Perioperative Quality Improvement Committee Meeting

Meeting Agenda

Perioperative Quality Improvement Committee Meeting

Aim: To introduce the Perioperative Quality Improvement Committee and begin work on M&M system issues

Meeting Date: / Tuesday,January 20th 2009 / Leader: / Dr. Jeff Dattilo / Facilitator:
Scribe: / Susie Leming-Lee
Susie Leming-Lee
Time: / 6:30 a.m. -7:30 a.m. / Attendance: / Please see Attendance List
Project: / Perioperative Quality Improvement Committee
Location: / Bill Wilkerson ,8380 A-B, MCE / Guest/New Member/s: / Dr. Rajnish Gupta: Ad Hoc Member

Objective(s) of the meetingNote: Record additional attendance on opposite side

1. / To review Central Line Placement and Management: SonoSite Training for Residents and Faculty
2. / To review Coagulation Protocol Progress Report
3. / To review Tracheostomy Training Support
4. / To review Packing of Surgical Wounds Not Being Removed once patient leaves OR
5. / To review Pod Safety Officers
6. / To review December 2008 M&M Cases for Next Steps: a) Management of Trauma Patients with Orthopedic Injury; b) Risk of Exposure: Disinfection and Sterilization of Instruments-Patient Exposure to Unsterile Instruments
7. / To review Laterality Case
Pillar / Time
P.M. / Who / Topic / Summary or conclusions, decisions, assignments, and next steps
Quality & People /

I.INTRODUCTIONS

6:30 to 6:31 / Dr. Jeff Dattilo /

A.Purpose of Today’s Perioperative Quality Improvement Committee Meeting

6:31 to 6:33 / Group /

B.Introductions of Committee Members

6:33 to 6:34 / Dr. Jeff Dattilo /

C.Ground Rules and Housekeeping

II.OLD BUSINESS

B.Review of Previous M&M System Issues

6:34to 6:40 / 1.Central Line Placement & Management Follow-up
Dr. Lee Parmley / a)Check Status of SonoSite Training for the Residents
Dr. Jeff Dattilo / b)Explore Training for SonoSite for Faculty
6:40 to 6:45 / Dr. Rajnish Gupta / 2.Patient with Hematoma related to Epidural Placement: Coagulation Protocol Progress Report:
6:45 to 6:50 / Audrey Kuntz / 3.Update: Tracheostomy Report to Hospital Quality Council & Request for Support for Educational Process
6:50 to 6:55 / Audrey Kuntz / a)Create Web In-Service Educational Module regarding Tracheotomies and Assign to Appropriate Staff
6:55 to 7:05 /

4.Morbidity Issue: Packing of Surgical Wound Not Being Removed: Prevention

Stephanie Randa / a)Conduct Survey of Surgeons and Nursing Leaders Advising on the Effort to Prevent Retained
Undiscovered Packing of Patients: In Survey give participants 4 Options on How to Prevent Retained Undiscovered Packing of Patients

Provide Survey Results to Committee

Stephanie Randa /

b)Create Method to Address Verbal Nursing Handoff Process Regarding Packing of Patient’s Wound

Stephanie Randa & Audrey Kuntz /

c)Create a Learning Module after Surgical Wound Packing Issue is Resolved

III.NEW BUSINESS

A.Safety Issues Related to M&M Conferences

7:05 to 7:10 / Dr. Jeff Dattilo and Committee Members /

1.Pod Safety Officers

7:10to 7:15 / Dr. Jeff Dattilo and Committee Members /

2.Management of Trauma Patients with Orthopedic Injury:

a)Need for Physiological Checklist; Need for Parameters/Markers to recognize Patients who get “out of bounds”

b)Communication of Patient condition across care providers; how to assure all providers are aware of condition and have consensus about patient care approach
7:15 to 7:20 / Dr. Jeff Dattilo and Committee Members / 3.Risk of Exposure: Disinfection and Sterilization of Instrument Case: Patient Exposed to Unsterile Instruments:
a)Prevention of Event: Add announcement of “sterile integrators to Time Out”? Other actions??

b)Disclosure of Error to Patient and Family: What is most efficient and effective method?? Rapid Response Team??

7:20 to7:28 / Audrey Kuntz /

B.Mortality Selected Case Reviews

1.Laterality Case

IV.NEXT STEPS

7:28 to 7:30 / Dr. Jeff Dattilo /

Summary of Today’s Meeting Activities, Next Steps & Evaluation.

Next Meeting

Date: / Tuesday February 17th 2009 / Recorder: / Susie Leming-Lee
Start Time: / 6:30 a.m. / End Time: / 7:30 a.m.
Location: / 8380 A&B Conference Room

Signature Line: ______, Chairperson/Leader of Meeting/Improvement Initiative