SANDRA TROTTER PERKINS

7.1%Combined severe sepsis and septic shock mortality
85% Sepsis Screening Accuracy, up from 58% in 2015
80% IV Fluids within 1 hour
95% Antibiotics within 3 hours; 74% Antibiotics within 1 hour
73% Sepsis CMS Bundle Compliance, up from 52% in 2015
100% Opportunities for Improvement addressed with MD/RN

A “one message, one time” patient transition model was developed to allow essential providers to hear the same information at the same time after the patient’s arrival in the ICU—with no interruptions. This approach, which used the I-PASS method, also helped staff answer family questions more consistently. The model was embedded in the organization’s EMR system. Having information technology experts at the table through the development of the tool allowed the team to make adjustments along the… Show more

A “one message, one time” patient transition model was developed to allow essential providers to hear the same information at the same time after the patient’s arrival in the ICU—with no interruptions. This approach, which used the I-PASS method, also helped staff answer family questions more consistently. The model was embedded in the organization’s EMR system. Having information technology experts at the table through the development of the tool allowed the team to make adjustments along the way and made this effort much more manageable.
Six months into the project, the organization demonstrated a reduction in care failures, and staff members recognized they had been missing several opportunities for good communication. The culture of safety data showed progress—even at the mid-point within the collaborative. And handoffs were happening in almost half the time. The hospital has since taken this model and disseminated it to multiple units. Show less

As part of the California Hospital Engagement Network and the California Hospital Association: Description:
$218 million was awarded to 26 State, regional, national, or hospital system organizations to become Hospital Engagement Networks (HENs). In the California HEN, 5 Network Facilitators support 174 hospitals to significantly reduce patient harm in eleven areas: Adverse-Drug-Events, CAUTI, CLABSI, Early–Elective-Deliveries, Falls, OB-Harm, Pressure Ulcers, Readmission, SSI, VAP/VAE, and… Show more

As part of the California Hospital Engagement Network and the California Hospital Association: Description:
$218 million was awarded to 26 State, regional, national, or hospital system organizations to become Hospital Engagement Networks (HENs). In the California HEN, 5 Network Facilitators support 174 hospitals to significantly reduce patient harm in eleven areas: Adverse-Drug-Events, CAUTI, CLABSI, Early–Elective-Deliveries, Falls, OB-Harm, Pressure Ulcers, Readmission, SSI, VAP/VAE, and VTE.

Aim:
174 California Hospitals will reduce hospital-acquired-harm 40% and readmissions 20% by the end of 2013.

Actions Taken:
Each CalHEN hospital was assigned a network facilitator. The individual hospital action plan was developed to optimize the resources available. The actions included basic and advanced quality improvement training, sharing webinars from best practice sites, collaborative meetings, on-site coaching visits, community workshops, CEO and physician engagement, and recognition events.

Summary of Results:
•Number of Participating Hospitals that have achieved at least 30% improvement (15% for readmissions) harm-area or sustained zero rate for the past 6-12 months Adverse-Drug-Events= 26 Hospitals CAUTI=82 Hospitals CLABSI=132 Hospitals Early–Elective-Deliveries =55 Hospitals Falls=70 Hospitals OB-Harm=55 Hospitals Pressure Ulcers=98 Hospitals Readmission=84 Hospitals SSI=74 Hospitals VAP/VAE=91 Hospitals VTE=21 Show less

Pressure ulcers are among the most commonly reported preventable patient harm event s in both adults and pediatrics. This harm can be in the form of increased length of stay, infection, surgical intervention and sepsis. Additionally, these events are reportable in number of states and can have financial impacts.
An initiative to decrease pressure ulcers was initiated in 2009. At the time, this posed as a daunting challenge in a tertiary care pediatric facility. A retrospective review… Show more

Pressure ulcers are among the most commonly reported preventable patient harm event s in both adults and pediatrics. This harm can be in the form of increased length of stay, infection, surgical intervention and sepsis. Additionally, these events are reportable in number of states and can have financial impacts.
An initiative to decrease pressure ulcers was initiated in 2009. At the time, this posed as a daunting challenge in a tertiary care pediatric facility. A retrospective review including a root cause analysis of all pressure ulcers events was conducted. The root cause analysis identified misuse of specialty beds, lack of understanding of pressure ulcer physiology, lack of supplies and the need for multidisciplinary involvement. Quality Management, Patient Safety, Nursing Education, Purchasing, Nursing management, WOCN and IT collaborated to evaluate the needs of the organization to reduce pressure ulcer rates. This collaboration resulted in an 85% reduction in the incidence of pressure sores over a 2 year period. Show less

10 interventions that resulted in an 86% reduction in hospital acquired pressure ulcers in pediatric patients at Stanford University Medical Center.

Lucile Packard Children’s Hospital at Stanford in Palo Alto, California, a CHCA hospital, has achieved great results from its participation in CHCA’s Collaboratives, says Patient Safety Program Manager Sandy Trotter. “We decreased our catheter-associated bloodstream infections in the NICU by 25 percent in the first year,” she says. “And before we started, people thought we were already as good as we could get.”

Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test… Show more

Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test showed statistically significant increases in nurses' communication self-efficacy to carry out medical disclosure (t = 6.68, p < .001). Ratings of setting "realism" and simulation effectiveness were high (21 out of 25 composite score). Findings provide preliminary support for further research on simulation-based disclosure training for healthcare professionals. Show less

Four improvement projects completed in four months demonstrate the value of internal collaboration at Stanford University Medical Center.
The four projects: Reduce Infections, Improve Hand-off Communication, Improve Patient Flow and Decrease Costs.

We went live with our electronic medical record (EMR) and computerized prescriber order entry (CPOE) in October 2007.
This implementation was associated with improvements in patient safety and quality measures and a statistically significant reduction in hospital-wide mortality rate while the CMI increased.
Based on our data, we estimate 36 children’s lives were saved over 18 months in association with the EMR intervention.
.

According to U.S.News & World Report’s publication of America’s Best Children’s Hospitals 2010, Lucile Packard Children’s Hospital (LPCH) at Stanford University Medical Center is among the nation’s best pediatric hospitals. The hospital’s Patient Safety Program has won national recognition
for its patient safety efforts, including being a two time winner of the Race for Results Award from the Child Health Corporation of America. Not content with their achievements, patient safety
leaders… Show more

According to U.S.News & World Report’s publication of America’s Best Children’s Hospitals 2010, Lucile Packard Children’s Hospital (LPCH) at Stanford University Medical Center is among the nation’s best pediatric hospitals. The hospital’s Patient Safety Program has won national recognition
for its patient safety efforts, including being a two time winner of the Race for Results Award from the Child Health Corporation of America. Not content with their achievements, patient safety
leaders at the Stanford, CA hospital knew they could leverage their incident report data more strategically, but were frustrated by the difficulty of compiling and analyzing the data quickly
enough to identify trends. In particular, LPCH leaders wanted to use near-miss information more fully, according to Packard Children’s Patient Safety Program Director Sandra Trotter, MBA,
MPHA, CPHQ. Show less

Lucile Packard Children’s Hospital (LPCH), located at Stanford University Medical Center in Stanford, CA, has won national recognition for its patient safety program. But hospital leaders knew they could improve their care environment even further if they found a faster way to identify and address patient care problems.Providing near-miss information directly from front-line staff in real time, the on-line incident reporting system identified trends very quickly.

Involved patients and parents in an initiative to better manage pain in healthcare settings.Instituted many measure including safe use of patient controlled analgesic devices.

Since 2001, Packard Children's Hospital at Stanford University Medical Center has had a goal to reduce medication errors.

The world of patient safety and quality assurance has recently become front-page news. Over the past five years, Packard Childrenʼs has been a leader in partnering with families around this sensitive but
crucial area of healthcare.

Presentation at 2009 Quality Colloquium at Harvard

Adult Surgical Checklist's are modified for children. These modified Safety Checklists help to standardize the practices in the operating rooms to avoid mistakes.

Contributed to research: Children are particularly vulnerable to medication errors and adverse drug events because of pharmacokinetic issues, difficulties in calculating dosages by weight or mass, and narrow therapeutic-to-lethal ranges of many medications used in pediatric patients. Identification of
ADEs was more effective when a trigger tool was used than when incidents were voluntarily reported. I am credited for my contributions to this research in the article.

New IV pumps with patient safety protections are customized for pediatric and neonatal patients.

Contributed to research: After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days).

Packard’s Patient Safety Program has transformed the traditional model of punitive peer reviews into a pro-active method of systemic transparency that involves staff participation at all levels.

A number of studies have shown successful management of the supply chain is cost effective and generates real money savings for organizations. The purpose of this analysis is to show that there are other quality benefits that can be achieved by ensuring that staff has the supplies and equipment needed to perform their jobs. Along with the critical importance of having the right equipment or supply when needed for patient care, the system is utilized to manage recalls, infection control… Show more

A number of studies have shown successful management of the supply chain is cost effective and generates real money savings for organizations. The purpose of this analysis is to show that there are other quality benefits that can be achieved by ensuring that staff has the supplies and equipment needed to perform their jobs. Along with the critical importance of having the right equipment or supply when needed for patient care, the system is utilized to manage recalls, infection control concerns, preventative maintenance, and the status of repairs. We will consider some technological solutions that can be used in the healthcare setting to make this management easier and some implementation ideas for optimally organizing the management of the supply chain. The purpose of our presentation is to raise awareness of the importance of managing hospital supply chains and to provide some tools to assist hospital administrators with successful implementation. Show less

We developed a high fidelity, hands-on, simulation-based training program utilizing parent advisors to assist staff in communicating errors with empathy in order to maintain trust and create a truly healing experience.

The Child Health Corporation of America has awarded Lucile Packard Children's Hospital its 2005 Race for Results award recognizing hospitals that "demonstrate significant and sustained improvements in the delivery of efficient and effective clinical care."

The hospital won the award—its fourth in 12 months for patient safety— for a program that reduced adverse drug events in the hospital by 70 percent in a 24-month period. The field for this annual award included 40 other children's… Show more

The Child Health Corporation of America has awarded Lucile Packard Children's Hospital its 2005 Race for Results award recognizing hospitals that "demonstrate significant and sustained improvements in the delivery of efficient and effective clinical care."

The hospital won the award—its fourth in 12 months for patient safety— for a program that reduced adverse drug events in the hospital by 70 percent in a 24-month period. The field for this annual award included 40 other children's hospitals from around the country. Show less

Implementation of barcode patient identification to increase efficiency and decrease errors at Stanford University Medical Center.

Lucile Packard Children’s Hospital is gearing up to introduce new bar-coded ID wristbands for patients, a technology that shows promise for improving both patient safety and health-care efficiency.