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Hospital adapts practices to meet pediatric needs

Accreditation Connection, January 20, 2005

Obtaining a perfect survey score is not an easy feat. But with extensive preparation and a staff continuously dedicated to ensuring patient safety, Lucile Packard Children's Hospital (LPCH) at Stanford (CA) University did just that during its five-day August survey.

Because its patients are infants, children, adolescents, and expectant mothers, the 265-bed LPCH often has to adapt the JCAHO's National Patient Safety Goals to meet its own needs.

For example, the facility had a problem using armbands with identification for infants because they cut babies' sensitive skin. To meet the need, the facility began using bands made of very soft material, says Sandy Trotter, CPHQ, patient safety program manager.

Trotter is working with other pediatric facilities to compile accurate data for patient falls, which are rare for most children's hospitals. "We're joining with other children's hospitals to get enough cases to make sure the data are valid," she says.

The three surveyors appreciated the hospital's unique approach to the time-out process required by the Universal Protocol. The hospital uses a boarding pass as a checklist to verify correct side, site, and patient before an invasive procedure, says Sue Flanagan, RN, chief operating officer of LPCH.

When the protocol first came out, the boarding passes were printed on cardstock with a picture of a train. Patients could hold onto the passes until reaching the OR when they would fill out the checklist.

"Patients liked it because it involved them," says Trotter. "We try to think of ways to make it fun. We didn't want to bring out another checklist-everyone's eyes sort of glaze over when you do that."

However, the hospital recently had to switch from using the creative boarding pass to a plain checklist-although it was still called a boarding pass-to make scanning the list easier, as it must be included in the medical record.

Once the team verifies the information on the checklist, they complete the boarding pass and are ready to operate, says Flanagan.

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