Nursing Patient Safety Program
The Department of Nursing is a key player in many patient safety initiatives. Working in conjunction with the School of Nursing and various multi-disciplinary committees in the medical center, representatives at all levels of practice continue to make key contributions to improving safe patient care in all areas of the Medical Center. Key initiatives are described in this section.
Patient Safety Committee:
This multi-disciplinary committee provides oversight to all patient safety issues raised throughout the medical center. Nursing is represented on this committee at the Director level, through Nursing Performance Improvement, and by a staff nurse member of the Patient Safety Fellows group.
The IHI 100 Thousand Lives Campaign
This is a Medical Center wide initiative incorporating six “best practices” designed to reduce medical errors and improve patient outcomes.
Nurses are working on multi-disciplinary teams to:
- Implement A Rapid Response Team (Patient Care Directors).
- Reduce ventilator-associated pneumonia (Clinical Nurse Specialist)
- Catheter-associated blood stream infections (Clinical Nurse Specialist)
- Reduce medication errors through medication reconciliation across the continuum of care (Nursing Performance Improvement; Patient Care Director; Nurse Practitioner; Nurse Manager; Staff Nurse)
- Improve care for patients with Acute Myocardial Infarction (Clinical Nurse Specialists)
- Prevent surgical site infections (Infection Control Nurse; Clinical Nurse Specialist; Nurse Educator)
The Nurse Patient Safety Fellows
Because we believed that nurses practicing at the bedside are the key to any error reduction initiative, we established a patient safety fellowship, funded by a University hospital Consortium Grant to develop a “core group” of staff nurse leadership for the project. We conducted interviews and selected eight nurses for the fellowship experience that began in January 2002. The fellows selected represented a broad cross-section of clinical areas/divisions at the Medical Center including: Adult Med/Surg; Pediatric Acute Care; Adult Critical Care; Perinatal; Perioperative; Emergency Department; and Post Anesthesia Care.
The fellowship experience consists of monthly meetings, training and project work. To more fully integrate the work of the patient safety fellowship into unit based practice, “associate fellows” were and continue to be recruited to ensure that each nursing unit has an active link to the project. The fellows/associate fellows are working to develop unit-based patient safety committees whose charge is to gather information on critical events, near misses and exemplary practice, review these events at staff meetings, and make recommendations for changing unit and hospital-wide practices that contribute to errors.
An integral part of the Fellowship is the “Stories from the Bedside Program,” in which staff nurses present first-hand accounts of errors or near misses, as well as a systematic analysis of system factors that contributed to the errors, and recommendations for improving the system to reduce the chance of error.
A Patient Safety Fellow serves as a member of the Medical Center Patient Safety Committee.
The Integrated Nurse Leadership Program
UCSF Medical Center was one of 8 hospitals in the Bay Area to receive funding through the Integrated Nurse Leadership Program (INLP) in 2005-2006. This program was funded by the Gordon and Betty Moore Foundation, and administered by the Center for the Health Professions, housed on our Laurel Heights campus. The purpose of the overall program was to enhance patient safety and nurse retention through leadership training, teamwork effectiveness, and project support at the selected sites. Our project, Using Our Voices: Lifesaving Skills for Nurses, consisted of a training program for staff nurses and resident physicians to improve the effectiveness of communications related to the successful rescue of patients who experienced sudden changes in their status. The project was piloted on a single unit in 2006, and was very successful. The Patient Safety Fellows have assumed responsibility for the training program, and they offer a 4-hour continuing education class twice a year based on the original INLP content. Elements of the program have also been incorporated into orientation of all new nurses, and nurses’ annual review training.
The Triad Study for Optimal Patient Safety (TOPS)
In 2005, UCSF Medical Center was one of three facilities in the Bay area to receive funding as part of the Gordon & Betty Moore Foundation’s project, Triad Study for Optimal Patient Safety (TOPS). The Medicine service, nursing, support staff, and pharmacy all participated in the two year project to improve communications and teamwork on this complex medical unit. The program completed in March, 2007, but the skills learned by staff are still being practiced to enhance the care to these patients. Plans are currently underway to harvest successes from this project and diffuse them throughout the Medical Center.