure our patients receive safe care when they walk through the doors of our campuses. Throughout the week we will be highlighting our Safety Award recipients – people who have made a difference in patient safety culture, systems and care. Together, we really are a SAFER system.
Mount Sinai’s Emergency Department continues to put safety first during construction
It is no small task to renovate the hospital while operating it, and there is no department that has experienced the impact of redevelopment as acutely as the Emergency Department. From rotating hoarding that significantly reduces the footprint of an already cramped space, to excavating right outside the window, the Emergency Department has shown tremendous resilience and adaptability over the past year.
Not only have they demonstrated grace under fire, but redevelopment has highlighted that the Emergency Department leadership is wholeheartedly dedicated to patient and staff safety. Although they run the most acute area within the hospital, they always find the time to file safety reports, attend reviews, address patient complaints, and advocate for the changes they require to drive safety. Over the course of the project thus far, the Emergency Department has tackled safety risks with courage and determination, resulting in improvements to the way our contractors work and the way we deliver urgent care. When contractors said we needed to shut down resuscitation bays to allow for construction, the Emergency Department highlighted the risk to patient safety of doing so, and advocated for contractors to find innovative ways of completing construction with minimal impact to these critical areas within the department. Day or night, post call or pre-dawn, the Emergency Department staff has made themselves available to ensure that we continue to deliver the best possible care at every phase of construction.
It takes leadership to improve the patient safety culture, and this year, we are acknowledging Dr. David Dushenski, Gillian Wilde-Friel and Kelly Shillington, as well as the rest of the ED team, for pushing the dial on safety. We look forward to the end of Phase 3A and the new, state of art Emergency Department that will serve our patients and our staff well. In the interim, we are humbled by the work of our Emergency Department team, which prioritizes safety above all.
Patient Dr. Karen Jones receives inaugural Patient Safety Award
When Dr. Karen Jones came to Mount Sinai Hospital in August of 2017 for a bilateral temporomandibular joint replacement she did not expect that she would end up leaving the hospital four weeks later following an unplanned admission to the ICU. When a patient suffers serious harm as a result of receiving care in a hospital that is not as a result of a known or inherent risk associated with the care, or as a result of an underlying medical condition, this is deemed by the provincial Hospital Act as a critical incident.
Over the period of a few hours the morning after her surgery Karen experience increased facial swelling that resulted in an emergency transfer back to the operating room to place a tube to protect her airway “out of an abundance of caution”. The situation, however, turned critical and Karen required a life-saving tracheostomy.
At the time of the incident the surgical team reviewed the case as is typical with any unplanned event; however neither Karen nor her husband were involved in the review process. This incident occurred just prior to the implementation of the new policy requirement that all patients or their family members are interviewed before any interdisciplinary quality review. Their questions and concerns are to be brought forward for discussion by the team and documented as part of the review process. Later, when Karen reached out to us and shared her experience, we immediately reopened her case as she provided additional information that was not considered as part of the original review.
As a result of Karen sharing her perspective, first as a patient, but also as a Public Health and Preventive Medicine specialist physician, we learned the following patient safety factors contributed to Karen’s outcome: not using a standardized communication tool such as SBAR (Situation, Background, Assessment, Recommendation), miscommunication between different members of the health care team, not using available resources such as the Access team, and a failure in escalation in care when a deterioration of care was noted. Karen and her husband also found that at times throughout her stay they did not feel listened to by some members of her team.
These stories are never easy to hear, however they are a necessary part of a strong patient safety culture. We acknowledge that our systems have vulnerabilities and that it is important that we understand what happened so that we can work to ensure that it doesn’t happen again. One of the changes as a result of Karen coming forwards is that we will create a new Safety Quality Aim which will be to participate in the implementation of Toronto Academic Health Science Network Escalation of Care protocols.
Karen is being awarded the inaugural Patient Safety Award for her contribution to advancing the patient safety culture at Sinai Health System.
How Dr. Jackie Thomas’ leadership improved patient safety in our Women’s and Infants program
Ever wonder whether a medical device or piece of equipment is associated with preventable patient harm? That was the experience of a front-line clinician who wondered whether a post-surgical bleed was related to a relatively new medical device procured by the Women’s and Infants Health program. Dr. Jackie Thomas directed that a safety report be entered, which was received by quality improvement leaders in the program, who sprang into action.
Pending a full review, clinical leaders made a decision to remove the device from circulation. Working with Risk and Information Services, Jackie initiated a comprehensive chart review of all operative cases in which a bleeding complication was noted. In doing so, she identified a trend of post-surgical complications that were likely associated with the design of the device recently procured by the hospital. As a result, the device was permanently removed from circulation and alternatives were identified and procured by the clinical team.
Jackie is dedicated to patient safety. She can often be seen working tirelessly alongside Nely Amaral, Director, Nursing Quality and Performance and Magnet Program Director, to identify opportunities for improvement, with courage and perseverance. It takes leadership to improve the patient safety culture, and this year, we are acknowledging Jackie for her contributions to improving safety in the Women’s and Infants Program. Congratulations Jackie, along with the rest of the team in the Women’s and Infants Program, for pushing the dial on safety this year.
Safety efforts by Bridgepoint’s Palliative Care Team brings dramatic results in reducing falls
At Bridgepoint, over the past year, clinical teams at every level of the building have been busy implementing a gold standard falls plan of care that includes screening patients for falls risk within 24 hours of admission, reviewing patients’ status at safety huddles, as well as completing and implementing a falls plan of care for those patients who are at risk of falls. In addition, Bridgepoint invested in innovative flooring that is designed to reduce the impact of falls. This flooring was installed in targeted areas across the hospital, and clinical teams worked diligently to assess patients who were at a high risk of falls-related injuries to triage them into these rooms.
As a result, we have seen a very significant decline in the number of falls at Bridgepoint resulting in harm. In fact, it has been 10 months since a Bridgepoint patient was severely harmed from a fall! This is an incredible testament to the diligent and focused work of our clinical teams on reporting, reviewing and acting on safety events.
The palliative care team on 4N at Bridgepoint has in particular distinguished itself in terms of its compliance with falls screening and implementing the falls plan of care (which reduces the likelihood of falls) and in triaging the most appropriate patients to rooms with the innovative flooring (which reduces the impact of falls if they occur). 4N has not had a serious injury from a fall since January 2017.
The Palliative Care Team on 4N is being awarded a Sinai Health Safety Award for their contribution to reducing preventable harm from falls. It takes leadership to improve safety culture, the Palliative Care Team has distinguished itself in caring for our most vulnerable patients. Please join me in congratulating the Palliative Care Team, along with the rest of Bridgepoint team, for a humbling example of the impact we can have on eliminating preventable harm in health care.
Nurse Fred Dykstra’s quick thinking during a fire earns him a Sinai Health Safety Award
Earlier this month, the team on 10N at Mount Sinai faced a very serious safety event when a fire was ignited in a patient’s room. The moment that the fire broke out, RN Fred Dykstra rushed into the room to contain the fire and minimize patient harm. The rest of the team was right behind him, activating a Code Red and calling for the medical team. The clinical team, supported by Security and Service Assistants, did not miss a beat to ensure the environment was safe and the clinical team could focus on addressing the patient’s urgent needs. And when the situation stabilized, a SAFER report was filed, which triggered a critical incident review.
The management of this situation was seamless. The foundational work in quality and safety by all members of the team – clinicians, and all those who support clinicians in their day to day work, enabled the resolution of this event with the least adverse outcome. The safety event was troubling, but the response and commitment to reviewing the event are reminders that we have the systems, talent and skill to pull us through. Several opportunities for improvement have been identified during the subsequent critical incident review, including developing a checklist to assess risk for patients who smoke, which will be rolled out across the organization.
Fred is being awarded a Sinai Health Safety Award for his contribution to minimizing patient harm during a critical incident. It takes leadership to improve safety culture, and during events like the one experienced by the team on 10N, Fred distinguished himself as a leader during a time of crisis. Please join me in congratulating Fred, along with the rest of the team on 10N, Security and our Service Assistants, for an awe-inspiring response during a serious safety event.