August 2005
Dear Colleague:
More on quality – coming soon.
Quality resources will be soon be added to our thousands of pages in Safety topics A to Z — stay tuned!
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Premier's Perspective data supports beta-blocker use in reducing mortality among high-risk surgical patients: New England Journal of Medicine study
- First patient safety and quality law encourages medical error reporting
- New techniques dramatically decrease ICU infections in multiple states; initiatives support IHI's '100,000 lives' campaign
- Written reminder prompts removal and reduction in urinary catheter days and related infections
- Harvard Patient Safety course for clinicians: Boston, October 20-21, 2005
- Special precautions protect high-risk patients during year-long construction project
- AHA Quest for Quality Prize honors leadership in quality, safety
- Influenza pandemic among concerns prompting APIC launch of advocacy center and worldwide monitoring for infectious diseases
- Ban lifted on use of alcohol-based surgical prep solutions if fire prevention precautions are followed
Safety tools
- Patient safety culture survey tool – Available in Spanish; English
- IHI white paper – Reducing hospital mortality rates
- JCAHO Perspectives special issue – Resources for 2006 National Patient Safety Goals
- CDC tool – Preparing for a terrorist bombing
- Patient Safety video series "First do no harm" – Special promotion
- Pocket guide – Influenza vaccination
Premier's Perspective data supports beta-blocker use in reducing mortality among high-risk surgical patients: New England Journal of Medicine study
A Springfield, MA-based research team at Baystate Medical Center published a study using data from Premier, Inc.'s Perspective™ database that supports earlier research on the efficacy of perioperative beta blocker therapy associated with a reduced risk of in-hospital death among high-risk patients undergoing major non-cardiac surgery. The study, published in the July 28, 2005, issue of the New England Journal of Medicine, examined data on more than 780,000 patients from 329 hospitals submitting information to Perspective™.
The results indicated that the perioperative administration of beta-blocker therapy was associated with clear and clinically significant reductions in mortality among 2 percent of surgical patients at highest risk (those with a Revised Cardiac Risk Index Score (RCRI) of 3 or greater) and appeared to be beneficial in the 10 percent of patients with a RCRI score of 2, but was no benefit – and possibly harmful – among patients in the lowest risk categories (RCRI score of 0 or 1).
"The size and diversity of Premier's Perspective database were invaluable in this observational study," noted Dr. Peter Lindenauer, lead author of the article, medical director of Clinical Quality and Informatics and a member of the Division of Healthcare Quality at Baystate Health System.
The Perspective database, the largest in the nation for hospital quality benchmarking, contains clinical and charge data from more than 400 U.S. hospitals. Hospitals use the database to improve care processes and outcomes by integrating the latest evidence-based clinical research, identifying specific drivers of clinical quality variance and evaluating physician practice variations.
"The Perspective database allows healthcare professionals and researchers such as the team led by Dr. Lindenauer to compare data from peer institutions regardless of their size or type – teaching or non-teaching, urban or rural, small or large," said Stephanie Alexander, senior vice president and general manager of Premier Healthcare Informatics. Perspective also powers Premier's Clinical Advisor product, providing hospitals with detailed patient-level analyses and comparative data to identify improvement in clinical quality and efficiency.
While complications such as heart attack and heart failure following surgery are uncommon, they often lead to serious additional complications and a high risk of death. And, while physicians are able to accurately identify who is at risk, few therapies have been proven to be effective at reducing these risks, making the findings of the NEJM study all the more important.
Additional authors of the NEJM article include Dr. Evan M. Benjamin, vice president, Division of Healthcare Quality at Baystate, and Penelope Pekow, PhD., also from the Division of Healthcare Quality; Kaijun Wang, M.S., School of Public Health and Health Sciences, University of Massachusetts Amherst; Benjamin Gutierrez, Ph.D., formerly of Premier Healthcare Informatics, Premier, Inc.; and Dheeresh K. Mamidi, M.B., B.S., M.P.H.
Lindenaurer et al. NEJM abstract (.doc) (26 KB)
Premier Healthcare Informatics, visit http://www.premierinc.com/informatics or call 800.805.4608.
First patient safety and quality law encourages medical error reporting
The long awaited Patient Safety and Quality Improvement Act (P.L.109-41) was signed into law on July 29, 2005, to encourage a culture of safety in healthcare organizations by providing legal protection of information on medical errors and adverse events voluntarily reported to patient safety organizations (PSOs). Lawmakers intend the information to be used to improve patient safety and reduce medical errors. The law could cost the healthcare industry $60 million over five years to implement.
Voluntary and confidential reporting
The new law creates a voluntary system for health providers to
confidentially report and share information about medical errors and other adverse events. The law also
preserves confidentiality of patient information under the Health Insurance Portability and Accountability
Act (HIPAA) of 1996. Data reported to new, independent "patient safety organizations" (PSOs) will be
shielded from disclosure in most malpractice suits, and cannot be used against healthcare providers by
employers, accrediting bodies or other regulators. Reported data can, however, be used in a criminal
proceeding if a judge first determines that it "contains evidence of a criminal act; is material to
said proceeding; and is not reasonably available from any other source," according to the new law.
Development and use of database
The Health and Human Services (HHS) Secretary is charged with developing the criteria for PSO eligibility,
as well as annually reviewing and certifying each organization. The law requires the HHS Secretary to develop
voluntary national standards for privacy-protected electronic data exchange and provide interactive evidence-based
management resources for health providers, PSOs and others. Aggregated reported data will be submitted by PSOs to
a national database for analysis. At the discretion of HHS, data may be released upon request to public and
private organizations charged with recommending strategies for improving patient safety and reducing medical
errors. PSOs also are directed to offer feedback to providers and foster a dialogue on best patient safety practices.
Measuring effectiveness of the national database
The law directs the Comptroller General to issue a report
on the effectiveness of this new patient safety evaluation system in approximately five years. The HHS Secretary
also is required to investigate the feasibility of providing a single point of access to the database for designated researchers.
Accountability and funding
Although the law does not address conflicts of interest among organizations
applying for PSO certification, it does require full disclosure of any financial, reporting or contractual
relationships among healthcare entities participating in the new system. Such conflicts could be grounds for
initial disqualification or revoked certification. The law authorizes funding for only the effectiveness
study and not regulation related to implementation.
Premier Safety News article (8/5/05)
Thomas Internet law Web site for the bill or law information:
http://thomas.loc.gov/cgi-bin/bdquery/
z?d109:SN00544:|TOM:/bss/d109query.html.
New techniques dramatically decrease ICU infections in multiple states; initiatives support IHI's '100,000 lives' campaign
New techniques, including culture change and the "bundling" of evidence-based practices, are being widely employed to reduce central line-related bloodstream infections and ventilator-associated pneumonia across the country. Dramatic success is being reported by a number of groups that are collaborating for improvement, including hospitals in the Pittsburgh Regional Healthcare Initiative, Michigan Keystone Project and the New Jersey Hospital Association ICU Collaborative.
Pittsburg Regional Health Initiative
New techniques implemented within the Pittsburgh Regional Healthcare Initiative area hospitals reportedly reduced bloodstream infections associated with the use of intravenous catheters
by 63 percent during the past four years, according to the Pittsburgh Post-Gazette. Participating hospitals began a strict
enforcement of safety guidelines in 2001, and the incidence of catheter-related bloodstream infections has dropped from 4.3
to 1.6 bloodstream infections per 1,000 catheter days since that time. New practices such as the strict implementation of a
set of practices known to reduce the risk of infections during catheter insertion – including the use of large sterile barriers,
gowns, gloves, masks, and head coverings; application of appropriate skin antiseptics; insertion of the catheter in the neck
versus the groin area; and completion of a checklist verifying that all infection control procedures – were used correctly
with empowerment of nurses to intervene when protocols not followed to assure compliance.
New Jersey Hospital Association ICU Collaborative
Several hospitals in New Jersey have participated in a collaborative
program and successfully reduced catheter-related bloodstream infections, ventilator-associated pneumonia, and length of
stay in ICU patients. Sponsored by the New Jersey Hospital Association (NJHA), participating hospitals analyzed evidence-based
practices to update ICU protocols and introduce patient safety improvements.
The NJHA Collaborative for Improving Quality
of Care in Hospital ICUs included workshops, surveys, and conference calls to facilitate communication
and determine best practices. Some participating hospitals have reported periods of up to six months without a case of
ventilator-associated pneumonia or catheter-related bloodstream infection.
The New Jersey collaborative was created with the assistance of Dr. Peter Pronovost, a leading safety expert and medical director for the John's Hopkins Center for Innovation in Quality. Pronovost and colleagues at Hopkins are known for their groundbreaking research in ICUs to improve safety culture among staff, reduce length of stay, and reduce mortality among ICU patients by implementing a comprehensive unit-based safety program that includes monitoring the culture of safety, implementing daily goal sheets and communication tools, teamwork training, interdisciplinary rounds, and a set or "bundle" of specific evidence-based practices to reduce catheter-related bloodstream infections, ventilator-associated pneumonia and sepsis. (See "Eliminating catheter-related bloodstream infections in the intensive care unit" Berenholtz et al.)
Michigan Health and Hospital Association – Keystone ICU Project
Pronovost also has been working with the Michigan Keystone
ICU project that includes 120 hospitals committed to improving the quality of care of their ICU patients and reducing infections
in the ICU. The focus of the project centers on establishing a patient safety culture in the ICU that includes a number of strategies,
including creating a set or "bundle" of standardized evidence-based procedures known to reduce rates of ventilator-associated
pneumonia and catheter-related blood stream infections. An article in the March/April 2005 issue of Healthcare Executive by
Pronovost and Christine Goeschel, executive director of
Michigan Keystone Center for Patient Safety,
reported that after six months into the project, 22 of the Michigan ICUs dropped their catheter-related bloodstream infections
to zero. The University of Michigan Hospital, a participant in the Keystone ICU project, recently reported a reduction in the
number of days an indwelling urinary catheter was in place by implementing a system that prompts removal of the catheter
(see following related story on "written reminders").
IHI's 1000,000 Lives Campaign
The Institute for Healthcare Improvement's "100,000 Lives" campaign includes prevention of
pneumonia and central line infections among its six interventions that have been proven to prevent avoidable deaths. These interventions:
- Deploy rapid response teams,
- Deliver reliable, evidence-based care for acute myocardial infarction,
- Prevent adverse drug events (ADEs),
- Prevent central line infections,
- Prevent surgical site infections, and
- Prevent ventilator-associated pneumonia.
IHI's Web site offers, tools, resource kits, "how-to" guides, discussion groups, and education programs to help hospitals make "major, rapid changes" using best practices for creating ventilator and central-line bundles, that is, groups of interventions that can be implemented together.
Pittsburgh Regional Healthcare Initiative: http://www.prhi.org/ourmodel.cfm
Information on the formation of the NJHA Collaborative for Improving Quality of Care in Hospital ICUs (.pdf) (149 KB)
Eliminating catheter-related bloodstream infections Berenholtz et al. (.doc) (25 KB)
Michigan Keystone ICU Project: http://www.mha.org/mha/keystone/icu/index.jsp
IHI Web site: http://www.ihi.org
Written reminder prompts removal and reduction in urinary catheter days and related infections
A simple reminder system shows promise as a new tool for preventing catheter-associated urinary tract or bloodstream infections. The system was found to reduce by 7 percent the amount of time an indwelling urinary catheter is in place, a step that could help stem infections among the 25 percent of hospital patients who have such catheters in place at any given time. Evidence shows that the number of catheter-associated infections increases in proportion to the length of time catheters remain in place. A study published in the August issue of the Joint Commission Journal on Quality and Patient Safety demonstrated that a simple reminder system to prompt doctors to remove the devices after two days was effective in reducing the number of days with indwelling urinary catheters.
A controlled trial was conducted for 16 months in four wards of the University of Michigan's University Hospital (UMHS). Two of the wards used the reminder system and two did not, but a nurse checked the urethral catheter status of patients daily. A pre-written order and a "sign-here" sticker was attached to each patient's chart every day after the catheter had been in place for 48 hours. Physicians who did not respond to the reminder by either placing an order to continue the catheter or remove it were then paged. About two-thirds of the doctors on the reminder wards routinely filled out the daily order after the paging reminders began.
After adjustments were made for patient age, sex, and length of stay, the average proportion of time patients were catheterized increased by 15.1 percent in the control group but decreased by 7.6 percent in the intervention group. No difference was found in urethral recatheterization between the two groups. "Doctors are responsible for ordering the removal of catheters, but research has shown that many of them forget which patients have catheters and how long they have them," said lead author Sanjay Saint, M.D., MPH, a hospitalist at the VA Ann Arbor Healthcare System and an associate professor of internal medicine at the University of Michigan Medical School.
The researchers estimated the new system would result in $53,449 in cost savings, based on conservative estimates of the number of catheterized days, the proportion of doctors who would comply, the risk of urinary tract infection and the cost of treating symptomatic infection. Cost savings would be considerable as the number of doctors who comply increased. Maureen Thompson, R.N., MSN, who checked the patient records during the study period, said catheter reminders are now a routine part of patient care in UMHS intensive care units. "Through our involvement with the Keystone statewide initiative to improve patient safety within ICUs, we have made the daily consideration of invasive line discontinuation a key element of our daily patient safety review," Thompson said.
Abstract Reminder Reduces Urinary Catheterization
(.doc) (24 KB)
Joint Commission resources: http://www.jcrinc.com/publications.asp?durki=4
Harvard Patient Safety course for clinicians: Boston, October 20-21, 2005
A comprehensive course on improving patient safety will be held October 20-21, 2005, at the Sheraton Boston Hotel. The goal of the course is to provide clinicians and other healthcare leaders with information about emerging trends and best practices applicable in their own organizations. Topics will include an introduction to the problem of medical error and its emergence as a public health problem, as well as the nature of error in healthcare, drawing heavily from human factors engineering and systems theory.
Supported by the Premier Safety Institute, the course is sponsored by Dana-Farber Cancer Institute Center for Patient Safety, Brigham and Women's Hospital Department of Medicine and Center of Excellence for Patient Safety Research and Practice, and Beth Israel Deaconess Medical Center Department of Medicine.
The curriculum is designed for practicing physicians, as well as those with an interest in improving patient safety. Participants may include medical educators, medical practice directors, nurses, pharmacists, risk managers, QI professionals, administrators, researchers and specialists in high-risk areas such as oncologists, critical care clinicians, emergency physicians, and hospitalists.
Saul N. Weingart, M.D., Ph.D., David W. Bates, M.D., M.Sc., and Hans Kim, M.D., MPH are the course directors with an experienced faculty, including: Sylvia Bartel, RPh; Troyen A. Brennan, M.D., JD, MPH; Booker Bush, M.D.; Maureen Connor, R.N., MPH; Frank Federico, RPh; Allan Frankel, M.D.; Thomas Gallagher, M.D., FACP; Tejal K. Gandhi, M.D., MPH; Jerry Gurwitz, M.D.; Christopher P. Landrigan, M.D., MPH; Lucian L. Leape, M.D.; Ann Louise Puopolo, R.N.; Daniel B. Raemer, PhD; Patricia Reid Ponte, R.N., DNSC; Jeffrey Rothschild, M.D., MPH; Benjamin P. Sachs, M.D.; Kenneth Sands, M.D., MPH; Lawrence N. Shulman, M.D.; Steven R. Simon, M.D., MPH; and C. Christopher Smith, M.D.
Fee for the two-day course is $650 ($350 for residents and fellows).
Additional course information, including a complete faculty listing, agenda, CEUs, and online registration, are available at the conference web site at: http://www.cme.hms.harvard.edu/safety
Download the course brochure and registration form
(.pdf) (112 KB)
Special precautions protect high-risk patients during year-long construction project
During a recent year-long construction/expansion of its bone-marrow transplant unit, Phoenix-based Banner Good Samaritan Medical Center implemented special precautions that reduced the risk of infectious complications in the most vulnerable patients. Banner's bone marrow unit could not be moved because of its special ventilation system. Hospitals and healthcare facilities undergoing any type of construction project today are required to carry out an infection control risk assessment (ICRA) and determine how to best protect patients and staff. The Arizona Republic recently described banner Good Samaritan's plans in a special report.
Kerry Montefour, director of infection control, told the newspaper that patients in the bone marrow transplant unit "are the most immune-compromised patients with a very, very high rate of risk." Based on an assessment of potential patient risks, Banner administrators and construction teams, including Mark Patterson, president of the central Arizona chapter of the American Institute of Architects, worked together to develop a construction plan that successfully prevented any patients from being harmed by the six-bed addition. A variety of methods were used to reduce the movement of potentially contaminated air and debris from the construction area into the patient care areas, including the use of temporary walls, special high-efficiency ventilation equipment, covered trash bins, plastic tents with Velcro-tabbed doors, and filtered vacuums to remove dust from clothing of construction workers before exiting the construction area. Montefour said no construction-related infections among patients were documented during the construction program.
Tools and resources for infection control risk assessment and construction planning
The Premier Safety Institute's
Construction-ICRA Web site provides guidance and tools to help hospitals develop plans for construction
projects to reduce infection risks to patients. The site includes agency guidance from the American Institute of Architects
(AIA), the Centers for Disease Control and Prevention (CDC) and the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO). The CDC Guidelines for Environmental Infection Control include recommendations consistent with the current AIA guidelines,
as well as JCAHO standards for the Environment of Care (EOC). The Construction-ICRA module includes the updated version of the 2005
ICRA matrix, and excerpts from pertinent EOC standards. The APIC "State-Of-the-Art-Report on Construction and Renovation" (SOAR),
as well as sample tools, and resources for protecting the environment from airborne, chemical, biologic and radiologic hazards,
also are included.
Arizona Republic article (.doc) (26 KB)
Premier construction module - ICRA: http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/
AHA Quest for Quality Prize honors leadership in quality, safety
Applications are now available for the 2006 American Hospital Association McKesson Quest for Quality Prize®: Honoring Leadership and Innovation in Patient Care Quality, Safety, and Commitment. The award is supported by grants from McKesson and the McKesson Foundation. Applications are due October 14, 2005 and awards will be presented in July 2006 at the AHA/Health Forum Leadership Summit in San Francisco.
The winner will receive $75,000 and two finalists will each receive $12,500. Other hospitals may be recognized with Citations of Merit.
The goals of the AHA McKesson Quest for Quality Prize® are to raise awareness of the need for an organization-wide commitment to highly reliable, exceptional quality, patient-centered care; reward successful efforts to develop and promote a systems-based approach toward improvements in quality of care; inspire organizations to systematically integrate and align their quality improvement efforts throughout their organization; and communicate successful programs and strategies to the hospital field.
In 2006, the AHA McKesson Quest for Quality Prize® will honor organizations that:
- Have committed in a systematic manner to achieving the Institute of Medicine's (IOM) six quality aims – safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity;
- Can document progress in achievement of all six of the IOM aims; and
- Provide replicable models and systems for the hospital field.
All U.S. hospitals are eligible for the AHA McKesson Quest for Quality Prize®.
Applications and information on the prize are available at http://www.aha.org/questforquality, by calling 312.422.2700, or by writing the Office of the Secretary, American Hospital Association, One North Franklin, Chicago, IL 60606.
Influenza pandemic among concerns prompting APIC launch of advocacy center and worldwide monitoring for infectious diseases
Concerns about an influenza pandemic that could affect as many as 47 million people in the United States has prompted a number of public and private initiatives, including an advocacy center sponsored by Association for Professionals in Infection Control and Epidemiology (APIC) to enable members and the public to express their concerns to policy makers and a daily monitor of developments in infectious diseases worldwide in collaboration with University of Minnesota's Center for Infectious Disease Research and Policy.
Contact your legislature via APIC VIP Action Center
APIC has designed a system for government advocacy called the
VIP Action
Center. The VIP Action Center enables direct correspondence with local and federal policy makers to more
actively engage health professionals and the public in the legislative process. APIC's mission is to improve health and promote
patient and worker safety by reducing risks of infection and related adverse outcomes. By accessing APIC's web site and entering
a zip code, elected officials at the state and federal levels can be contacted and informed of critical infection prevention
and control issues. The APIC VIP Action Center has other tools to enhance outreach efforts, including media action alerts,
newsletters, and calls to action.
Support bill to prepare U.S. for influenza pandemic
APIC's VIP Action Center enables the public to provide support for
Sen. Barack Obama's (D-IL) AVIAN Act . The AVIAN (Attacking Viral Influenza Across Nations) Act of 2005
addresses the possibility of a deadly pandemic flu, and recommends measures to better manage the harm caused by such an
outbreak. Although an apparently effective Avian influenza vaccine was recently reported, limitations of
vaccine production are a reminder of the urgency for adequate antivirals supplies.
HHS preparedness plan
History has demonstrated that influenza pandemics have led to high levels of
illness, death, social disruption, and economic loss. It has been estimated that a "medium-level" pandemic in the United
States could cause 89,000-207,000 deaths, between 314,000 and 734,000 hospitalizations, 18-42 million outpatient visits,
and another 20-47 million people becoming ill. Between 15 percent and 35 percent of the U.S. population could be affected
by an influenza pandemic. Because of these differences and the expected size of an influenza pandemic, it is important
to have completed planning and preparedness activities for a prompt and adequate response. For that reason the U.S.
Department of Health and Human Services (HHS) supports pandemic influenza activities in the areas of surveillance
("detection"), vaccine development and production, antiviral stockpiling, research, and public health preparedness.
HHS also is nearing completion of a National Pandemic Influenza Preparedness Plan. Coordination and funding to optimize
these efforts are critical and Obama's AVIAN Act represents one additional measure to optimize national action. Go to
VIP Action Alert to register your response to support this and related bills.
Worldwide monitoring of infectious diseases
APIC, together with the Center for Infectious Disease Research and Policy
at the University of Minnesota (CIDRAP), are providing an innovative new service that combines extensive clinical information
with the monitoring of developments in infectious diseases worldwide. With the speed of recent developments in avian
influenza and the prospect of a global pandemic, time is critical. This service provides daily alerts on developments
in infectious disease worldwide from leading experts. To access the
Infectious Disease Center,
visit APIC's web site, and click on the scrolling items in the upper right-hand corner. Viewers also may link to the
CIDRAP site.
APIC VIP Action Center: http://www.apic.org
Sen. Obama's AVIAN legislation S 969 (H.R.3369)
(.pdf) (79 KB)
New York Times article about the Avian influenza vaccine
Go to: http://www.nytimes.com
Search "Avian Flu Vaccine," August 7, 2005.
CDC: http://www.cdc.gov/flu/avian/gen-info/pandemics.htm
APIC VIP Action Alert:
http://capwiz.com/apic/issues/
alert/?alertid=7896796&type=CO
APIC CIDRAP web site: http://www.apic.org
More influenza resources on
Premier's Safety Institute web site.
University of Minnesota CIDRAP Web site:
http://www.cidrap.umn.edu/
Ban lifted on use of alcohol-based surgical prep solutions if fire prevention precautions are followed
The National Fire Protection Agency (NFPA) has lifted a 6-month-long ban on the use of alcohol-based surgical prep solutions during laser and electrocautery procedures providing specific fire prevention precautions are followed. An amendment that provides healthcare facilities with new guidance to manage the risk of fire when alcohol based surgical prep solutions are used in the presence of an ignition source (laser, electrocautery, etc.) was passed by the NFPA, effective August 18. The American Society for Healthcare Engineering's (ASHE's) tentative interim amendment (TIA) to amend the NFPA 99 Standard for Health Care Facilities (2005 edition) was accepted by the NFPA at its July 2005 Standards Council meeting. The original language of the existing NFPA 99 prohibited the use of alcohol skin prep when use of ignition source was contemplated. The TIA sought to balance fire risks with the increased risk of surgical site infection resulting from a ban on flammable products in operating rooms, since appropriate skin antisepsis before surgery is a critical measure for preventing surgical site infections. Required precautions include using skin prep solutions according to manufacturer instructions, use of a "time-out" by the surgical team to ensure the surgical site is dry before turning on an ignition source such as electrocautery, preventing pooling of solution under surgical drapes, and removing solution-soaked materials. For more background on this issue, see the May 2005 issue of Safety Share and the CDC guidelines on preventing surgical site infections.
ASHE was assisted by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations in drafting the TIA. Many professional organizations contributed their support and evidence-based findings, including the Association for Professionals in Infection Control and Epidemiology (APIC), the Association of periOperative Registered Nurses (AORN), and the Society for Healthcare Epidemiology of America (SHEA). The amended language will be published in the August edition of NFPA News. CMS is expected to issue guidance on this issue soon.
NFPA amendment (.pdf) (26 KB)
Premier Safety Share, May, 2005, "OR surgical preps ban raises concerns and recent compromise."
ASHE web site: http://www.ashe.org
CDC Guidelines on surgical site infections
Safety tools
Patient safety culture survey tool – Available in Spanish; English
Premier's Safety Institute has developed a Spanish version of the Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey on Patient Safety Culture survey tool, as well as a customized Microsoft® Excel data tool for easy entry and rapid display of survey results. These tools, which complement other resources from AHRQ for implementing the survey, as well as analysis and benchmarking of results, include:
- Complete toolkit – the survey, detailed user's guide for administration of paper or web-based methods, data collection and analysis, customizable templates for reporting results, references, and results of the pilot study.
- Survey form – now in either English or Spanish, in Adobe® PDF or Microsoft® Word versions.
- Benchmarking data – preliminary benchmarks permitting comparisons against the results from 20 hospitals that participated in a 2003 pilot.
- Hospital culture survey feedback template test.
- Premier's customized Excel data tool.
- Audio conferences – three Microsoft® PowerPoint® presentations, (interpretation of results; case studies; communication).
To access these resources go to: http://www.premierinc.com/quality-safety/tools-services/safety//culture/
IHI white paper – Reducing hospital mortality rates
A new Institute for Healthcare Improvement (IHI) Innovation Series white paper expands on a previous paper, "Move Your Dot: Measuring, Evaluating, and Reducing Hospital Mortality Rates," that introduced a novel perspective and methodology for understanding and reducing inpatient deaths. "Reducing Hospital Mortality Rates (Part 2)" summarizes preliminary results from a three-year pilot project in which eight hospitals, working with IHI, are testing the theory that hospital mortality can be consistently reduced through a combination of evidence-based interventions. White papers from IHI on other topics include:
- Going Lean in Health Care;
- Transforming Care at the Bedside;
- The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement;
- Improving the Reliability of Health Care;
- Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings; and
- Seven Leadership Leverage Points for Organization-Level Improvement in Health Care.
(http://www.ihi.org/IHI/Products/WhitePapers/
ReducingHospitalMortalityRatesPart2.htm)
White papers are free and available online at:
http://www.ihi.org/IHI/Products/WhitePapers/.
JCAHO Perspectives special issue – Resources for 2006 National Patient Safety Goals
The Joint Commission's August issue of Perspectives on Patient Safety offers suggestions on meeting the 2006 National Patient Safety Goals (.pdf) (345 KB). The special issue, provided free for a limited time, describes each goal and accompanying requirements and offers compliance tips. For example, JCAHO describes measures implemented by some organizations to increase compliance with hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC), which is required under the goal for reducing the risk of healthcare-associated infections. Tips for non-hospital settings, such as home care or long-term care, are also included where compliance needs could differ from acute care settings.
CDC tool – Preparing for a terrorist bombing
Although terrorists use a variety of methods to inflict harm and create fear, bombs are used most frequently. According to the FBI, bombings accounted for nearly 70 percent of all terrorist attacks in the United States and its territories between 1980 and 2001. This practical summary focuses on common sense principles that will be useful in a bombing event. It describes how every person, family or organization should prepare for an emergency or disaster, including knowledge of work, school and community disaster plans. If you are not familiar with the plans, contact your supervisor, school administrators, or your local fire department for more information. The document (.pdf) (137 KB) details what should be done if a bomber is suspected.
Patient safety video series: 'First do no harm' – Special promoti
The "First, Do No Harm®" interactive video series helps people get engaged and focused on being patient-centered and systems-based. "First, Do No Harm Part 1: A Case Study of Systems Failure," was released in 2000 and is closely based on actual events drawn from closed malpractice claims files of the Risk Management Foundation of the Harvard Medical Institutions. In "First, Do No Harm Part 2, Taking the Lead" (released in 2002), the story continues as the hospital's clinical, executive and administrative leaders – as well as members of the board of directors – deal with the tragic adverse event and decide what to do next. "First, Do No Harm Part 3: Healing Cultures, Saving Lives" premiered in late 2004 and examines the hospital's efforts to care for traumatized family members and staff, decide whether to apologize, manage media attention, and move forward in building stronger interdisciplinary teams and a culture perceived by all to be just and patient-centered.
Each part of the First, Do No Harm® series is a complete training package in both DVD and VHS formats that include a 20 minute case study, facilitator's guide, graduation certificates, and interviews with leading experts on the issues raised by the film. The combination of reality-based drama and expert commentary lasts from 50 minutes to a complete multi-day seminar. A preview of each First Do No Harm® film is available at www.p4ps.org. A bulk discount of approximately 18 percent is available until September 30, 2005. Download the form (.doc) (58 KB) to access this special Premier, Inc. offer.
Pocket guide – Influenza vaccination
The National Influenza Vaccine Summit is planning to produce an "Influenza Vaccination Pocket Information Guide." The purpose of the guide is to provide frontline healthcare personnel with information about indications and contraindications for the two types of influenza vaccines, as well as groups to be vaccinated and how to administer the vaccines. The draft of the guide for the 2005-06 influenza vaccination season contains product-specific information for three injectable influenza vaccines. This information has been included even though their licensure and availability may not be known before the start of the influenza vaccination season. Last year's guide is available online at http://www.immunize.org/influenza/pocketguide.htm, and this site should be checked periodically for the 2005-2006 version.
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, BA, Web master
About Premier
Premier, Inc. is a healthcare alliance entirely owned by 200 of the nations leading not-for-profit hospital and healthcare systems. These systems operate or are affiliated with 1,500 hospital facilities and hundreds of other healthcare sites. Premier provides an array of resources supporting health services delivery, including clinical and operational comparative data applications for quality/safety performance improvement, group purchasing and supply chain services, and insurance programs. The Centers for Medicare and Medicaid Services (CMS) has recently partnered with Premier for a three-year quality incentive demonstration project. Participating hospitals using Premier’s Perspective Online ™ database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.
