Rice Hospital in Willmar, Minn., projects ongoing to offer safe care
WILLMAR -- When Rice Memorial Hospital conducted a hospital-wide survey late in 2010 on the organization's patient safety culture, one of the things learned was that information about errors in patient care wasn't being fully captured.
Compared to other hospitals of similar size, "our staff tended to report fewer safety events," said Wendy Ulferts, chief nursing officer.
Over the past year, Rice has been taking steps to change this and to increase the hospital's ability to collect and act on patient-safety data.
It's one of several areas being addressed in Rice's ongoing efforts to provide safe, quality care to patients.
Safety is "part of everything we do here at the hospital," Ulferts told the hospital board in a report this past week on the state of safety projects at Rice Hospital.
"Safety and quality really go hand in hand. It's something we think about in everything we do."
From safety reporting to reducing the risk of pressure ulcers and hospital-acquired infections, Rice tackled multiple projects last year aimed at avoiding preventable harm to patients.
Statistics bear out the results. According to the hospital's value-based purchasing scorecard, a collection of key measures of safety performance, Rice averaged less than one surgical site infection per 100 surgery cases throughout 2011. No bloodstream infections associated with the use of a central line were reported. The rate of hospital-acquired pressure ulcers was at or below the national benchmark of 9 percent for most of 2011 with the exception of the first quarter, when it was 13.6 percent.
Reporting safety-related incidents is just one aspect of Rice's patient safety efforts but it's an important one for the data it provides and the ability to analyze the information in more detail, Ulferts said.
A landmark report issued more than a decade ago by the Institute of Medicine estimated that 98,000 Americans die each year due to medical error. The true number is difficult to pin down, however, nor does it include serious injuries, errors that resulted in no injury or close calls. Many patient-safety experts maintain that medical errors are often underreported and hence might not be fully recognized or addressed.
Although it's not entirely clear why Rice staff were less likely to report incidents than staff at other hospitals, hospital leaders believed at least part of the reason was the paper-based system being used.
One of the hospital's goals last year was to investigate software systems that are easier and do a better job of collecting data, Ulferts said.
"We really want a system that's electronic, that eliminates paper, that gets to the right people in a timely manner," she said. "We want to give our staff the ability to tell the story about what happened and why it happened, so we can understand."
Once the system is in place, it will allow staff to make confidential reports about errors, she said. It also will give hospital leaders the ability to track actual numbers, identify trends or patterns, and analyze more deeply what might be contributing to particular types of errors -- for instance, medication mistakes.
As the database grows, it also will enhance the hospital's ability to monitor how specific safety initiatives are faring and whether they're making a difference.
Rice also stepped up its staff education last year on safety reporting.
Safety reporting continues to be a focus this year but several other projects are under way as well, Ulferts said.
One will involve an in-depth analysis of hand hygiene, one of the key ways to avoid spreading infection within the hospital, she said. "How can we get every person in our system to be compliant with hand hygiene?"
Another project aims to study interruptions, their impact on safe processes and effective ways to reduce interruptions at critical times.
This project is being launched in the pharmacy to start with, and will eventually be expanded to other departments, Ulferts said. "We plan to share this learning across our organization."