"Keeping each patient safe": quality safety teaching/learning packets

University of Pittsburgh Medical Center (UPMC) McKeesport developed a tool, the UPMC McKeesport Quality Safety Teaching/Learning Packet, to provide physicians, nurses, and therapists with a common language to address complex safety issues. Teaching/learning packets were developed to "keep each patient safe": by calling for help early; from falls and confusion; and from hospital-acquired infections (http://McKeesport.upmc.com/KeepingPatientsSafe.htm).

In July 2002, the concept of calling for help early became a requirement at UPMC McKeesport. The code team was to be called for any significant change in status and for traditional code arrests. In 2004, a teaching/learning packet addressed the concepts of fall risk and acute (delirium) and chronic (dementia) confusion. Strategies were implemented to reduce the rate of falls through risk screening and interventions for falls and delirium. In April 2004, a teaching/learning packet was introduced to reduce hospital-acquired infections, and professionals were positioned to better address isolation, hand hygiene, central-line-associated bacteremia, Clostridium difficile, and appropriate antibiotic usage.

Three quality safety teaching/learning packets, which provided the professionals in the organization with the common language (culture) to advance patient safety, accomplished rapid change and were well accepted by staff and physicians.