7 Ways UCSF is Improving Safety at the Point of Care

UCSF Medical Center, including the UCSF Benioff Children’s Hospital, has made increasing the safety of health care one of its highest priorities. Here are just some of the ways it is working toward that:

stock photo of handwashing

Tracking Progress On Quality Measures

The medical center collects performance information on areas such as central line-associated blood stream infections, fall prevention, hand hygiene, hospital-acquired pressure ulcers, patient satisfaction and ventilator-associated pneumonia in order to track its progress.

Proper hand hygiene is one of many measures at UCSF that have helped lower the rate of infections. Every health care worker is expected to clean their hands every time they go in or out of a patient's hospital room or exam room.

To ensure compliance, data are collected through monitoring, both discreetly and openly, and on camera in some areas.  Since this program was implemented in July 2010, the medical center’s rate of proper hand hygiene has improved to about 90 percent each month – the highest compliance level ever among clinicians.

All patient care providers also are trained in pressure ulcer prevention, with many techniques such as providing good skin care, regularly assisting patients to change position in bed, and using pressure-reducing cushions and other devices. Thanks to these training measures, quality metrics in the reduction of pressure ulcers are at their peak.

Implementing an Electronic Health Record System

UCSF Medical Center implemented an electronic health record system last year, allowing medical orders to be entered online rather than on paper. The system also makes templates available to physicians treating common and complex issues, improving standardization and reducing the risk of inadvertent errors. 

In addition, use of the UCSF My Chart portal has grown rapidly:  As of March 2013, more than 50,000 patients have enrolled in the online resource that enables patients to request appointments or referrals, check lab results and request medication refills all using secure technology.

Designing a State-of-the-Art Robotic Pharmacy

Medication errors are among the most common and most dangerous errors made in hospitals – whether it’s medication given at the wrong time or to the wrong patient, or clinicians giving the wrong medication or the wrong dose.

With the robotic pharmacy launched in 2011 at Mission Bay, a family of giant robots now counts and processes patient medications.

Housed in a tightly secured, sterile environment, the automated system prepares oral and injectable medicines, including toxic chemotherapy drugs. In addition to providing a safer environment for pharmacy employees, the automation also frees UCSF pharmacists and nurses to focus more of their expertise on direct patient care.

The pharmacy operation also is now linked to the health record system, creating an end-to-end electronic system in which a nurse at the bedside picks up a bar code reader, scans a bar code on the patient’s wristband, scans the bar code on the medication the patient is to receive, and scans the bar code on his or her own ID badge. Only after confirming the information matches does the nurse administer medication to the patient.

Earning Magnet Status for Nursing Excellence

The medical center was recently recognized as a Nursing Magnet Hospital, an important milestone for UCSF.

UCSF Medical Center team, led by Chief Nursing Officer Sheila Antrum, center, prepares for a video shoot designed to inspire and prepare nursing staff for a five-day site visit by Magnet appraisers.

The achievement indicates a strong collaboration between the medical center and School of Nursing, which has for years fostered a work environment in which nursing education and expert clinical practice are encouraged and valued.

The Magnet program was launched in 1994 to recognize health care organizations for high-quality patient care, professional excellence and innovations in nursing practice, and designation has been a standard for nurse recruitment efforts and patients seeking the best care.

Addressing Potential Medical Errors with an Interdisciplinary Team

The medical center’s interdisciplinary approach to solving problems extends to its Root Cause Analysis process, established to identify and address potential medical errors.

Teams comprise nurses, pharmacists, doctors, and medical center leaders, but also may include staff in medical records or environmental services – less apparent areas that also impact a patient’s care. 

The focus of team meetings is on understanding the underlying causes that allowed the error to occur and on collaborative problem solving. An open and vigorous discussion ends with a clear action plan, which might involve implementing a new system, purchasing a piece of equipment, or training the doctors and nurses in communication strategies.

Collaborating with Other UC Medical Centers

UCSF is working with the University of California and its four other medical centers to share best practices with each other and with others across the country.

The medical centers joined the federal government’s Partnership for Patients, a $1 billion patient-safety initiative aimed at improving care and lowering costs. A public-private collaboration that includes hospitals, employers, health plans, physicians, nurses and patient advocates, the national initiative focuses on hospital safety with the goal of reducing preventable hospital-acquired conditions by 40 percent, saving 60,000 lives, and reducing hospital readmissions by 20 percent over the next three years. The partnership has the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare alone.

The initiative aligns with UC Health’s efforts to advance patient safety, including the Center for Health Quality and Innovation, which further supports UC projects that improve quality, access and value in the delivery of health care.

Enhancing Surgical Safety with Simple Tool

In the operating room, the final surgical count is a critical task that requires focus and concentration.

UC San Francisco operating room nurse Margo Peterson, RN, invented a bright orange towel intended to reduce interruptions during the final surgical count and to prevent sponges and other surgical items from being waylaid or miscounted.

A new safety product, invented by UC San Francisco operating room nurse Margo Peterson, RN, is intended to reduce interruptions and to prevent sponges and other surgical items from being waylaid or miscounted after surgery. It’s a bright orange towel that reads in bold black letters “Count in Progress.’’

“I wanted to make the surgical count more accurate and efficient,” says Peterson. “The towel is to help people know that we are doing an important task that we need to focus on.’’

A trial run to raise awareness of the towel was conducted in September 2011 and has since been put into use in some operations at the UCSF Medical Center Mount Zion campus.

The UCSF Office of Innovation, Technology & Alliances recently licensed Peterson’s idea to Ansell Sandel Medical Solutions LLC to manufacture and market the product to hospitals nationally.