At the heart of our UNC Department of Medicine, patient safety is more than a priority, it’s a daily practice woven into every aspect of care. In recognition of Patient Safety Day on September 17, we highlight how our providers put patient safety into action to safeguard patients and strengthen a culture of trust, collaboration, and resilience.
Preventing Infections and Complications in the ICU
It’s the mindset that small mistakes, near misses, or weak signals are important warning signs. Instead of dismissing them, high-reliability teams pay close attention because they may reveal larger vulnerabilities in the system.
In the ICU, even small oversights can have significant consequences. That’s why our teams approach patient care with a proactive focus on identifying risks before they lead to harm. Two initiatives, focused on infection prevention and procedure standardization, demonstrate how a proactive approach protects patients and strengthens a culture of safety. Kenton Dover, MD and Honey Jones, DNP, have championed these efforts.
Solutions implemented
Central Line-Associated Bloodstream Infections (CLABSI) and Hospital-Acquired Pressure Injuries (HAPIs)
- Since FY22, interdisciplinary Central Venous Access Device (CVAD) Stewardship and CLABSI Prevention Rounds are conducted weekly on patients with central lines.
- Interdisciplinary Wound Care and HAPI Prevention Rounds are held weekly with wound care specialists to monitor and support patients at risk.
The interdisciplinary nature of these quality rounds has been essential, not only reducing complications but also shifting the culture within the ICU. By creating consistent spaces for collaboration, nurses, physicians, and specialists are able to spot risks early, share expertise, and reinforce safe practices together.
Standardizing Endotracheal Intubation
- Developed a formal interdisciplinary checklist (including respiratory therapy, nursing, pharmacy, and providers) to standardize materials, assign roles, and conduct a safety “time-out” before administering Rapid Sequence Intubation medications.
- Implemented standardized documentation through an Epic note template to ensure consistency.
- Collected feedback with pre- and post-implementation staff surveys to assess perceptions and improve processes.
Coaching and collaborative design were critical in building this checklist and documentation process. By empowering staff to speak up and reinforcing a standardized approach, the team enhanced both provider confidence and patient safety during one of the ICU’s most high-risk procedures.
Improving Patient Safety in OPAT Transitions of Care
The Outpatient Parenteral Antibiotic Therapy (OPAT ) Team, including Angela Perhac, PharmD, Terre Oosterwyk, RN, and Claire Farel, MD, recognized that the complex transition from the medical center to a patient’s home could create significant safety risks. To address these potential issues, we developed a multi-faceted strategy focused on standardizing processes and providing tools to ensure patients receive safe and accurate care outside the hospital.
Our efforts centered on three key areas: ensuring safe transitions, standardizing documentation and monitoring, and enhancing communication and management post-discharge.
Ensuring Safe Transitions to Home
We created resources to standardize the handoff process and proactively identify potential safety concerns.
- “Run Your List” Phone Rounds: We implemented scheduled phone rounds with ID consult attendings to proactively assess patient eligibility for OPAT. This verbal communication addresses concerns about antimicrobial selection, therapy duration, and the patient’s ability to safely self-administer medications at home, preventing inappropriate or unsafe transitions.
- Referral for ID Consults Flowchart: This flowchart acts as a safety checklist, guiding all providers and clinical teams through the steps required for a safe OPAT transition. By ensuring every critical step is checked, we help prevent crucial oversights. A QR code gives team members immediate access to this guide on the go.
- OPAT Contact Card: We provided a direct phone line and chat group for our team. This quick access to expertise allows providers and care managers to efficiently screen patients for home infusion candidacy and provides all staff with immediate support to address potential safety issues.
Standardizing Documentation and Monitoring
We developed a suite of tools to help providers accurately and consistently manage patient care, reducing the risk of error.
- Reference Poster and Pocket Card: These resources guide providers and pharmacists to order the correct safety labs and visually demonstrate different outpatient administration devices. This standardization helps prevent medication errors and ensures critical safety monitoring is not overlooked.
- SmartPhrases and Standardized Documentation: We created simplified documentation templates for ID providers and team members to standardize outpatient monitoring, including required lab tests and screening for adverse reactions. This directly reduces the risk of missed safety checks.
- Clinic Order Reference Poster: This guide helps providers efficiently and accurately place necessary orders for Central Vascular Access Devices (CVAD) and diagnostic imaging. By streamlining this process, we minimize the risk of ordering errors and help ensure the integrity of the patient’s care plan.
Post-Discharge Management
After a patient is discharged, we follow up to ensure continued safety. We reach out to review key information on medication administration, reportable side effects, and OPAT contact information. Our team also places a weekly OPAT clinic note with updated labs and medication adjustments to ensure consistent, safe care.
By focusing on these strategies and tools, the OPAT team is constantly working to mitigate significant barriers to a safe transition of care, ensuring a higher standard of safety for patients continuing their treatment at home.
A Safer Pathway for Chest Pain Patients
Chest pain accounts for nearly 7 million emergency department visits every year, but most patients are not experiencing a heart attack. Traditionally, many of these patients were admitted “just in case,” leading to unnecessary hospitalizations and costs.
-
Solution implemented: A project by John Pryor, Anand Shah, MD, MBA, Scott Keller, Joseph Rossi, MD, and Cody Deen, MD, created a Chest Pain (CP) Transition Clinic for moderate-risk patients. Using a combination of high-sensitivity troponin testing and HEART scores, eligible patients receive rapid outpatient follow-up with cardiology, rather than automatic hospital admission.
-
Results: Since implementation, the clinic has led to a statistically significant reduction in ED admissions without increasing patient risk. No patients in the program experienced heart attack or death, reinforcing the safety of this structured outpatient pathway.
-
Shared learning: By resisting the urge to oversimplify chest pain as “admit or discharge,” the team created a more nuanced, patient-centered approach that reduces unnecessary admissions, lowers costs, and maintains excellent safety outcomes.