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Recommended Patient Safety Practices for Making Health Care Safer |
The Center for Laparoscopic Obesity Surgery (CLOS) Practices for Patient
Safety |
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Evidence Report/Technology Assessment, No. 43 Prepared for: Agency for
Healthcare Research and Quality, Contract No. 290-97-0013 |
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Incident Reporting |
The CLOS has a data driven incident reporting system |
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Root Cause Analysis |
Root cause analysis is part of our quality management system |
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Computerized Physician Order Entry (CPOE) with Clinical Decision Support
Systems (CDSSs) |
CLOS uses a computer driven order entry system |
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The Clinical Pharmacist's Role in Preventing Adverse Drug Events |
In place |
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Computer Adverse Drug Event (ADE) Detection and Alerts |
Implemented computer driven adverse drug detection system |
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Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to
Anticoagulants |
Anticoagulants are no longer used removing the risk of anticoagulant
bleeding complications |
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Unit-Dose Drug Distribution Systems |
Drugs are distributed in unit dose format |
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Automated Medication Dispensing Devices |
Automated dispensing device in place |
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Practices to Improve Hand washing Compliance |
Hand washing protocols in place |
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Impact of Barrier Precautions in Reducing the Transmission of Serious
Nosocomial Infections |
Closed surgery improves barrier in surgical procedures |
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Antibiotic Use Practices on Nosocomial Infections and Antimicrobial
Resistance |
Antibiotics used per protocols |
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Prevention of Nosocomial Urinary Tract Infections |
No Foley catheters lead to reduced risk of urinary tract infections |
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Prevention of Intravascular Catheter-Associated Infections |
No central venous catheters and less than 24 hours of all iv catheters
leads to lower risks of catheter associated infections |
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Prevention of Ventilator-Associated Pneumonia (VAP) |
Short operating times, short acting drugs lead to minimal ventilation
periods |
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Patient Positioning: Semi-recumbent Positioning |
All patients positioned in 60 degree head up to decrease risk of
aspiration. |
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Localizing Care to High-Volume Centers |
Surgery performed by high volume surgeon |
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Learning Curves for New Procedures |
Learning curve long since passed. |
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Prevention of Surgical Site Infections |
Short efficient closed procedure leads to lowered rates of infection |
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Prophylactic Antibiotics |
Protocol antibiotics all given PreOp |
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Perioperative Normothermia |
Short closed procedure -> maintenance of normothermia |
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Supplemental Perioperative Oxygen |
Supplemental oxygen per protocol |
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Perioperative Glucose Control |
Clinical pathway maintains glucose control |
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Retained Surgical Sponge |
Closed procedure – no surgical sponge |
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Pre-Anesthesia Checklists To Improve Patient Safety |
Preanesthesia checklist |
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The Impact Of Intraoperative Monitoring On Patient Safety |
Intraop monitoring per protocol |
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Beta-blockers and Reduction of Perioperative Cardiac Events |
Beta-blockers used in cardiac patients per protocol |
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Prevention of Falls in Hospitalized and Institutionalized Older People |
Minimal sedation/minimal pain – rapid return to ambulation |
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Prevention of Pressure Ulcers in Older Patients ( |
No anticoagulants decreases risk of bleeding |
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Prevention of Delirium in Older Hospitalized Patients |
Minimal sedation because of short surgery time and minimal pain |
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Prevention of Venous Thromboembolism |
Short surgery, rapid return to full activity |
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Prevention of Clinically Significant Gastrointestinal Bleeding |
Elimination of anticoagulants decreases risks of GI bleeding |
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Pain Management |
Short surgery, minimal trauma and manipulation – decreased pain. |
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Range of pain relief: Patient controlled analgesia, supplemental
parenteral and oral narcotics. Pretreatment with analgesics. |
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Promoting a Culture of Safety |
As demonstrated in this list. |
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Information Transfer |
Data driven research based practice |
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Information Transfer Between Inpatient and Outpatient Pharmacies |
No hand written prescriptions. Prescriptions computer generated
including detailed descriptions of justifications, risks and allergies. |
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Discharge Summaries and Follow-up |
Computer driven discharge summaries. |
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Fatigue, Sleepiness, and Medical Errors |
Completely focused on the care of bariatric patients, no night call. |
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Procedures For Obtaining Informed Consent |
Extensive preoperative education using audio and video feedback |
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Other Practices Related to Patient Participation |
Aggressive inclusion of the patient in pre and post operative management |
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Practice Guidelines |
All patient treated as part of a practice guideline |
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Critical Pathways |
All patients managed on critical pathway |
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Clinical Decision Support Systems |
Data driven clinical decision support system |
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Educational Techniques Used in Changing Provider Behavior |
Data disseminated from DSS |
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Other Approaches to Improving Patient Safety |
Independent reviews of outcomes and patient satisfaction. |
