Abstracts

Rationale: Patient safety is an important focus for all health care environments. Patients in epilepsy monitoring units (EMU) can be potentially harmed by provoked seizures, medication changes, medical co-morbidities, and falls. Strategies for improving patient safety include surveillance; analysis of contributing technical, process or human factors; and corrective actions to prevent future harm. Patient safety rounds are one intervention that has been successfully employed to improve inpatient care, but safety rounds specific to the EMU setting have not previously been reported. Methods: In January of 2011 we initiated a program of active prospective surveillance for safety issues in patients admitted to the EMU at Mayo Clinic Arizona. Multidisciplinary safety rounds were incorporated into the regularly scheduled epilepsy surgery conference which included epilepsy neurology, neurosurgery, neuropsychology, EEG technology, radiology, and nursing. Events and recommended responsive actions based on multidisciplinary discussion were tracked. Findings from Jan 1, 2011 through May 31, 2012 are reviewed. Results: During the 17 month time frame there were 345 adults monitored for a total of 1475 days. 17 safety events were identified: 1 prolonged focal motor seizure requiring IV medication, 1 fall, 2 shoulder dislocations from convulsions in patients with history of same, 3 potentially serious cardiac arrhythmias, 1 ICU transfer for complication of intracranial monitoring, 2 potential medication errors, 4 technical issues with EEG monitoring, 1 missed pregnancy test in a non-pregnant patient undergoing nuclear imaging, 1 issue with nursing seizure assessment, 1 patient with a weapon (gun) in bed. 5/17 events resulted in harm to the patient, and 12/17 were near miss events. 10/17 (59%) events were considered preventable. 11/17 (65%) events resulted in changes in policies or procedures after discussion in safety rounds. Conclusions: With prospective surveillance potential safety issues were identified in 5% (17/345) of EMU admissions and lead to harm in 1.5% (5/245). Multidisciplinary safety rounds provided opportunity for inter-professional education and a safe, effective environment for dissemination of information on safety risks. It resulted in root cause analyses and formulation of responsive actions to reduce preventable harm. Safety rounds facilitated quality improvement through changes in policies and procedures to improve future outcomes in the majority of events reviewed.