Patient Safety, 2005

Los Angeles County Department of Health Services

January 2005

The Los Angeles County Department of Health Services (DHS) is using several AHRQ products in its efforts to improve the quality of its community health care. In fact, according to Quality Consultant Liz Augusta, RN, MSN, of LA County's Quality Improvement Program, "Nearly all our activities are supported by AHRQ data."

County DHS initiatives for patient safety and quality improvement include the following:

• Patient Safety Brochure
• Near-Miss Reporting Program
• DHS Best Practices Committees
• DHS Patient Safety Web Site
• Employee Patient Safety Handbook
• Patient Safety Hotline and E-mail Notification
• Patient Safety Climate Survey

The Patient Safety Brochure, a publication developed using AHRQ's 20 Tips to Help Prevent Medical Errors fact sheet, will be distributed to patients at the time of inpatient admission in LA County public hospitals. The four-panel brochure has a tear-off panel for patients to record their medications and keep handy. Upon discharge, patients will receive a short survey to measure the brochure's effectiveness. Once effectiveness is determined, use of the brochure will expand to outpatient settings.

The Near-Miss Reporting Program was developed after LA County staffers read about reporting errors in AHRQ's Evidence Report No. 43, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. The program was designed to capture those events that could, but did not, cause adverse consequences to patients, and to use the information to identify modifiable systems issues that have a direct impact on patient safety.

After extensive training and a pilot run in early 2004 at one of LA County's acute care facilities, staff were encouraged to report near-misses in an anonymous drop box. "Results from the Near-Miss Program have been very promising. The program has directly impacted quality improvement actions related to patient safety and prevention of injury," Augusta reports.

Based on some of the near-miss reports received, the facility has made system changes to prevent the near-misses from becoming actual errors and events. This program was presented in September 2004 at the National Association of Healthcare Quality Annual Conference and was also published in the Forum Newsletter of the California Association for Healthcare Quality.

The County also has established four DHS Best Practices committees, consisting of Emergency Department Best Practices, Radiology Best Practices, Anesthesia Best Practices and ICU Best Practices committees. The ICU Best Practices Committee reviews and implements evidence-based practices that have a beneficial impact on patient safety and ICU care. One of the tenets of the ICU Best Practices Committee is to review and implement, where appropriate, AHRQ measures and recommendations. For example, the chairperson reports that the Committee developed a ventilator-weaning protocol as suggested by AHRQ materials.

LACDHS has also implemented several other safety components to carry out AHRQ's recommendations. The county has a DHS Patient Safety Web site, an educational site accessible by employees via the DHS intranet. It highlights current areas of patient safety issues, such as handwashing, JCAHO National Patient Safety Goals, and Near-Miss reporting. The Employee Patient Safety Handbook is available in hard copy as a 25-page booklet and also in electronic format via the County's DHS Patient Safety Web site. The handbook is given to new staff during hospital/clinic orientation. Handbook contents detail the JCAHO National Patient Safety Goals, medication safety, surgical safety, equipment safety, and other important patient safety topics.

To complete the circle that began with AHRQ's patient safety recommendations, LACDHS has created two new ways of alerting officials about potential safety issues. The Patient Safety Hotline is an anonymous toll-free phone number that visitors, patients, or staff can call to report any conditions or issues that they feel may impact the quality or safety of patient care. Posters with this information are displayed in prominent patient and visitor areas. A Patient Safety E-mail Notification address is also available to allow anyone to report patient safety concerns. The E-mail address is listed on the Patient Safety Hotline Posters and in the Employee Patient Safety Handbook.

To measure the perception of patient safety within LA County's DHS system, the Patient Safety Climate Survey was created. The Safety Climate Survey is a tool developed as part of an AHRQ-funded project at the University of Texas Center of Excellence. The survey was available to all DHS employees for completion either through the DHS Web site or by hand.

Patient Safety Climate Survey results will be shared with each facility CEO and the Director for the Department of Health Services, Augusta reports. Based on the responses, specific educational activities and system changes will be implemented. The survey will be repeated later to measure the effects of those efforts and changes.

Augusta is also planning a 2.5-day DHS Patient Safety Seminar for all DHS employees, with a target audience of Patient Safety Leaders, Hospital Administrators, Managers, and DHS Executives.

The Los Angeles County Department of Health Services is the second largest public health system in the nation. It provides direct patient care and public health services for 10 million county residents. LA County's DHS has an annual budget exceeding $3 billion and employs more than 22,000 people. For more information, refer to the County's Web site: http://www.ladhs.org.

Impact Case Study Identifier: Multi-Center 05-07 (COE, CQuIPS)
AHRQ Product: Evidence Report
Topic(s): Patient Safety
Scope: California

20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/20tips.htm

Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Summary. July 2001. AHRQ Publication No. 01-E057. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety/summary.htm.

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