The San Diego Patient Safety Council consists of county-wide representatives from acute facilities across multiple disciplines including nurses, pharmacists, physicians and other experts. Council members have been working together to improve patient safety since 2005. Over the past four years, the Council has developed three comprehensive tool kits to help hospital staff improve patient safety:

• Patient-Controlled Analgesia Guidelines of Care
• Safe Administration of High-Risk IV Medications
• ICU Sedation Guidelines of Care

Current Project

Sepsis: Reduction of Incidence and Morbidity

The Patient Safety Council’s current project is to increase early identification and treatment of severe systemic infections (Sepsis) in order to reduce Sepsis incidence and related deaths countywide by 25 percent and improve overall patient outcomes. Although Sepsis is treatable with appropriate and early intervention, it occurs in 1 percent to 2 percent of all hospitalizations in the United States, affecting at least 750 000 persons and costing $17 billion per year to treat. The Patient Safety Council’s goal is to increase compliance countywide with evidence-based best practices to reduce the incidence of Sepsis and subsequent associated morbidity.

San Diego Patient Safety Council Honored with ISMP Cheers Award

The prestigious Institute for Safe Medication Practices (ISMP) Cheers Awards honor individuals, organizations, companies, and agencies that have, through their actions during the previous year, set a superlative standard of excellence for others to follow in the prevention of medication errors and other adverse events. The San Diego Patient Safety Council received the 2009 ISMP Cheers Award for their two tool kits, Patient-Controlled Analgesia (PCA) Guidelines of Care and Safe Administration of High-Risk IV Medications. Visit the ISMP website to find out more about other Cheers award winners.

Recent Publications
Tool Kit: ICU Sedation Guidelines of Care (December 2009) + ICU Sedation Tool Order Set
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. The ICU patient is at high risk for developing a ventilator-associated pneumonia, and deep ICU sedation can prolong the use of artificial ventilation. The ICU Sedation Council Members included county-wide representatives from acute facilities across multiple disciplines including nurses, pharmacists, physicians, and respiratory therapists. For this tool kit, Council members reviewed literature, applied process improvement tools, and shared best practices to obtain consensus and develop an evidence-based standard for safe and effective management of pain, sedation, and delirium in the adult ICU ventilated patient. The tool kit consists of their recommendations and tools from the literature to assist acute care organizations in implementation of the guidelines. The tool kit is intended for Intensive Care Clinical Leaders involved in the care of ICU patients.

Tool Kit: Patient-Controlled Analgesia (PCA) Guidelines of Care (February 2009)
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 council. The tool kit is intended for the Acute Care Clinical Leader.

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 tool kit 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.