Mistake Proofing projects work on improving patient safety

“When there are issues that have been identified, incidents that have occurred whether regionally or provincially, that’s where we target the most,” she said.

In the ER, there was one critical incident that may have been related to medical reconciliation, sparking the BPMH Mistake Proofing project.

“There was an incident and one of the issues that presented at that time was the Best Possible Medication History was one of the reasons for that issue that presented and as a result of that incident, many things occurred immediately,” she said.

According to the report, BPMH will help identify patient medications early on, preventing future issues.

“There’s process of reconciling what [patients] are on, what new medications they are on to ensure that there is no error or no overdosing or interaction that would cause some harm,” she explained.

As a result of the report, BPMH has expanded to all patients, not just high-risk patients, which was the protocol before the project.

This also helped the defect rate in the ER concerning BPMH drop from 72 per cent to 49 per cent. It is expected to continue to drop as staff education continues and becomes common practice.

Leschyshyn said the main change that was made as a result of the project was the creation of a work standard, so that the BPMH process is done the same way by all staff, for each patient.

“They’re very important and really patients are the centre of everything we do in the health system and this is really a great way of ensuring that mistakes and errors are zero.”

Frank Suchorab, nursing unit manager, alongside his team, looked at Mistake Proofing wound packing (medical materials inserted in various wounds for recovery).

This is after three incidents occurred throughout the health system where wound packing led to health complications. “So they [wound packing] were either lost or they were not removed as ordered and remained in the body cavity and caused … some side effects,” Suchorab said.

One of the key areas of concern that was identified and addressed when it came to wound packing in the OR was the interrupted flow of information. This meant communication between departments lacked in some way.

Now, Suchorab said, they’ve created one single sheet that will have space for the appropriate information to be communicated and tracked.

“We created more visuals for continuity … if there is packing being utilized it’s very clearly marked on the dressing itself and there’s also a separated area for wound care in the inpatient file itself and there is wound records, a consistent wound record was implemented and it’s on every inpatient files and it’s very easy to find,” he explained, which clearly outlines areas to document amounts and lengths of packing.

Their report showed this has brought the unit’s defect rate down to 21 per cent.

Moving into the future, Suchorab said more education is needed for staff to continue success.

“We’d like to see this process change throughout the region and implement further this single wound record and have that follow consistently as patients move through the system,” he said.

For more information on Mistake Proofing visit the PAPHR website.

sstone@panow.com

On Twitter: @sarahstone84

by Sarah Stone

Mistake Proofing projects work on improving patient safety

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