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February 2003

Dear Colleague:

We hope you enjoy our free safety newsletter.

Each individual issues is archived on the Safety Institute Web site with all of the resources available any time you need the information.

Please continue to share with your colleagues and encourage them to subscribe so they don't miss any issues.

Sincerely,

Gina Pugliese, Editor
Vice President, Premier Safety Institute

News

Safety tools

 

Outbreak associated with contaminated bronchoscopes

There have been a number of recent news reports about an outbreak of Pseudomonas involving 16 patients at Allegheny General Hospital in Pittsburgh. The outbreak is related to contaminated bronchoscopes that were reprocessed in the Steris System I™ sterilizer. The outbreak is currently being investigated by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Hospitals using any automated endoscope reprocessing equipment should review and carefully follow the manufacturer’s instructions.

In 1999, the FDA and CDC published an advisory that contained guidelines for endoscope/bronchoscope maintenance. The advisory followed an outbreak related to inadequately reprocessed scopes using an automated reprocessing system. One recommendation from this advisory is to incorporate a final drying step that includes flushing all channels with alcohol. To remove the alcohol, purge the channels with air, which should greatly reduce the possibility of recontamination of the scope by waterborne microorganisms such as Pseudomonas.

This final drying step with alcohol has also been incorporated into the guidelines for endoscope care of numerous professional societies, including the American Society for Testing and Materials (ASTM) and APIC (Association for Professionals in Infection Control and Epidemiology). Download the APIC Guidelines for Infection Prevention and Control in Flexible Endoscopy below.

All staff handling and reprocessing endoscopes should comply with the manufacturer's instructions for cleaning and reprocessing of these devices, beyond any additional advisory recommendations from the FDA and CDC.

Downloads and links

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FCC action prompts required registration of telemetry to avoid interference

Beginning October 16, 2003, the Federal Communication Commission (FCC) will remove a restriction on the licensing of high power mobile radio transmitters operating in the same frequency range as many medical telemetry monitoring systems. This action may grant a flood of licenses for new portable radio equipment. Operation of this equipment may cause random interference with medical telemetry monitoring system. For the past several years, the American Hospital Association (AHA) and the American Society for Healthcare Engineering (ASHE) discussed with hospitals problems related to medical telemetry interference. Interference comes from multiple sources, including television stations and mobile radio devices. With the emergence of many digital TV (DTV) stations, hospitals’ attention has mostly been directed toward interference from DTV. However, any devices operating within the 460-470 MHz band will cause new and wider potential for random interference.

Medical telemetry monitoring systems allow clinicians to monitor, uninterrupted and in real-time, multiple patients’ vital signs safely and effectively. In light of workforce shortages, hospitals rely on medical telemetry systems to extend patient monitoring throughout the hospital, including critical care units, emergency departments, and medical/surgical floors. Interference could make these efficient and cost-effective patient care systems unreliable. And data corruption due to interference can cause entire telemetry systems to fail, leaving critically ill patients with no monitoring at all. Facilities can protect vital data from being corrupted due to interference from other telemetry systems and digital TV systems by registering telemetry equipment. Registration with ASHE is mandatory in the WMTS frequency bands (608-614, 1395-1400, 1427-1432 MHz) and helps protect telemetry units from harmful interference. The FCC requires that "prior to operation, authorized healthcare providers who desire to use wireless medical telemetry devices must register all devices with a designated frequency coordinator." [47 CFR Section 95.1111] This registration process licenses such equipment. (It’s important to remember that while a system may be operational, it might not be officially licensed. Data within the system can only be protected from interference unless it is registered with ASHE, the exclusive frequency coordinator appointed by the FCC. Also, the FCC can shut the system down and levy fines.) To learn more about WMTS, potential risks from interference, and to register equipment, visit http://www.ashe.org.

Downloads and links

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CMS issues final quality assessment and performance improvement standards

In an effort to further reduce medical errors, the Centers for Medicare & Medicaid Services (CMS) has published a new rule instructing hospitals to develop and implement quality improvement programs. Under the final rule, announced January 24, 2003, hospitals must develop and implement a quality assessment and performance improvement (QAPI) program to identify patient safety issues and reduce medical errors.

Under the recently issued Medicare Conditions of Participation (CoP) rule, hospitals must:

  • Establish, implement, maintain, and evaluate their own QAPI program;
  • Have a QAPI program reflecting the complexity of its organization and services;
  • Have a hospital-wide QAPI program focused on maximizing quality of care outcomes; and
  • Include preventive measures fostering patient safety, such as reducing medical errors.

To increase the use of information technology (IT) in healthcare, the rule also allows hospitals to implement information technology programs as part of their QAPI programs. Last November, CMS announced a pilot project in Maryland, New York and Arizona to test the most effective ways to communicate with consumers about the quality of hospital care. At the same time, the nation's hospital leadership called on hospitals to voluntarily report outcomes of key quality measures related to patient care.

A previous quality assurance CoP for hospitals was published in 1986. At that time, the healthcare industry embraced a quality assurance approach of measuring and improving patient care. Since then, the industry has moved toward a QAPI approach. The quality assurance approach involves identifying a problem, devising a solution, implementing the solution, and evaluating the solution at a later date. This problem-oriented process does not foster continual performance improvement, and problems are addressed individually, rather than being considered as possible system-wide problems.

In 1997, CMS issued a proposal to change the focus from quality assurance to a more proactive and ongoing improvement process. The final rule, announced January 24, reflects public comments to the 1997 proposed rule. Most Medicare participating hospitals are privately accredited and use a standard that already reflects a QAPI approach, but others are certified on behalf of Medicare by states. This rule assures a uniform standard of quality across all Medicare-participating hospitals. Under Medicare law, the Secretary of Health and Human Services establishes minimum health and safety quality standards, known as Conditions of Participation, which must be met by providers and suppliers participating in the Medicare and Medicaid programs. The rule becomes effective March 24, 2003.

The announcement complements efforts recently launched by the American Hospital Association (AHA), the Federation of American Hospitals (FAH), and the Association of American Medical Colleges (AAMC) to voluntary collect and report hospital quality performance information. The QAPI rule is one component of an overall initiative (Link to January PSS) to make information about hospital performance accessible to the public and to invigorate quality improvement efforts.

Downloads and links

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USP MEDMARX reports highlight top drug error risks -- insulin, pediatric patients, and ED

Highlights from the United States Pharmacopeia (USP) MEDMARX 2001 data base indicate that insulin remains the drug most involved in harmful medication errors, and in the emergency department (ED), only 23 percent of errors are intercepted compared to 39 percent intercepted in other areas of the hospital. Additionally, 20 percent of pediatric medication errors cause harm to patients, prompting the USP's Center for Advancement of Patient Safety to publish prevention guidelines to reduce medication errors in children.

MEDMARX Findings

The USP's MEDMARX program is an Internet-accessible, anonymous reporting program and quality improvement tool used to track medication errors. More than 600 hospitals subscribe to this program. The 2001 aggregate results of the national MEDMARX medication error database analysis cover 105,603 errors reported by 368 institutions. Among the highlights are the following:

  • 2.4% of patient errors were documented as harmful or fatal. This affirms that to improve safety, focus must be placed on areas that do not result from overt error.
  • 6.2% of errors originating in the emergency room were harmful, suggesting that safety in the emergency department (Editor: link to 2_A Look at the Emergency Department.pdf) has been under-addressed for the past several years.
  • The top 10 drugs (in decreasing order) involved in patient harm include: insulin, morphine, heparin, warfarin, KCl, furosemide, vancomycin, hydromorphone, meperidine, and diltiazem. If the study looked at morphine, meperidine, and hydromorphone combined, narcotics would be the number one drug involved in patient harm, suggesting that efforts should focus on narcotics, insulin, and anticoagulants.
  • In terms of error types, harmful insulin and heparin errors were mostly due to wrong dose, omission errors, giving the drug when it wasn’t ordered, or off-label use. . Morphine was commonly involved in wrong dose errors. Warfarin errors were mostly those of omission or unauthorized drugs. KCl errors were caused from misreading the serum K or misunderstanding the K-replacement protocol.
  • The most common error of omission was for albuterol. While not harmful, most incidents occurred because of distracting emergencies, higher workload, and insufficient staffing.
  • "Performance deficits" and "procedure not followed" were attributed to most errors. MEDMARX has limitations to investigating or recording truer root causes. The most common action taken (66%) was to "inform staff." Other measures included education, improving communication, or no action at all. Less than 1% of reported errors resulted in true systems changes, according to MEDMARX.

USP Recommendations for Pediatrics

USP's Center for the Advancement of Patient Safety (CAPS) created recommendations for preventing medication errors in pediatrics after analyzing data from its databases. For example, pediatric medication errors can often occur when a decimal point is misplaced in a medication dose or an incorrect weight conversion from pounds to kilograms is made. Healthcare practitioners must consider a child's age, weight, medication dosing frequencies, and other factors to ensure the safety of young patients.

USP offers the following recommendations to help prevent medication errors among pediatric populations:

  • Dosage forms and/or preparations that are compounded, prepared in serial dilutions, and/or extensively manipulated should be prepared in the pharmacy and verified by a pharmacist. When possible, a second healthcare professional familiar with dilutions and compounding should verify the product preparation and labeling.
  • Policies and procedures should be developed and implemented when automated dispensing machines are used for pediatric medications, including double independent verification of medications loaded into the machines and the inability to override system safeguards.
  • When possible, pediatric medications should be prepared and dispensed in "unit-dose" containers.
  • Dispense liquid medications used in an outpatient setting with appropriate measuring devices and offer patients instructions on how to use the product. When possible, the measuring device should be demonstrated to the patient/caregiver.
  • A healthcare professional should review a prescription order for appropriateness and dosage accuracy based on the patient's weight, age, and other appropriate indicator(s) before giving each dose and/or refill to pediatric patients.
  • The patient's weight, age, and other appropriate dose indicator(s) should be available and clearly identified on all prescriptions and orders before any dose is dispensed and administered.
  • A validated computer algorithm as part of an integrated medication order entry system should calculate pediatric dosages. Calculations, whether computerized or manual, should be double-checked by another pharmacist and approved by at least one other licensed healthcare professional to confirm accuracy.
  • Abbreviations, acronyms, and symbols used throughout an organization should be standardized and readily available. A list of abbreviations, acronyms, and symbols not to be used should also be available.
  • To prevent 10-fold overdoses, a terminal or trailing zero should never be used after a decimal. A leading zero should always precede a decimal expression of less than one.
  • In all healthcare settings, patients, parents, and/or caregivers should be provided verbal and written information about the pediatric patient's medication, the common side effects, and the adverse events that should be reported to a healthcare professional.

In December 2002, USP released its report providing an analysis of medication errors captured by MEDMARX in 2001. Many experts agree that USP’s analysis and third annual report, Summary of Information Submitted to MEDMARX in the Year 2001: A Human Factors Approach to Medication Errors, is the most comprehensive compilation of medication error data submitted by hospitals and health systems nationwide.

Downloads and links

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IOM calls for smallpox education to supplement vaccination

The Institute of Medicine (IOM) issued a report to the Centers for Disease Control and Prevention (CDC) urging caution as smallpox vaccination begins. Specifically, the report states that CDC must balance the need of quickly implementing the program with concerns about the vaccine's safety, and address communication and education. Communication with healthcare workers and the public are important as well as the ability to learn from mistakes and make changes as the program evolves, the IOM noted in its report.

The CDC responded to the IOM recommendations in a January 17 teleconference. The CDC anticipated that the program would begin on its scheduled date of January 24 and began shipments of the vaccine. All 50 states now have approved vaccination plans.

The IOM report also recommended that the CDC proactively communicate, train, educate, and customize those methods to reach diverse audiences, including potential vaccinees, all healthcare providers, and the general public. The CDC has been seeking input and responding to public health agencies, clinicians, and other categories of healthcare providers by creating numerous educational tools, such as educational workshops, videoconferences, web-based training, slide presentations, CDs and videos.

A wealth of additional smallpox vaccination information was presented during the IOM hearings. The link below permits download of a number of slide presentations.

Downloads and links

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Deaths from influenza and RSV on the rise in the U.S.

The Centers for Disease Control and Prevention (CDC) recently released data indicating that the number of people dying from influenza and respiratory syncytial virus (RSV) each year in the United States is substantially higher than previous estimated. The data, as part of a CDC study, are published in the January 8 issue of the Journal of the American Medical Association (JAMA).

CDC scientists estimate that an average of 36,000 people (up from 20,000 in previous estimates) die each year from influenza related complicated in the United States. In addition, about 11,000 people die per year from respiratory syncytial virus (RSV), a virus causing upper and lower respiratory tract infections primarily in young children and older adults. The study demonstrates that most deaths caused by RSV occur in the elderly. CDC researchers believe the increase is caused in part by the aging of the U.S population. Over the past several decades, the 85 or older population has doubled. The most virulent of influenza viruses - influenza A (H3N2) - has been the most common strain circulating during the last decade. Vaccinating individuals at greatest risk of serious complications from influenza will continue to be the primary strategy for preventing influenza associated deaths, according to the CDC. The CDC has a complete list of resources on influenza.

The U.S. Department of Health and Human Services (HHS) recently announced a new policy allowing nursing homes, hospitals and home health agencies that serve Medicare and Medicaid beneficiaries to remind patients when it is time for an annual vaccination and ask if they want to receive a shot. As noted in the December issue of Safety Share, to encourage influenza vaccinations during hospital stays, the Centers for Medicare and Medicaid Services (CMS) modified its Conditions of Participation to relieve physicians from writing individual orders for each influenza and pneumococcal vaccination. The federal rule, which went into effect October 2, 2002, states that, where allowed by state law, appropriate non-physician personnel can provide these vaccinations to Medicare and Medicaid patients under a facility-approved standing order protocol. A Q&A Guide assists in addressing reimbursement issues.

Downloads and links

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Emergency surgery, heavier body weight are risk factors for retained instruments

A study funded by the Agency for Healthcare Research and Quality (AHRQ) and published in the January 16 issue of the New England Journal of Medicine estimated that a surgical instrument or sponge is left in more than 1,500 surgical patients each year. Researchers, led by Atul Gawande, M.D., M.P.H., of Brigham and Women's Hospital and Harvard University in Boston, studied 54 patients who had a total of 61 foreign bodies left inside of them after surgery. Of those items, 69 percent were sponges and 31 percent were surgical instruments.

The study found that patients who had emergency surgery were nine times more likely to have a sponge or surgical instrument left in their body; the risk increased by four times for patients who had unplanned changes in their procedure. Patients who had a higher body mass index were found to be more likely to have a foreign body left after surgery. Researchers listed a number of techniques to reduce the incidence of foreign bodies left in patients after surgery, including counting instruments and sponges before and after procedures and X-raying patients for instruments that may have inadvertently been left behind.

Downloads and links

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First environmentally green hospital planned in Pittsburgh

The commonwealth of Pennsylvania has revealed plans to provide $5 million in capital budget redevelopment assistance to help the Children's Hospital of Pittsburgh build one of the first environmentally "green" hospitals in the nation. This project is anticipated to create approximately 400 new jobs. The new $420 million, 1.4 million-square-foot hospital will be built using environmentally sensitive technology and design. Targeted for completion by 2007, the facility will include an inpatient tower, ambulatory care facility, parking garage, and a new pediatric research facility. More information on building "green" hospitals may be obtained from Hospitals for a Healthy Environment (H2E). In addition, a guidance document is available from the American Society of Healthcare Engineering in conjunction with its sustainable design award application.

Downloads and links

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Sprinklers among issues resolved in CMS adoption of NFPA

The Centers for Medicare & Medicaid Services (CMS) is adopting the 2000 edition of the National Fire Protection Association's (NFPA) Life Safety Code (LSC) for inpatient facilities that care for Medicare beneficiaries. Over the past several years, the American Society of Healthcare Engineering (ASHE) and the American Hospital Association (AHA) worked closely with leaders of the healthcare fire safety community urging CMS to adopt the most current Life Safety Code.

According to CMS, the announcement eases regulatory burdens for healthcare providers and ensures the health and safety of patients and staff. "This update will benefit Medicare beneficiaries and the facilities that provide their inpatient care," said CMS Administrator Tom Scully. "Our old rule was out of date and was creating confusion and additional work and expense without any gain in fire safety."

The new rule adopts a compilation of NFPA's Life Safety Codes (LSC) for new and existing buildings and was published in the Federal Register on January 10. The 2000 LSC requires sprinkler systems in all new construction and major renovations. Quick-response sprinkler systems have proven to be a life saving device and have been a requirement in the LSC since 1991. By permitting construction alternatives as sprinklers are added on a compartment-by-compartment basis, healthcare facility building costs are lowered by permitting design concepts that reduce the level of corridor wall separation, increase travel distances, reduce exit capacities, and modify the level of compartmentalization. This concept of construction alternatives in sprinkler-installed buildings is also permitted in the 2000 edition of the International Building Code.

The 2000 LSC allows a care setting to be defined as "business occupancy" unless four or more patients in the same time period within the facility are rendered incapable of taking action for self-preservation within the facility. ASHE will analyze the CMS final rule adopting the 2000 LSC and provide information on implementation and the status of the CMS specific code modifications that were identified in the Notice of Proposed Rulemaking issued October 26, 2001. ASHE is a charter member of the Healthcare Organizations Committee, a coalition of major organizations that impact the healthcare community in terms of national codes and standards issues in the built environment. Committee members include: American Health Care Association (AHCA); ASHE; CMS; Department of Defense (DOD); Department of Veterans Affairs (VA); Indian Health Service (IHS); International Fire Marshals Association (IFMA); JCAHO; and NFPA. The committee's principle task is to reduce the duplication of effort when multiple agencies inspect healthcare facilities' physical environments to assure compliance with multiple standards. These efforts save the healthcare community hundreds of millions of dollars, with no compromise in patient, staff and public safety, as well as the quality of the physical environment of medical facilities.

Downloads and links

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Safety tools

 

Videos - Disclosing adverse medical events

The National Patient Safety Foundation (NPSF) has a 30-minute video entitled, "Let's Talk," providing guidance on how to talk with patients and families when an adverse medical event has occurred. The video provides step-by-step instructions on how to disclose medical errors, why disclosure is important, and how open communication can strengthen the patient-provider relationship.

  • To obtain a copy, contact NPSF at 312.464.5672, or visit its Web site at http://www.npsf.org.
  • Additional free, award-winning patient safety videos are available from Premier’s Safety Store.

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Wall chart - Chemical terrorism agents

The North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina at Chapel Hill has developed a wall chart on chemical terrorism agents. A small version of this wall chart is available on the SPICE Web site for educational purposes as long as the chart is used in its complete form (including the disclaimer and credit given to the North Carolina Statewide Program for Infection Control and Epidemiology). The purpose of the chart is to display information for medical personnel in emergency rooms, urgent care centers, physicians' offices, and other primary care first responders. The chart presents a concise summary of signs and symptoms to assist with early recognition, as well as to alert healthcare workers about the potential for chemical terrorism agents. Once a chemical terrorism agent is suspected, the healthcare worker will need to consult more in-depth resources. A large (24-by-32), colorful version designed for display is available for purchase.

  • For information on purchasing a printed copy, call Medical Illustration and Photography (at the University of North Carolina at Chapel Hill) at 919.966.4232.
  • Visit the SPICE Web site at:
    http://www.unc.edu/depts/spice/

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Report, FAQs - JCAHO National Patient Safety Goals

The Joint Commission on Accreditation of Healthcare Organizations has issued a special report on Perspectives on Patient Safety (1.2 MB). The report is devoted entirely to JCAHO'S 2003 National Patient Safety Goals and provides practical advice and tips for meeting those goals. As of January 1, 2003, healthcare organizations across the United States are required to focus attention on a series of specific actions to prevent medical mistakes. These actions will help avoid: confusion in identifying patients; miscommunication among caregivers; wrong-site surgery; unsafe use of infusion pumps; medication mix-ups; and problems with equipment alarm systems. Because of the significance of this information, it can be accessed without a password from the JCAHO Web site at www.jcaho.org.

Information in the special report includes practical guidance for meeting JCAHO's 2003 National Patient Safety Goals. Examples include: how to ensure proper patient identification; how to implement a verbal order read back policy; how to verify the correct site, patient, and procedure; and how to make sure your alarm systems are in working order.

Additional answers about how to meet these goals, such as what would be considered two identifiers for proper patient identification and in what settings the National Patient Safety Goals apply, are also included.

The JCAHO National Patient Safety Goals were established to help accredited organizations address specific areas of concern relating to patient safety. Each goal includes no more than two succinct, evidence- or expert-based recommendations. To ensure a greater focus on priority safe practices, no more than six goals are established for any given year. In succeeding years, certain goals are likely to be continued, while others will be replaced because of new emerging priorities. The JCAHO Board of Commissioners approved the 2003 six National Patient Safety Goals, representing 11 recommendations for improving the safety of patient care. The 2003 six National Patient Safety Goals were to be implemented January 1, 2003. To review questions on topics concerning how the goals and recommendations should be implemented and how they may be surveyed, download a list of frequently asked questions (61 KB).

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CD-ROM and video - New smallpox preparedness resources from the CDC

Originally broadcast December 5-6, the program, "CDC Bioterrorism Update: Smallpox Preparedness," is now available on CD-ROM and VHS videotape formats. The program provides basic information required to implement a smallpox vaccination preparedness program. Presented in a series of modules, it is directed at state and local health department and clinical personnel. For registration and certification information, call 800.418.7246 or send e-mail to ce@cdc.gov (include "CDC Bioterrorism Update: Smallpox Preparedness" in the subject line).

Single copies of the CD-ROM and videotape are available free of charge from the Public Health Foundation online bookstore at:

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Online journal - AHRQ launches Web M & M patient safety journal

AHRQ launched a new online peer-reviewed journal, Web M & M (Web Morbidity and Mortality), to showcase patient safety lessons drawn from actual cases of medical errors. The journal is designed to educate healthcare providers about medical errors in an engaging, blame-free environment. Authors of cases chosen for posting will receive an honorarium while retaining their anonymity. Every month, five interesting cases of medical errors and patient safety problems across a broad array of medical specialties will be posted, along with commentaries from experts and a forum for readers' comments. Visit http://www.webmm.ahrq.gov to preview the site and learn how to submit cases anonymously. By registering through the site, you can also choose to receive monthly notices of topics and commentaries beginning in mid-February.

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Editorial team

Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, associate editor
Donna Bernstein, MPH, marketing consultant
Derek Kleckner, BA, Web master

About Premier

Premier, Inc. is a national strategic alliance of leading hospitals and healthcare systems representing more than 200 not-for-profit owners that own, operate, or are affiliated with approximately 1,600 facilities. Premier  members  have access to a wealth of resources that support them as they evolve into integrated delivery systems and improve community health across the continuum of care.  Premier maintains corporate offices in San Diego, CA; Charlotte, NC; Chicago, IL; and Washington, DC. For information, visit www.premierinc.com.

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