Developing a Comprehensive Procedural Fire Safety and Prevention Program
It is most unfortunate when an adverse event occurs while a patient is receiving care. However, learning from that event and developing systems and programs to prevent or drastically minimize a similar event in the future, is a responsibility we have to our patients. Developing a comprehensive approach to eliminate the risk of fire for all procedural care patients was one such responsibility and an opportunity to improve patient safety.
Demonstrated effectiveness:
Using the literature and partnering with an external subject matter expert, risk management, quality, patient safety, and surgical leaders created the basis of the hospital program via a comprehensive, specific and detailed policy and procedure. Some of major changes required include:
· Completion of a fire risk assessment (FRA) on every patient having an invasive procedure
· Communication among the procedural team of the FRA score during the time out before the procedure – and discussion of strategies to keep the patient safe if the risk is high
· Specific fire prevention practices for high risk clinical procedures
· Environmental changes including the presence of a basin of sterile water (for extinguishment) and CO2 fire extinguishers in every procedure room, and acquisition of O2 blenders where needed
· Development of mandatory practitioner and staff education
Culture of patient safety is evident:
Learning from an event, and developing system changes shows a high level of leadership support for a culture of safety. The tactical practice that most embraces culture is that the FRA score is built into the procedure’s time out; it is included as an item on the procedural safety checklist to assure it is addressed each and every time an invasive procedure is performed. Inherent to the time out is the responsibility/authority of every team member to speak up if something does not appear right. Fire prevention also embraces the concept of teamwork to keep the patient safe.
Effectiveness in reducing the frequency of and harm to patients:
o New practice and accompanying education is evidence-based and is mandatory
o Routine observational auditing every month will monitor fire risk safety practices and provides feedback to staff on their performance
Lasting results in patient safety:
o All staff and practitioners whose practice or care includes performance of, or involvement in, invasive procedures, will have regular training (annual for staff, biannual for practitioners upon application for reappointment)
o Once a year every hospital will hold a scenario based team drill to practice response to a patient fire during a procedure
Evidence of spreading throughout the organization:
o The program has been implemented in all Allina Health hospitals – in all procedure areas (i.e. surgery, radiology, CV labs, OB)
o A clinic-specific procedure has been developed and implemented in all Allina Health clinics to implement clinic-appropriate fire safety prevention practices and education of key individuals