George Dikeou - COPIC Jeni Dingman - PULSE St. Mary's Medical Center (Grand Junction) Exempla Saint Joseph Hospital Colorado Health & Hospital Association Patient Safety Initiative Team

Sample of 2004 Patient Safety Projects:

The Colorado Patient Safety Coalition is aware of a number of commendable projects that are underway in the state, and offers the following list as examples.  The list is not intended to be complete.  Rather it is a sample of active projects to heighten the awareness of current activities.

Improving Medication Safety at Kaiser Permanente
A collaboration effort of pharmacists, physicians and researchers at Kaiser Permanente of Colorado to improve medication safety, this project has successfully reduced medication errors for patients who have renal insufficiency or are prescribed critically interacting drugs (especially warfarin) or drugs that require lab monitoring.

Additional information is available from Beth Chester, PharmD, BCPS at (303) 326-7612 or beth.chester@kp.org.

Colorado Health and Hospital Association Patient Safety Initiative
Working with many other Colorado health care organizations, the Quality Management Professionals of the Colorado Health and Hospital Association developed and implemented 2 guidelines that are now in effect in all Colorado hospitals.  These guidelines address the verification of the appropriate patient, procedure and site for patients undergoing procedures, and the verification of verbal or telephonic orders.  Standardizing these processes is a key factor in avoiding error.

Further detail is available from the Colorado Health and Hospital Association, (720) 489-1630 or http://www.cha.com

Stroke Program at Swedish Medical Center
Teamwork is a key feature of Swedish Medical Center’s interdisciplinary Stroke Program.  The program addresses rapid treatment, screening for risk of complications (such as swallowing difficulty), guidelines for the prophylaxis and care of comorbid conditions such as DVT and atrial fibrillation, secondary prevention and education, among others.

Karleen Goerke, RN, MS, CNOR can provide additional information.  She is available at (303) 788-8436 or karleen.goerke@healthONEcares.com

Building Safety into Parker Adventist Hospital
Several years prior to the recent opening of Parker Adventist Hospital the leadership team began to address how to build patient safety into their new facility.  As a result of this planning, new patient safety principles have been present from the hospital’s inception, including the areas of environment, communication of patient care information, patient education, medication safety and culture.

Details are available from Terry Ritchey, Chief Nursing Officer, (303) 269-4015 or terryritchey@centura.org

Glenwood Springs Family Safety Fair
Valley View Hospital in Glenwood Springs has been instrumental in educating and assisting their community regarding safe car seats and bike helmets.

More about Valley View’s efforts can be learned from Susan Scott, RN at (970) 945-3429. 

High Alert Medication Task Force at Vail Valley Medical Center
High alert medications in inpatient and outpatient sites of care are the focus of a multidisciplinary team at Vail Valley.  The team communicates each medication alert through a communications roll-out plan.

The task force is chaired by Mickie Hunter, PharmD who can be reached at (970) 479-7284 or hunterm@vvmc.com.

Applied Strategies for Improving Patient Safety
An ongoing collaborative effort between the University of Colorado Department of Family Medicine and numerous organizations to analyze the causes and effects of errors in primary care and reduce the incidence of errors. ASIPS works with two practice-based research networks, the Colorado Research Network (CaReNet), which focuses on rural and urban minority and underserved primary care populations, and the High Plains Research Network (HPRN), which focuses on rural, "frontier" primary care practices and hospitals. ASIPS has contributed to our knowledge regarding confidential vs. anonymous reporting systems and the taxonomy of errors in the ambulatory setting.

For further information contact David West, PhD at (303) 724-9762 or david.west@uchsc.edu.

St. Mary’s Medical Center Project to Reduce Misidentification of Laboratory Specimens
St. Mary’s Medical Center in Grand Junction uses the Failure Mode and Effect Analysis process to evaluate their performance and vulnerabilities in the proper identification of laboratory specimens.  Their efforts have resulted in misidentifications now being included in their institution-wide occurrence reporting system and better data upon which to evaluate the process of improvement. 

Jan Ronzio, RN, MSHA, MBA can provide further information.  She can be reached at (970) 244-2282.

Patient Safety Focus of the Month Project at Montrose Memorial Hospital
A different aspect of patient safety is the subject of each monthly communication of Montrose Memorial Hospital’s patient safety program.  They use “Ponder the Safety Frog,” whose motto is, “think before you leap,” as their symbol.

Further information is available from Bert Hatter, RN at (970) 240-7351.

Pre-Printed Order Sets at St. Mary’s in Grand Junction
Over 80 different sets of pre-printed orders for use in inpatient and outpatient settings are in use in St. Mary’s Medical Center in Grand Junction.  This has improved the safety environment through reduction of illegible handwriting, avoidance of dangerous abbreviations and improved consistency of care.

The Clinical Pathway Coordinator at St. Mary’s is Lori Fink, RN who can be reached at (970) 244-2260.

Safe Transport of Patients at the Medical Center of Aurora
The Medical Center of Aurora has developed a “patient status transport checklist” for inpatients being transported off their respective units for diagnostic or therapeutic procedures.  The tool was developed using a Failure Mode Effects Criticality Analysis and has proved effective in improving the communication of important information during “hand-offs.”  This has resulted in safer patient care.

Lindy Garvin, Risk Manager ((303) 695-2827) and Suzanne Ginsburg, Quality Director ((303) 671-4930) are leaders of the project.

Technology Improves Order Entry in Denver Health’s MICU
Denver Health Medical Center is successfully integrating technology with provider order entry to link order entry directly to the pharmacy.  This has improved the safety and efficiency of medication use through improved communication while reducing or eliminating errors due to confusing abbreviations.  The project was started in the Medical Intensive Care Unit and is currently being made available in other areas of the hospital.

Denver Health’s Coordinator of Nursing Research, Catherine Dingley, RN, FNP, PhDc is available to discuss the project.  She can be reached at (303) 436-4912 or catherine.dingley@dhha.org.

A Rapid Assessment Team Improves Care at Exempla St. Joseph Hospital
Clinically unstable patients at Exempla Saint Joseph Hospital now have access to a Rapid Assessment Team, consisting of an ICU nurse, ICU physician and a respiratory therapist.  The team can be called by any member of the nursing or medical staff who thinks a patient may be unstable.  The team assesses whether ICU care is needed and provides safe transportation if it is.  They also help to identify patients who can safely be cared for in a less intense setting.  This process has resulted in a dramatic reduction in the number of cardiac/respiratory arrests occurring in unmonitored areas of the hospital and a 30% reduction in unnecessary transfers to the ICU. 

The team is lead by Pam Ferlise, RN, MSN, Maria Kinsella, RN, BSN and Tom Stelzner, MD.  Pam can be reached at (303) 866-8538 or ferlisep@exempla.org, and Maria at (303) 866-8514 or kinsellam@exempla.org.  Dr Stelzner is at thomasjstelzner@kp.org

Rules Technology to Reduce Medication Orders: Denver Health Medical Center
Using rules technology to improve the interface between computerized provider order entry and an integrated clinical decision support system, Denver Health Medical Center has shown an increase in provider awareness of potentially harmful medications and improved laboratory monitoring for potential evolving injury.  The project took place in an outpatient clinic.

Details are available from Andy Steele, MD, MPH at (303) 436-4812.

Littleton Adventist Hospital Evolves a Comprehensive Patient Safety Program
Involving every level of its organization, Littleton Adventist Hospital is evolving a comprehensive program of patient safety.  It has instituted weekly Patient Safety rounds, and has regular patient safety team meetings.  There are also thorough patient safety review processes and outcomes-driven initiatives.

Rhonda Ward, RN, MSN is the Director of Quality Management and can be reached at (303) 730-8900.