Did you know the Canadian Patient Safety Institute estimates the rate of pressure injuries across health care institutions in Canada to be 26 per cent?  A pressure injury is an injury to the skin and/or surrounding tissue and is the result of pressure from lying or sitting in one position for an extended period of time compounded by other factors, such as nutritional status and moisture.

nurse, holding a baby arm outstretched to hold another

A nurse in Mount Sinai’s neonatal intensive care unit during one of the hospital’s pressure injury audits.

Pressure injuries can cause considerable harm to patients in hospital, hindering recovery, frequently causing pain with the risk of development of serious infections. That’s why in November of 2018, Sinai Health System started capturing pressure injury reports in SAFER, our Safety And Feedback Event Reporting tool.

Since SAFER launched in July of 2018, the system has captured over 10,000 safety and patient feedback reports from the 17 buildings and three parking lots that make up our Mount Sinai and Bridgepoint campuses.

While both Mount Sinai and Bridgepoint perform quarterly pressure injury audits, the addition of the reports through the system, helps to capture what is happening across the hospitals between the audits. “We review the reports monthly,” noted William Mundle, Manager, Quality and Performance, Surgical Service & Urgent and Critical Care at Mount Sinai Hospital. “The reports help validate what we hear from our front line health professionals, highlight some overall themes around pressure injury prevalence and identify what we can do as a system to make an impact. For example, the types of equipment and supplies we use.”

Seeing themes and trends in safety reporting has already helped to make investments in our falls prevention efforts. “Understanding the factors that lead to falls with injury helped us to be creative in expanding our prevention tool kit,” said Agnes Tong, Manager of Quality & Patient Safety at Sinai Health. “We were able to make an investment in SmartCell flooring, a cushioning layer of subflooring, at Bridgepoint and Mount Sinai. The floors, along with our other fall prevention tools help to ensure patients who can most benefit from this safety feature are in these rooms.”

The power of these initiatives is evident from the reporting out of the Palliative Care unit at Bridgepoint, which hasn’t had a serious fall since January 2017

“Looking at trends and process to help Sinai Health make decisions that will have the greatest impact on delivering safe, high-quality care is exactly what the SAFER system is designed to do, said Cynthia Harris, Risk and Patient Safety Specialist. “Because SAFER is so broad in what it can capture, we are now capturing and sharing data related to building services, codes and even construction!”

So what’s to come in year two of SAFER? “We are continuing to look at ways we can evolve the system and make more customizations to the tool”, said Cynthia. “Mostly, I want to encourage people to keep using SAFER. Every report that is filled out helps us to actively improve the care experience for our patients.”

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