MONTREAL – Bed sores, a long-overlooked problem in hospitals across North America that can cause severe infections and in rare cases even death, are in rapid decline at the Jewish General Hospital.
Thanks to an innovative quality-control program, the Jewish General became the first hospital in the province last year to launch a “no shame, no blame” campaign of tracking medical errors.
And while the medical “incident and accident registry” has highlighted mistakes, it has also led the hospital to fix systemic problems like bed sores.
In March 2010, the Jewish General discovered that one in four patients admitted to the hospital developed painful pressure ulcers while lying in bed.
Some of those bed sores were so severe that they turned into open wounds that cut into the bone.
Two years later, after monitoring the problem on a monthly basis and making a series of improvements, the hospital has succeeded in reducing the prevalence of bed sores to six per cent, exceeding all expectations.
“If you don’t measure these things, you can’t improve,” said Wendy Bergeron, an enterostomal therapy nurse in charge of the program.
“The ‘no blame, no shame’ policy allows people to feel free to recognize when there’s an issue.”
Bergeron recalled that hospital staff were stunned to learn that 25 per cent of all patients develop new bed sores while at the Jewish General.
The fact that the national rate is 26 per cent was of small consolation to staff.
Bergeron and her colleagues carried out monthly audits of each hospital ward, checking to see what staff were doing right and what they were missing.
They implemented a new protocol of assessing each patient’s skin on admission to the hospital, turning the bodies of at-risk patients every two hours while they’re in bed, and making sure that nurses and orderlies confirm in writing that they have moved a patient at a designated time.
The hospital purchased 40 specialized beds, each costing several thousand dollars, for those who are highly susceptible to bed sores, including the elderly, the obese, the extremely thin and people with circulatory problems.
“We were very happy with the results,” said Cynthia Certosini, coordinator of one of the hospital’s “continuous quality improvement” committees.
“Essentially, we want to partner with patients and families. We have a speak-up campaign, where we are encouraging patients and families to speak up when they see something that is not right.”
Bergeron said that the program requires constant vigilance to prevent “backsliding” by some staff, but she added that “there’s a real sense of pride and ownership in what everyone is doing on each of the (wards).”
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