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A Strong
Commitment to Quality Improvement/Patient Safety at KDH
A reorganization of the nursing management
structure took place in October 2007, to include Kathy McLenaghan’s position as
Manager of Quality Improvement/Patient Safety.
In her role, Kathy will continue to work with administration, the Board and
the health care team, to meet accreditation standards, required organizational practices
for patient safety and to support the implementation and integration of evidence-based
practices. Kathy shares the responsibility
of risk management with hospital CEO, Mr. Hal Fjeldsted.
This role enhances the hospital’s goal to provide safe, quality care and
service, with an aim to exceed our client’s expectations.
The hospital is scheduled for its next accreditation survey by Accreditation
Canada, in May 2009.
New Risk Management Program
The hospital is in the process of completing a number of modules as a part of HIROC’s
RMSAM Program (risk management self-assessment
modules). Ten teams consisting of front
line staff members, physicians, nurse practioners, management and senior administration
are involved in this review and will build action plans to address any areas of
improvement identified. The Kirkland
and District Hospital takes a proactive approach to the prevention of any risk issues.
Prevention of Surgical Site Infections
The Kirkland and District
Hospital has been involved with the Safer Healthcare Now Campaign since 2005 for
the prevention of adverse drug events.
In addition to our continued efforts in the area of medication safety, the hospital
had implemented evidence-based interventions for the prevention of ventilator -associated
pneumonia, suggested by this Campaign.
This year the hospital will implement the following care components to reduce the
incidence of surgical site infection.
Appropriate use of antibiotics, appropriate hair removal, and post-operative normothermia
for colorectal and open abdominal surgeries.
We will audit these practices and monitor patient outcomes using a team approach.
Prevention of Central Line Infections
Another Safer Healthcare
Now initiative that will be a focus from a patient safety perspective, is the implementation
of eight components of a bundle of evidence-based interventions for reducing central
line infections. The Kirkland and District
Hospital cares for patients with both central venous catheters and peripherally
inserted central catheters. During
insertion, there will be a focus on hand hygiene, maximal barrier precautions, chorhexidine
skin antisepsis, and optimal catheter site selection.
There will be daily review of line necessity, with prompt removal of unnecessary
lines, dedication of a lumen for Total Parenteral Nutrition (TPN), accessing of
lumens aseptically, and checking entry sites for inflammation with every change
of dressing. Such collaborative efforts
will be audited to evaluate their impact on incidence of central line infections.
Prevention of Ventilator-Associated
Pneumonias
In 2007-2008, the Kirkland
and District Hospital had implemented some evidence-based interventions for the
prevention of ventilator-associated pneumonias.
We will continue to monitor our practices in 2008-2009 as part of our infection
control program.
Medication Safety Increased
The pharmacy department
has been working diligently, performing medication safety assessments as suggested
by the Institute for Safe Medication Practice (ISMP Canada) to identify and address
any areas for improvement that will decrease potential for adverse drug events.
Recent changes have been made to the storage of opiods and heparin products and
there are plans to review the utilization and administration of insulins as another
patient safety initiative.
The hospital will continue to
be involved with the Safer Healthcare Now Campaign for the prevention of adverse
drug events and our ongoing efforts to improve medication reconciliation on admission,
transfer and discharge.
Continued Involvement in the OHA’s,
“Your Health Care - Be Involved” Campaign.
The hospital continues
to involve and communicate openly with patients, families and caregivers about the
importance of being involved in one’s own health care experience through the media,
patient information pamphlets, fact sheets, posters and signage.
This patient-focused empowerment strategy is essential to ensuring patient
safety.
Hand Hygiene
KDH had been a participant
in the Ministry of Health and Long-Term Care’s Provincial Hand Hygiene Pilot Project. The hospital has formed a Hand Hygiene
Committee, showing its commitment to the importance of hand hygiene as a first line
of defense in the prevention of infections.
New hand hygiene stations have been purchased and are located at the entrances of
the hospital so that the staff and public will use the hand santizer provided upon
entering or leaving the hospital. Hand hygiene audits will be a continued practice
to ensure the sustainability of this program.
The hospital will participate
in the OHA’s new campaign, “Clean Hands Protect Lives”, which is intended to educate
clients about the importance of hand hygiene and this will be partnered with the
MOHLTC’s hand hygiene campaign, “Just Clean Your Hands” which was intended for healthcare
workers.
Smoking Cessation Program
This program will be offered to all
in-patients and will provide nicotine replacement therapy, individualized counseling
and arrangement for community follow-up once the patient is discharged.
Quitting smoking is the single most
powerful disease prevention strategy available and the Kirkland and District Hospital
would like to work with patients in meeting their health care needs.
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