Mistake-proofing project protecting patients in Sun Country

Save your own life 24-10-13

Venous thromboembolism is a blood clot formed in a vein, a piece of which travels to the heart or lungs and blocks the proper operation of that organ. According to Safer Healthcare Now, VTE is one of the most common and preventable complications of hospitalization. Patients can die, or experience complications if they don’t receive the preventive treatment, and are at risk.

Audits last year at St. Joseph’s Hospital in Estevan showed a large variation in the use of a screening tool that would recognize susceptibility and offer the appropriate treatment to each patient every time. In some months, the process was followed correctly 90 per cent of the time. In other months, it was followed only 20 per cent of the time.

As part of their Lean training, a team of health care professionals in Sun Country Health Region (SCHR) conducted a mistake-proofing project last year to ensure consistent use of the treatment designed to prevent VTE.  Mary Anne Veroba, Director of Patient Care at St. Joseph’s Hospital, was part of the team that developed this mistake-proofing project. “

Prevention is the key to addressing this complication,” says Veroba. “Failure to provide VTE prevention to those with identifiable risk factors is now considered negligence. Health care workers are very busy. We don’t always follow the best treatment unless we can develop ways to make the best care an automatic response every time. That was the idea behind the mistake-proofing project. We wanted to remove the possibility for error.”

The SCHR team — which included Chris McKee, Executive Director, Kaizen Promotion Office; Felecia Watson, Regional Director for Quality of Care; Niki Rodine, Clinical Improvement Facilitator; and Wanda Miller, Regional Director of Primary Health Care — used root cause analysis to determine why the screening tool was not being used for every patient. Then they created a new process for staff, doctors, patients and families to follow.

With the co-operation of everyone involved, they eliminated errors and quickly reached a 100 per cent use of the proper preventive treatment. Since the project was completed and implemented at St. Joseph’s Hospital last winter, 100 per cent of the patients at risk for VTE have received the appropriate care within 12 hours of admission; this improvement has been sustained ever since.

“It’s amazing,” says Veroba. “I’ve been trying to get this VTE project going since 2008.” She says she’d done a lot of improvement projects but none of the other effortss in the past have ‘taken’ as well as this one did with staff and doctors. “I think it’s because we didn’t have the same set of skills that we have now. We used the Lean tools to keep the whole process simple and make it standard work for everyone, so it’s used every time.”

The Canadian Patient Safety Institute estimates about 24,000 patients die each year as a result of a preventable harm. Some of those people died because of a failure to follow correct VTE preventive measures. This team is sure that patients who check into St. Joseph’s Hospital won’t be among those statistics in the future. SCHR will replicate this process in other regional facilities in the future.

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3 Responses to “Mistake-proofing project protecting patients in Sun Country”

  1. Trish Livingstone
    April 29, 2014 at 11:53 pm #

    Great work, Sun Country! Thank you for working hard to make care safer for our patients.

  2. Marga Cugnet
    April 28, 2014 at 2:12 pm #

    The results of this project are currently benefitting the patients of St Joseph’s Hospital of Estevan, but even more amazing is that the best practices will be spread throughout Sun Country Health Region, and outside as well. So often we fail to share our successes. Our staff at the bedside had the opportunity to help plan the improvements to ensure all patients were screened and managed as per best practice.

  3. Donna Brunskill
    April 25, 2014 at 1:14 pm #

    Great work. It saddens me that Lean is such a political football these days. Great work. Look forward to seeing long term stats that there is a drop in your VTE rate. At least 10 percent of all govt spending should be on good r and d. That is what Lean is.

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