The San Diego Patient Safety Council is a grass roots effort with active members who have been working together since 2005. Following the sun-setting of the San Diego Center for Patient Safety, a small group of dedicated physicians, pharmacists, and nurses decided to carry on the work of the Center and cooperate as representatives from competing hospitals to address patient safety issues. The taskforce has developed two tool kits – PCA Guidelines for Care and Safe Administration of High-Risk IV Medications.
Current efforts focus on “Improving the Safety and Effectiveness of ICU Sedation” and development of an annual patient safety awards luncheon.
Current Project: Improving the Safety and Effectiveness of ICU Sedation
Improving the safety and effectiveness of ICU sedation is key to reducing ICU length of stay, reducing complications, and decreasing the overall cost of patient care. With a national focus on preventing hospital-acquired infections, reducing the stay in the ICU reduces the potential that patients will develop infections. The ICU patient is at high risk for developing a ventilator-associated pneumonia, and deep ICU sedation can prolong the use of artificial ventilation. In addition, the risk of developing a catheter-related central line infection increases as the length of stay in the ICU increases. The deeper the level of ICU sedation, the more difficulty clinicians have weaning patients from ventilators and developing a central line infection. Central line infections are difficult to treat, and the lack of an intravenous access creates many other potential treatment complications. In addition, deep sedation is associated with cardiac toxicity and other complications. The taskforce believes this third community initiative is unique, much needed, and transferable to other communities and hospital systems.
The ICU Sedation program will provide guidelines for the County of San Diego, involve approximately fifteen hospitals, and will potentially cover 3,000,000 patients. Additionally, the proposed project will serve as a model for other communities, eventually impacting a significantly larger patient population.
Recent Publications
Tool Kit: Patient-Controlled Analgesia (PCA) Guidelines of Care (December 2008)
Managing post-operative pain has been a focus of the Joint Commission, has been associated with some of the highest incidence of adverse drug reactions, and is associated with a wide variation in prescribing, administration, and monitoring. This tool kit was the result of almost two years of meetings and additional work by the leaders of the task force.
Tool Kit: Safe Administration of High-Risk IV Medications (November 2006)
Standardization of intravenous (IV) infusion medication concentrations and dosage units with and across hospitals in San Diego County was identified as a significant opportunity to reduce morbidity and mortality due to preventable, high-risk IV-related adverse drug events. The 2006 Institute of Medicine (IOM) report, “Preventing Medication Errors,” urges hospitals to take action to reduce the potential for errors. This toolkit provides the results of the work by the IV Safety Taskforce, along with tools and information to assist other acute care organizations in implementing this standard approach.
Hospital Pharmacy - Reduction in Variation of Intravenous Drug Administration in Seventeen San Diego Hospitals with Standardized Drug Concentrations and Dosage Units
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