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MUSC Children's Health participating in national effort to improve patient safety in children's hospitals

Staff Report | brazell@musc.edu | March 9, 2017

Dr. Elizabeth Mack
Photo by Sarah Pack
Dr. Elizabeth Mack (right) goes over a 'K-card' with MUSC Children's Hospital nurse Jaime Worsham at Cayden Church's bedside. The cards are used to improve patient safety in children's hospitals.

MUSC Children’s Health is participating in a first-of-its-kind effort by more than 110 children’s hospitals across the country and Canada to improve patient safety called Solutions for Patient Safety also known as SPS. Leading the effort at MUSC is pediatric intensive care physician and associate professor Elizabeth Mack, who launched the same program at Palmetto Health Children’s Hospital in Columbia several years ago.

“MUSC Children’s Health joined SPS in January 2016, and we are continuing to escalate our involvement with gracious support from our CEO Dr. Pat Cawley, our Chief Quality Officer Dr. Danielle Scheurer, Children’s Hospital leadership, and most importantly, our bedside care team members,” Mack said. “Our project manager Peter Gardella plays an enormous role in this work as well. We are proud to announce that MUSC Children’s Health is hosting two SPS conferences this summer, and look forward to sharing those details with our community.”

Through transparent sharing of data, successes and lessons learned, SPS and its member children’s hospitals are working to achieve specific goals to reduce harm in pediatric hospitals across the country and in Canada. According to the program’s website, the guiding principle of the program is to put aside competition and share safety successes and failures so that all children’s hospitals can achieve safety goals faster. Between 2012 and September 2016, the SPS Network saved 6,944 children from serious harm and led to an estimated savings of more than $130 million. As hospitals and families continue to take the necessary steps to prevent serious harm, more children will be saved from harm.

SPS hospitals work through a series of network phases that allow hospitals to learn from peer institutions through an “all teach, all learn” approach, while developing and implementing effective prevention standards that will be made available to all children’s hospitals nationwide and in Canada.

Hospitals also are employing the cultural transformation strategies of other high-reliability industries — such as nuclear engineering and naval aviation — to significantly reduce harm. Patient families are partners in this work, participating in the national steering committee that guides SPS’s efforts and at MUSC Children’s Health, in localized patient family committees. MUSC Children’s Health will begin its SPS work by analysis and process improvement regarding:

  • Antibiotic stewardship
  • Adverse drug events
  • Catheter-associated urinary tract infections
  • Catheter-associated bloodstream infections
  • Falls
  • Peripheral IV infiltrate & extravasation
  • Pressure injuries
  • Readmissions
  • Ventilator-associated events
  • Venous thromboembolism
  • Surgical site infections
  • Unplanned extubations

Helen Haskell, a South Carolina patient safety advocate, said she applauds the step. She is the mother of Lewis Blackman, a teenage patient who died at MUSC in 2000 due to medical error. “I am so pleased at all the good work MUSC has done and is planning to do as part of SPS. I think this is one of the most effective patient safety programs in existence. I look forward to seeing great things come out of MUSC Children's Hospital as the work with SPS progresses.”

SPS began in Ohio in 2009 as a network of eight hospitals. It has now expanded to more than 110 hospitals across the country and Canada, all focused on reducing harm by addressing specific hospital-acquired conditions and building a culture of safety within each hospital. SPS is the only effort in the nation, including Canada, focused on improving pediatric care and reducing associated Medicaid costs. SPS is funded in part by the Cardinal Health Foundation, the Children’s Hospital Association and the federal Partnership for Patients program.

Mack, a self-described “doer and fixer,” said she loves leading the effort. “This puts safety, foremost, on everyone’s list. You have to remember the child’s story. How can you be complacent with harm that’s happening to children? You can’t.”

To learn more, visit the Children’s Hospitals’ Solutions for Patient Safety website. 


SPS Patient Tips for Families

  1. BE A PATIENT ADVOCATE FOR YOUR CHILD. Don’t be shy. Ask questions about your child’s care, raise safety concerns you have, or ask the caregiver to double check their chart before they act. Write down your questions to make sure the caregiver addresses them. You might say, “Excuse me, I have a few questions before you start treatment. Would you mind answering them, please?”
     
  2. YOU KNOW YOUR CHILD BEST. Share unique things about your child with caregivers that may be important for your child’s overall care (i.e. they have a fear of animals or only like to eat food cut in small pieces).
     
  3. WASH. Wash your hands and your child’s hands when entering and leaving the hospital, your patient room, the bathroom, and any treatment rooms (such as X-ray), and be sure to wash if you have handled any soiled material.
     
  4. ENSURE THEY WASH, TOO. Since you are part of your child’s health care team, do not be afraid to remind doctors and nurses about washing their hands before working with you—even if they are wearing gloves. You might say, “Excuse me, I didn’t see you wash your hands. I’d like to be sure everyone’s hands are clean. Please wash them before caring for my child.”
     
  5. STAY CLEAN & DRY. If your child has an intravenous catheter or a wound, keep the skin around the dressing clean and dry and let your caregiver know if it gets wet or loose.
     
  6. WATCH FOR RED OR IRRITATED SKIN. If you notice any new redness or irritation on your child’s skin, notify your child’s caregivers. Ask what steps can be taken to prevent harm to the skin.
     
  7. KNOW THE MEDS. Ask for the names of the medications your child is receiving in the hospital and how they are expected to help your child. Caregivers will check your child’s identification band before giving a medication to make certain the correct medication is being given. If you don’t see this, ask staff to double check that the medication is for your child. You might say, “Excuse me, that medication is not familiar to me. Can you please double check it against my child’s chart?”
     
  8. BE PREPARED WHEN GOING HOME. When your child is ready to go home from the hospital, make certain you know what medications and/or treatments your child will need once home. Ask what you should watch for that will require a call to your child’s doctor and which doctor to call if questions come up. Also ask when your child will need to follow up with a physician appointment.