Stay Safe in a Hospital: Tips on Patient Safety, Engagement and Empowerment Regarding Medication Safety and Avoiding Falls

Annamarie DeRoberts RN, BSN, MSHA
Process Improvement Engineer for Patient Care Services
Interim Director, System Nursing Operations
Main Line Health
Bryn Mawr, Pa

Background:

Annamarie (Andi) has held several positions at Main Line Health, including staff nurse, educator and process improvement manager. She works with teams to promote and sustain a culture of safety and quality by leading process improvement activities within the department of nursing and with others throughout the organization.

These team focus on quality and patient safety by improving processes to decrease errors such as teaching staff how to wash hands frequently, how to use the best approach to caring for patients in various circumstances, and how to avoid errors in care.

She received her BSN at Villanova University and her Masters in Health Services Administration from The University of St. Francis, Joliet IL. Annamarie is Lean Six Sigma Black Belt trained.

Overview:

Medical Errors are leading causes of death and/or injury to inpatients and account for an estimated 44,000 to 98,000 deaths in U.S. hospitals annually, according to the Institute of Medicine. The Agency for Healthcare Research and Quality (AHRQ) found that more people die from medical errors than from motor vehicle accidents, breast cancer or AIDS.

The kind of hospital injuries that make headlines are usually high drama, such as a wrong arm or wrong leg removed, or a surgical instrument left inside a body. But, while much less dramatic, the number-one cause of patient injuries at hospitals is falls. A simple fall during a hospital stay can cause serious and potentially life-threatening injuries for patients. Statistics indicate that patient falls occur in approximately 1.9 to 3% of all acute care hospitalizations with anywhere from 2-15% of inpatients experiencing at least one fall.  An estimated 30% of inpatient falls result in serious injury. According to the Institute for Healthcare Improvement (IHI), falls are a leading cause of death in people 65 years of age or older and 10% of fatal falls for the elderly occur in hospitals. The majority of falls occur in patients’ rooms and in bathrooms.  Hospital environmental conditions and medication related issues also put patients at risk for falls. Injuries from falls are costly for the patient and the hospital.

The new IOM report, Preventing Medication Errors, points out the staggering numbers associated with preventable drug-related injuries per year: 400,000 in hospitals—averaging more than one per day.

A fundamental root cause of many errors is improper patient identification.

Throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, and wrong person procedures.

There has been increasing national emphasis on preventing medical errors.  While physicians, nurses and hospital personnel are working to make health care safer, patients and their families also have a significant role.  Our objective is to assist people to become active participants in their own health care.  Experts consider patient involvement important in supporting safe and effective care.

3 Key Points:

1. Hospitals are doing many things to decrease variation and errors (standardization of process/bundles/checklists)
2. Patients and families can be engaged in their own safety.
3. Patients and families must partner with healthcare providers and speak up for safety!