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Quality

Tips for Keeping Patients Safe

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How to make KP the safest place to get and to give care

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Health care workers’ first obligation is “do no harm”— to see that the members and patients in our care suffer no injury or further illness. Unit-based teams across Kaiser Permanente launch hundreds of projects every year to improve patient safety. These tips can your guide your team in a patient safety improvement project and help ensure that KP is the safest place to get and to give care.

  1. Wash your hands often, and in accordance with local policies and procedures.
  2. Speak up if you observe a drift from safe practice. As the saying goes, “If you see something, say something!”
  3. Make sure patients (or family members) understand their diagnosis and plan of care. Have them describe, in their own words, their condition, what they need to do next and why that’s important.
  4. Label specimens accurately, completely and legibly.
  5. When administering high-alert medications have two people separately check specific steps of the process. For example, a pharmacist calculates dosage, prepares a syringe and compares the product to the order; then a nurse independently does the same and compares the results.
  6. Use tools such as SBAR (Situation, Background, Assessment, Recommendation) and clear language like “Safety Check” to identify a hazard, if someone is uncertain and does not feel it’s safe for the patient to proceed. 
  7. Keep yourself free from injury so you can keep your patients free from harm.

 

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  • Providing more information on the dialysis process
  • Scheduling surgery for fistulas sooner
  • Minimizing the time patients use catheters for dialysis

What can your team do to reduce infections? And are there ways educating patients can improve the care experience? 

 

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  • Looking for less expensive options, like switching from primary tubing to secondary tubing
  • Using secondary instead of primary tubing for IV patients, whenever it is medically safe
  • Working through the change so everyone on the team understands and adapts

What can your team do to make sure it's using the right supplies for the job? What else could your team do to keep KP affordable for patients and members?

 

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  • Reviewing upcoming ultrasound appointments to schedule reminder calls
  • Dividing call duties among different assigned staffers to ensure privacy
  • Calling a day in advance of appointments to discuss patient instructions

What can your team do to reach out to patients? And how could your team work with other teams to improve service? 

 

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  • Following the successful practice of another team that solved the same problem
  • Offering kid-friendly food like peanut butter and jelly sandwiches
  • Creating restaurant style menus with imagery of zoo animals

What can your team do to listen to the voice of the patient? And how could your team learn from other teams that have tackled challenges similar to yours?

 

 

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  • Creating call lists for patients at risk for hypertension
  • Targeting diabetic patients, who often overlook high blood pressure symptoms
  • Having clinical assistants chip in to check blood pressure and outreach

What can your team do to reach out to patients proactively? What else could your team do to help patients manage chronic conditions?

 

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  • Establishing a baseline measurement for how long moms are getting skin-to-skin contact with their new babies
  • Creating talking points of the benefits for both new baby and mother about this critical bonding
  • Communicating with staff to ensure a minimum of 60 minutes of skin-to-skin contact occurs post delivery

 What can your team do to explain the "why" behind what you are doing? 

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  • Using a checklist of important topics as a teaching tool for new parents at discharge with their new baby
  • Speaking with them at a time when they are most likely to understand and take in the information
  • Creating a script for nurses that doesn't feel rehearsed or fake

What can your team do to improve your communication with patients?

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  • Identifying the problem was with the needle supplier
  • Filing a Responsible Reporting Form, and working together to arrive at the solution
  • Switching needle suppliers to improve care and safety

 What can your team do to listen to the voice of the patient? 

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  • Educating about the proper use of VTE orders for post-operative patients
  • Coordinating with pharmacists and other teams to ensure orders are followed
  • Outlining how the Joint Commission's SCIP guidelines can help improve compliance

 What can your team do to work with other teams to improve outcomes for patients? 

 

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