Patient Safety

"...a Hospital...should do the sick no harm." — Florence Nightingale, Notes on Hospitals, 1859

Patient Safety is About:

  • Eliminating preventable medical mistakes
  • Guarding against the impact of human error
  • Establishing hospital-wide systems to safeguard patients' health and well-being.

Baystate Health emphasizes understanding "why" and "how" events happen, not focusing just "who" caused a particular event. The Division of Healthcare Quality is responsible for ensuring that Baystate facilities provide the safest treatment possible. Some patient safety initiatives are:

  • Taking a leadership role in educating Baystate employees to make patient safety their highest priority and to follow nationally recognized patient safety guidelines in all patient interactions.
  • Administering a Safety Reporting System (SRS), a web-based computerized event and near-miss event reporting system.
  • Helping patients understand their role in ensuring their own safety.
  • Educating patients about available patient safety resources.
  • Encouraging patients to use quality and safety data when making health decisions.

Baystate Health has joined other Massachusetts hospitals in subscribing to the "PatientCareLink" Continuing the Commitment to Safe Care" initiative.

Patients' Role in Patient Safety

Patients and their family members can take an active role in assuring that a hospital stay is safe and free of preventable medical errors by:

  • Being well-informed
  • Asking their physicians and nurses about their diagnosis and treatment
  • Making sure that every hospital employee providing care to them knows:
    • Who they are
    • What their health issues are
  • Questioning anything that does not seem quite right, such as:
    • If the hospital employee does not know their name
    • If a medication does not look familiar
    • If the employee is preparing the wrong part of the body for treatment.

Resources for patients who want to take an active role in ensuring their own safety.

Communication, Apology, and Resolution (CARe)

Baystate Health is committed to an open, honest, and transparent environment in which patients and families are promptly notified of unanticipated adverse events.

Baystate Health is a founding member of the Massachusetts Alliance for Communication following Medical Injury (MACRMI). MACRMI is a Massachusetts alliance of patient advocacy groups, teaching hospitals and their insurers, and statewide provider organizations committed to transparent communications, sincere apologies, and fair compensation in cases of avoidable medical harm. MACRMI’s two lead health systems—Baystate Health (and community hospitals) and Beth Israel Deaconess Medical Center (and community hospitals) have undertaken the implementation of Communication, Apology, and Resolution (CARe) to improve the way we evaluate and analyze unanticipated outcomes in healthcare. CARe is a quality improvement initiative that represents a new way of responding to medical errors that puts patient needs first. Its goals are to:

  • Improve communication between health care providers and their patients;
  • Determine what went wrong, and, if possible, prevent it from happening again;
  • Offer an apology and work with the patient and family to come to resolution, including offering compensation, if appropriate.

For questions, please contact Risk Management at 413-794-3359.

Patient Safety Accordion

Guidelines

View the patient safety guidelines observed at Baystate Health. Chief among these are:

  • Correctly identifying each patient all the time.
  • Ensuring that patients receive only the care intended for them, making certain that all dispensed medications are for the intended patient, that the patient is not allergic to the medication or taking another medication that might cause a negative reaction, and that all procedures or tests are performed as intended (for the correct patient and for the correct body part).
  • Speaking out about patient safety issues and voluntarily reporting errors, near misses, close calls and hazardous situations.
How to Use Safety Data to Make Informed Decisions

As a consumer of health care, you can improve your chances of a successful outcome and a safe hospital stay by using quality and safety data to make informed choices.

There are also websites where you can find quality, safety and/or patient satisfaction data that will help you determine which of several hospitals you are considering is right for you.

Visit websites, such as:

  • The Leapfrog Group - allows you to search for hospitals in your area (by city and state, ZIP code, or by name) and compare their Leapfrog results.
  • The U.S. Department of Health & Human Services Hospital Compare tool - enables you to compare any hospital's outcomes for healthcare practices you specify to the averages for the state and the nation.
  • Massachusetts Health Quality Partners (MHQP) is a state-wide consortium that collections and reports health quality data throughout the Commonwealth. MHQP's public reporting of this data enables consumers to review and compare these quality measures to those of other practices. The MHQP data also includes survey results reporting patients' care experiences (service, accessibility, etc.) at individual practices.
  • PatientCareLink - healthcare resource dedicated to voluntarily providing patients, families and caregivers with the most transparent information available on the care provided at Massachusetts hospitals.

For the procedure you are considering, take into account the quality indicators:

  • How much experience does the hospital have performing that procedure, and how does that compare with the other hospitals you could choose?
  • Positive outcomes
  • Mortality rates
  • Complication rates
  • Patient safety
Safe Practices at Baystate Health

SUMMARY OF LEAPFROG SAFE PRACTICES

Baystate Health fully satisfies all safety practices recommended by the National Quality Forum, including:

1. Creating and Sustaining a Culture of Safety

a. Leadership Structures and Systems
b. Culture Measurement and Interventions
c. Team Training and Team Interventions
d. Identification and Mitigation of Risks and Hazards

2. Informed Consent, Life-Sustaining Treatment, Disclosure, Care of Caregiver

a. Informed Consent
b. Life-Sustaining Treatment
c. Disclosure
d. Care of Caregiver

3. Matching Healthcare Need with Service Delivery Capability

a. Nursing Workforce
b. Direct Caregiver Workforce
c. Intensive Care Unit Workforce

4. Facilitating Information Transfer and Clear Communication

a. Patient Care Information
b. Order Read-Back and Abbreviations
c. Labeling Studies
d. Discharge Planning
e. Safe Adoption of Computerized Physician Order Entry (CPOE)

5. Medication Management

a. Medication Reconciliation
b. Pharmacist Leadership Structures and Systems

6. Healthcare Associated Infections

a. Hand Hygiene
b. Influenza Prevention
c. Central Venous Line-Blood Stream Infection (CVL-BSI)
d. Surgical Site Infection (SSI)
e. Care of Ventilated Patients
f. Multi-Drug Resistant Organism (MDRO) infections
g. Catheter-Related Urinary Tract Infection (CR-UTI)

7. Condition and Site Specific Practices

a. Wrong Site Surgery Prevention
b. Pressure Ulcer Prevention
c. Venous Thromboembolism (VTE) Prevention
d. Anticoagulation Therapy
e. Contrast Media-Induced Complication Prevention
f. Organ Donation
g. Glycemic Control
h. Fall Prevention
i. Pediatric CT Imaging

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