Patient Safety Updates

Providing quality patient care

Documentation Matters

Accurate, timely charting can make a difference in the quality of care that is delivered by providing clear, concise, and accurate communication from one care giver to another. It can also serves as a legal record and valuable defense tool during litigation.

  • Use correct punctuation, grammar, and spelling. The way you communicate in writing is considered a reflection of the quality of care you provide.
  • Use direct quotes when possible for simple phrases or words.
  • Use words like, "stated" or "reports" when documenting things that patients or families say to you.
  • Document facts rather than personal opinions or feelings about the situation.
  • Chart specifics of your patient teaching like medications, weighing daily, diet, BP monitoring etc.
  • Document referrals to a specialist.
  • Chart any statements made by the patient regarding non-compliance using quotes or phrases such as: Pt. states he isn't going to take his medications due to side effects. Pt. reports he has not been eating healthy the last 2 months. Pt. refuses to come in for a follow up appt. and states "I don't think I need to see the doctor so soon." Pt. states he is still smoking a pack a day and is not planning on quitting.
  • Document effects of any treatments, positive or negative, reported by the patient or family.

Lab Reminders

For those that work in the lab, several key points were reinforced.

  • Always ask the patient to speak their name and date of birth, to ensure it is the correct patient.
  • Use correct order of draw to prevent contamination.
  • Use aseptic technique and allow site to air dry prior to specimen collection.
  • Mix tubes with gentle inversion 5-10 times immediately after each tube fill to prevent clotting.
  • Label all tubes.
  • Remind the patient to remove a pressure bandage after 10 minutes

Swaddle Program

Baylor Scott and White provides the Swaddle program to support staff that have gone through unanticipated incidents such as the death of a patient, medical errors, lawsuits, or questioning /disciplinary action by the State Board. The program assigns a confidential mentor to help the employee work through many aspects of processing the event. CLICK HERE to access more information on this program.

Rapid Response Team!!

RRT is a code used in most hospitals today to help identify patients that might quickly escalate to a CODE BLUE status. A rapid response team is assigned to respond quickly to assess the patient and then provide care needed to hopefully avoid a more serious medical emergency. In our clinic, each team member will be assigned a duty such as bringing needed equipment, performing CPR, or communicating with 911 and other office staff. Ann will be organizing and communicating more information regarding the specifics of RRT for our clinic.