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To Kaiser Permanente National Patient Safety Program

Kaiser Permanente Mid-Atlantic States hired a full-time Patient Safety Officer (PSO) in early 2003. The PSO position is part of the Risk Management Department, within the Quality Management Division.

As with our other Quality Management programs, the patient safety program activities are conducted in collaboration with the designated Medical Group leader(s), and are coordinated and overseen by a Patient Safety Committee, formed in 2001, and blended with the existing Risk Management Committee in 2002.

Overall Patient Safety Perspective

• Patient safety has long been a central component of KP's vision, “to be the most sought after leader in providing quality, caring health care that is trusted by all”;

• We believe that patient safety is about providing the “right care to the right patient at the right time”,

• We view patient safety as “every patient's right, and everyone's responsibility” including the patient's;

• Patient safety is a central feature of Kaiser Permanente's rigorous, internal quality review audit;

• It is anticipated that through the additional resources, expertise, and high visibility of the Patient Safety Officer, a more systematic approach to implementing more comprehensive patient safety program initiatives will be possible.

Patient Safety Initiatives

Our pharmacy performs a concurrent review of each prescription at the time of dispensing. This review involves checking the following elements of each prescription at the time of fill: drug, directions, dosage, drug interactions, quantity, and correct patient. (Drug interactions between a newly prescribed medication, and with all previously prescribed and continuing medications are also checked by reviewing the patient's existing, centralized, online pharmacy profile. This profile represents a centralized profile for all Kaiser Mid-Atlantic pharmacies.)

The Pharmacy department utilizes an on-going medication error reporting process to retrospectively identify error trends in the dispensing process. These trends are then reviewed and actions are initiated to decrease the likelihood of similar errors happening in the future. The Pharmacy department also performs a 5% retrospective audit on all prescriptions filled to identify errors.

We maintain an electronic, pharmacy profile for each patient that is available throughout the region for all practitioners to access. This is also available within the core acute care hospitals for use with KP patients admitted to those facilities.

We have an electronic weekly newsletter, Plugged In, that is sent to all employees and practitioners. There have been several patient safety related topics addressed in various issues of “Plugged In”, including: specific safety and risk issues related to physicians corresponding with patients via e-mail; and the new “Photo ID” patient identity verification protocol. In addition, medication safety and patient safety tips are routinely part of the monthly Pharmacy and Therapeutics newsletter, Tips on Scripts

Other patient safety initiatives:

• Surgical Site Verification: Both of the ambulatory surgery centers in the Kaiser Permanente Mid-Atlantic States Region have a comprehensive surgical site verification process effect which is used with all cases;

• Pre-surgical Pause Procedure: In addition to the other patient procedures, site/side verification measures are in place within our two ambulatory surgery centers. The full team of staff in the operating room has recently implemented a formalized “surgical pause” procedure. This new protocol involves all members of the OR team individually verifying and reaching group consensus about: the patient's identity, and the specific procedure to be performed, prior to initiating any operation;

• Photo Identification Program: In order to verify patient identity, members are now asked to show some form of photo ID when presenting for any type of health care service. This will help to assure that the right patient is receiving the right care. It is also consistent with the rationale underlying the patient verification processes outlined in JCAHO's 2003 Patient Safety Goals.