February 16, 2010

Texas jury finds nurse not guilty for reporting a physician for unsafe practices

It took the jury less than an hour on February 11, 2010, to return a not guilty verdict for the nurse, Anne Mitchell, of felony charges of "misuse of official information," for reporting a physician to the Texas Medical Board for what she believed was unsafe patient care.

Since news of the criminal indictment – and Mitchell's being fired from her job – first spread through the nursing community, nurses across the country have followed developments. Labeling the criminal indictments "outrageous," an outpouring of support – and financial contributions to the Texas Nurses Association Legal Defense Fund – has continued.

According to a New York Times article on February 9, the prosecutors claimed that Mitchell intended to damage the physician's reputation when she reported him to the Texas Medical Board, which licenses and disciplines doctors. Mitchell explained that she felt an obligation to protect patients from what she saw as a pattern of improper prescribing and surgical procedures - including a failed skin graft that was performed in the emergency room, without surgical privileges.

Conflicts of interest seemed to be part of this case with allegations that this case was, in part, a result of the local sheriff being good friends with, and a former patient of the physician, and bending the rules to protect his reputation.

A number of nurses who had previous worked at the same Winkle County Rural Health Clinic testified in court that they left the clinic because of their concern about the care provided by the same physician that had never been addressed. The case is no less perplexing as to why Mitchell was even indicted - all witnesses (even the state's) have agreed nurses have a duty to report unsafe care.

The verdict is a resounding win on behalf of patient safety in the U.S., as well as nurses and other healthcare professionals who play a critical, duty-bound role in acting as patient safety watch guards in our nation's health care system. The greatest concern with this case has been the disbelief that a case such as this was even allowed to reach the trial stage and what a different outcome could have potentially meant for patient safety in this country. Even with an acquittal, the felony charges and trial had a chilling effect on many nurses who may think twice before reporting unsafe practices.

A civil lawsuit has been filed in federal court charging the county, hospital, sheriff, doctor and prosecutor with vindictive prosecution and denial of the nurses' First Amendment rights. A complete summary of the case is available on the Texas Nurses Association Web site.

Downloads and links

• NYT 02-09-2010 Nurse to stand trial
• Civil lawsuit
• Texas Nurses Association Web site. at www.texasnurses.org

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Three minutes from engine failure to flawless landing in the Hudson River: Lessons learned

Persistent attempts with endotracheal intubation despite continued difficulty is a common error for intensivists. Luckily for the passengers of U.S. Airways Flight 1549, a pilot trained in crew resource management (CRM) did not persist in his original plan to return to LaGuardia, but quickly reviewed available options before a flawless landing in the Hudson River.

Drs. Eisen and Savel, intensivists at Montefiore Medical Center, describe some of the lessons to be learned from CRM that guided a safe landing for all 155 passengers of Flight 1549, and how those lessons can be applied in emergency response. These include the use of checklists and the need for repeated training on simulators for both common and rare intensive care unit (ICU) emergencies, with assessment of skills.

A few examples of critical components for dealing with an emergency based on CRM deserve special mention. Having an effective team leader is essential to manage information, equipment and people, and to assign roles for all present staff. A recent review of emergency department cases found that 43 percent of errors were due to problems with team coordination. For example, while critical team coordination is part of many ICUs, the team coordinator may be off the unit during a disaster.

Communication Poor communication, shown to cause at least 15 percent of hospitals' ICU errors, is a key area for focused improvement in CRM training. All team members should monitor team performance and feel empowered to speak out when patient safety threats are observed. Interruption is another source of communication error. Many ICUs report experiencing high rates of interrupted communication, leading to cognitive overload and conflicting demands on attention and memory. Through CRM, pilots are taught methods for dealing with interruptions. Group debriefing, another CRM technique, should occur after all medical emergencies to evaluate performance and learn from the errors.

Simulation training is a very important part of CRM. The pilot of Flight 1549 had never experienced an engine failure in an actual flight, but had extensive experience with emergency scenarios on a flight simulator. Standard medical training is limited because of the random nature of medical encounters and assumptions that the senior colleagues that they are observing are good role models. Patients may also be put at risk because learning and patient care occur simultaneously. Further, medical personnel learn on the job about how to handle a novel emergency. For example, a team may respond to a cardiac arrest and use a defibrillator model they have never seen. The authors suggest that hospital ICU practitioners are among the most likely to benefit from simulation training given the grave consequences of medical errors in patients with critical illness. Simulation training appears to be a necessary complement to medical education and clinical experience, providing the chance to practice high-risk-low frequency events without endangering patients. It can also assess technical skills and competence in teamwork.

Checklists, used to enhance safety in the aviation industry for years, are being used in healthcare to improve the quality of care in intensive care units by reducing catheter-associated bloodstream infections and in surgery by reducing mortality and post-surgical complications.

Safety culture In a survey of ICU physicians, the majority reported that emergencies did not affect clinical performance, leading authors to emphasize the need for hospital ICU staff to embrace a culture of safety. The reason? A checklist is useless if it is not used and simulation training is ineffective if trainees do not buy in.

Downloads and links

• Crew management abstract
• AHRQ checklist site http://psnet.ahrq.gov/primer.aspx?primerID=14
• Premier Safety Institute's Safety Culture Web site

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Bacteria are not resistant to disinfectants, despite claims

A recent report from a U.K.-based laboratory reported on a common hospital pathogen, Pseudomonas, being resistant to a disinfectant, benzalkonium chloride (BKC). U.S. experts say not to worry; this disinfectant is not approved for use in the states because of its long history of ineffectiveness, and there is still no solid evidence that bacteria become resistant to in-use disinfectants.

Researchers of the laboratory study claimed they developed a strain of Pseudomonas that developed resistance to an environmental disinfectant, BKC. The study may have theoretical usefulness but as frequently happens, has little applicability to cleaning/disinfection in today's homes or hospitals. Some key points are noteworthy when reviewing studies such as this.

Recognized for decades as ineffective. BKC is rarely, if ever, used in U.S. healthcare facilities today. The reason? BKC, originally introduced in 1935, was found to be ineffective against Pseudomonas as far back as 1958. Furthermore, other researchers found Pseudomonas can grow very well in presence of BKC. As a result, it is no longer on the EPA's list of approved disinfectants for hospital selection and use. Even the theoretical risk that this disinfectant will create resistant bacteria does not apply to U.S. hospitals.

Not recommended by CDC as an antiseptic. Over 10 years ago, when BKC was used as a skin antiseptic agent, BKC was linked to a series of infections in which the BKC antiseptic solution used on the patients was found to grow organisms matching those causing the patient infections. As a result, CDC recommended that it also not be used as an antiseptic. Providers should use only those antiseptics approved by the FDA as safe and effective for patient care procedures.

No evidence that disinfectant use creates antibiotic resistance. This topic was also raised following other laboratory studies suggesting resistance could develop in environmental disinfectants. A leading CDC scientist, Dr. Arjun Srinivasan, MD, stated "CDC has not seen evidence that the use of disinfectants in healthcare has led to the development of antibiotic resistance. However, CDC has always encouraged healthcare facilities to use disinfectants properly, that is, only when indicated and always in accordance with the manufacturer's recommendations."

Lab investigations may not reflect bacterial response in natural settings. This study was conducted in a laboratory where resistance can be induced under certain conditions unlikely to be reproduced in real-world settings. Typically, studies of this type are first verified by another laboratory for reproducibility. Additional studies in natural settings must follow to see if the laboratory experience creates unrealistic conditions for survival of these unusual strains. Of note, even in this study, when the resistant strain was grown in the same culture as the naturally occurring strain, it was not able to survive. This suggests that this laboratory strain may not be able to survive in natural settings.

Downloads and links

• Microbiology 2010 Jan abstract
• Clin Infect Dis 2003 abstract
• Safety Share. 2008 (October)

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Needlestick reporting less likely if no witness

A survey of 699 recent medical school graduates from 17 medical schools found that at least one needlestick injury was sustained by 59 percent during medical school and 83 percent during residency. Although nearly half were never reported, reporting was more likely if someone witnessed the incident.

Residents who sustained a needlestick injury during medical school were also 2.6 times more likely than those who never did to have a needlestick injury during residency and 2.5 times more likely to incur an injury involving a high-risk patient. High-risk patients include those with a history of intravenous drug use or infection with HIV, HBV or HCV.

Reporting Nearly half of the needlesticks (47 percent) were never reported to employee health service. Although needlestick injuries involving patients not considered to be at high risk were less likely to be reported, in multivariate analysis, the only factor positively associated with reporting the injury was whether someone witnessed the incident.

The risk of underreporting, and thus delaying or forgoing treatment, is significant. If there has been an exposure to HIV, HBV or HCV, there are implications for personal relationships, future employment, and insurance coverage. (See Tools- Guidelines for bloodborne pathogens) Reporting also allows medical evaluation and prompt post-exposure prophylaxis for HIV and HBV and early treatment if HCV infection develops to reduce risk for chronicity.

Analysis The most recent injury reported revealed that more than half of the injuries were self-inflicted and occurred in the operating room during suturing. The most commonly perceived cause of the injury was rushing (57 percent) and lack of skill (17 percent). It "takes too much time" was the most frequent reason given for not reporting injuries (31 percent).

Education The authors recommend that education on needlestick safety and reporting begin in medical school. A system of testing and certification of basic techniques such as phlebotomy, suturing, and passing needles should replace the typical approach of "see one, do one, teach one" to ensure training and basic competency, which may reduce injuries from "sharps" and increase skill and confidence. Education regarding preventive strategies for reducing the incidence of needlestick injuries, including the use of blunt-tip needles, the practice of double-gloving when handling sharp instruments and "sharpless" surgery protocols, should be required for medical students and surgical residents. Reports estimate up to 28 percent of a general surgeon's practice can be completed without the use of any sharps.

Downloads and links

• Sharma abstract
• Safety Share: "Surgical residents sustain needlestick injuries"
• Needlestick prevention brochure from the Safety Institute on devices, work practices and medical follow-up for staff training across the continuum of care.
• See Premier Safety Institute's Web site on Sharps injury prevention.

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Technological solutions may enhance effectiveness of patient handoffs

A well-recognized risk to patient safety are communication errors that occur during handoffs at the transitions of care and hospitals continue to address the challenges with successful implementation of a standardized approach for handoff communications. 

"Handoff communication" now a Joint Commission standard, effective January 2010 The Joint Commission (TJC) continues to emphasize the need for "having a standardized approach to handoff communications," which moved from a National Patient Safety Goal to being scored as a standard, effective January 1, 2010. 

Technology solutions are suggested for improving hand-off effectiveness There is a growing emphasis on technology solutions to improve the quality and safety of patient care. In 2007, TJC, in collaboration with the World Health Organization, also published a Patient Safety Solution - Communication During Patient Hand-Overs to provide guidance and suggested actions, as well as to recommend the use of technologies and methods that would improve hand-over effectiveness and streamline information access and exchange.

The Society of Hospital Medicine recently published recommendations as a starting point to improve in-hospital handoffs based on a review of controlled studies and expert opinion. Their recommendations support the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. They also point out that technology solutions are associated with a reduction in preventable adverse events and improved satisfaction with handoff quality.

Despite years of work to standardize the approach, patient handoffs at transitions in care in hospitals vary widely without consensus on the primary purpose or most important interventions for improving handoff processes. Moreover, there are few standardized electronic tools to implement or evaluate the effectiveness of the handoff method.

Department of Veterans Affairs designs successful electronic handoff tool The Department of Veterans Affairs Medical Centers (VAMCs) recently designed and evaluated an electronic medical record (EMR) handoff tool to provide a standardized approach to handoff communications between physicians at change of shift and improve on their previous paper-based process.

Testing As described in their published study by Anderson and colleagues, seven geographically diverse VAMCs participated in software development and testing. For security, the handoff software is password protected and automatically draws information from the existing EMR (e.g., demographics, medication lists, and primary clinical team based on rotating service schedules), with mandatory and free text fields of key information. An example of a special design feature based on staff input was Code Status. As a safety reminder to physicians to confirm the patient's code status, if the code status of a patient was unspecified, the field was propagated with "Code Status Not Found," instead of assuming a full code. 

Downloads and links

• TJC-WHO Communication During Patient Hand-Overs
• Hospitalists recommendations
• VAMC EMR handoff tool

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ISMP survey finds sagging economy prompts layoffs, higher staff-patient ratios, safety concerns

Hospitals are not immune to the impact of the current recession, according to a recent practitioner survey by the Institute of Safe Medication Practices (ISMP). The survey found a majority reporting layoffs, reduced hiring, and dangerous staff-to-patient ratios, with more care being delivered by less experienced and unlicensed assistive personnel.

Survey ISMP received 848 responses to a survey conducted in September through November 2009 assessing the impact of the economy on patient safety and healthcare providers. Although no patient deaths were reported and not all hospitals were seeing an adverse effect on patient safety from the economy, the majority of respondents, 75 percent of whom were nurses, reported some degree of negative impact. The most frequently cited concern (68 percent of respondents) was the negative impact of layoffs and reduced hiring on staffing levels in hospitals. Some respondents reported staff-to-patient ratios at dangerous levels, while others indicated that more care was being delivered by less experienced and unlicensed assistive personnel. 

Staff ratios In a 2004 edition of Research in Action, the Agency for Healthcare Research and Quality (AHRQ) stated, "Hospital nurse staffing has an important relationship to patient safety and quality of care." This report and other subsequent studies have demonstrated an association between lower nurse staffing levels and higher rates of adverse patient outcomes. A number of adverse patient events, commonly called "nursing-sensitive outcomes," have been linked to nurse staffing levels. Among them are several of the Centers for Medicare & Medicaid Services (CMS) hospital-acquired conditions or HACs such as pressure ulcers and urinary tract infections. CMS no longer compensates providers for these HACs. Hospitals reducing staffing due to economic conditions must monitor outcomes carefully. In addition to the risk to patients, hospitals could experience further financial impact if these nurse-sensitive outcomes increase.

Economic impact The ISMP report also highlights a number of other cost reduction measures implemented by hospitals in the current economy, and how they negatively impact patient safety. Over half of the respondents reported reduction or elimination of the purchase and implementation of new equipment and technology. Additionally, the economy has affected the ability of more than half of the respondents to participate in continuing education and/or obtain/maintain specialty certification.

Safety culture Culture of safety indicators, such as staff willingness to report errors and leadership support for safety, appear to be the least impacted by the economic downturn; however, a little over one-third of survey respondents reported a large to moderate negative impact on these factors. Some respondents commented that budgetary constraints led staff to report errors less often due to lack of time, while others reported errors more frequently to show leadership.

Downloads and links

• ISMP Survey http://www.ismp.org
• AHRQ Research in Action
• CMS-Hospital-acquired conditions Web site
• Premier Safety Institute's Culture of safety Web site

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H1N1 ED triage of patients moving in their cars efficient and safe

Using a patient's car as a mobile triage unit was found to be highly successful in efficiency, isolation of patients and worker safety. 

Innovation during flu pandemic A recent emergency department study measuring identification of flu patients in a simulated outbreak using the patient's car as a mobile triage unit found staff were 100 percent successful in identifying flu patients in less than half an hour. Accuracy was based on using scenarios developed from real ED patients seen during the first wave of H1N1 in spring 2009. This suggests the feasibility of reduced ED crowding, protecting other ED patients during the next wave of H1N1 flu, which could occur as early as this spring.

News reports during 2009 H1N1 flu activity highlighted ED triage strategies such as the use of tents to protect the hospital and other waiting ED patients from suspected H1N1 patients needing assessment. Researchers at Stanford (CA) Hospital developed and tested this novel drive-through influenza clinic model for the rapid evaluation of patients during an influenza pandemic. Since this publication, a similar report in Texas during the actual H1N1 spring wave was published and appears successful.

Scenarios and simulation Charts of 38 patients with influenza-like illness who were treated in the ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic, using two parallel sets of stopping points. During the simulation involving one or more "family" members, a nurse near the ER stopped cars and sent appropriate cases to the drive-through area as located on the ground level of an open-sided, covered parking structure near the hospital. A clerk registered the car, placed a medical record under the windshield wiper; the car then moved to the next stop, where a nurse measured vital signs and documented the record. At the third stop, a physician performed and documented history, physical, testing and findings and then made an admittance decision. At the last stop, a pharmacist filled needed prescriptions or medications. Patients needing admission moved into another lane and were directed to the ED. Thus the car became a self-contained isolation compartment and a moving exam room with medical records maintained under the windshield wipers.

Measures and outcomes The exercise measured throughput times of simulated patients, successful identification of suspected flu patients, and safety of the workers, by measuring carbon monoxide levels of staff working in the parking lot.The median length of stay of 26 minutes did not increase later in the exercise when the system was fully loaded. As noted, physicians were able to correctly identify those patients who were admitted and discharged during the real ED visit with 100 percent accuracy. During the exercise, there were no significant increases of carbon monoxide levels in participants tested.

Downloads and links

• Drive-through medicine et al
• Outside the Box abstr Cruz AT et al
• More information - Premier Safety Institute H1N1 Flu Web site

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2010 NPSF 12th Annual Patient Safety Congress: Getting results – solutions that work

The National Patient Safety Foundation will host its 12^th Annual NPSF Patient Safety Congress May 17-19, 2010, in Orlando, FL, at the Gaylord Palms Hotel. Premier is pleased to be a sponsor of the 2010 Patient Safety Congress. Register by February 26 and save $145.

This year's event features the debut of the "Learning & Simulation Center," an innovative educational milieu that will use simulation to depict realistic scenarios of healthcare settings in the context of patient safety. Demonstrations using a variety of simulation modalities will create unparalleled educational opportunities for attendees and transform the exhibit hall into a lively, engaging learning environment. The NPSF Congress will offer in-depth breakout sessions, interactive full-day pre-Congress programs, motivational plenaries presented by influential healthcare leaders, and the popular breakfast roundtables.

Breakout education session tracks on May 18-19 include:

• Behaviors and cultural attributes that drive performance;

• Harmonizing and integrating operational practice with policy and regulatory mandates;

• Implications of health reform for patient safety;

• Enhancing process reliability and safety;

• Managing complex care across the continuum;

• Managing crowding and overuse of services: implications for patient safety; and

• Hot topics.

Pre-Congress program – Monday, May 17
Interactive programs offer unique opportunities to learn from patient safety experts and to share and innovate with peers.

• Leadership day – Created exclusively for C-suite and board level participants to explore the executive-level role in improving safety.
• Community engagement from the patient & family perspective – Developed to provide models for partnership for the community, patient and family representative and healthcare workers.
• New! Measurement boot camp – This half-day program is a deep dive into measurement programs designed to evaluate the effectiveness of patient safety efforts.
• New! Simulation fundamentals to advance your patient safety agenda – A half-day program on the application of simulation in today's healthcare, with demonstrations and discussion.

Downloads and links

• More information and online registration available at www.npsf.org.

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Steady seven-year improvement in quality and safety measures: Joint Commission reports

Dramatic improvements in quality and safety measures have occurred over the past seven years, the Joint Commission reports, including nearly 32 percent improvement in compliance with heart failure measures alone.

The Joint Commission last month released its fourth annual report on quality and safety, listing results through 2008 on more than 3,000 accredited hospitals. Thirty-one measures are grouped into five measure sets – heart attack, heart failure, pneumonia, surgical care and childhood asthma. Hospitals that perform well are consistently providing "evidence-based" care. The good news is that over the seven years that these measures have been tracked, hospitals have made significant improvement:

• Heart attack care, the composite measure is 96.7 percent, up from 86.9 percent in 2002.

• Heart failure care was at 91.6 percent, up from 59.7 in 2002.

• Pneumonia care was at 92.9 percent in 2008, up from 72.3 percent in 2002.

These are significant achievements, with improvement percentages of 9.8, 31.9, and 20.6, respectively. Surgical care is also showing improvement since one measure, stopping antibiotics within 24 hours, improved from 73.5 percent in 2005, to 90.5 percent in 2008.

Areas for improvement Improvement is still needed on certain measures. For heart attack patients, only 52.4 percent of hospitals provide fibrinolytic therapy for those who need it within 30 minutes of arrival. For pneumonia patients in intensive care, only 60.3 percent of hospitals provide antibiotics within 24 hours of arrival.

CMS and TJC Quality, safety and patient satisfaction results for specific hospitals can be found at www.qualitycheck.org and at the Centers for Medicare & Medicaid Services (CMS) Hospital Compare Web site at www.hospitalcompare.hhs.gov. The Hospital Compare tool presents data from hospitals that volunteered to participate in an initiative to receive incentives for public reporting. Hospital Compare and The Joint Commission measures are aligned. 

Downloads and linkss

• TJC 2009 report on quality and safety.
• Joint Commission Quality Check www.qualitycheck.org.
• CMS Hospital Compare www.hospitalcompare.hhs.gov.

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