February 2005
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Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Healthcare-associated infections likely to join other public safety/quality data reporting
- Worker fatigue, surgical fires, multi-dose vials among JCAHO's 2006 proposed patient safety goals
- Nearly half of adverse events in Minnesota's new mandatory reporting register are surgically-related
- Extended work hours increase intern risk of car crashes
- New guidelines aim to reduce performance measurement workload
- Private room requirement among proposed AIA/FGI guidelines; Comment deadline extended
- Isolating ICU patients does not reduce MRSA transmission, study finds
- Harmful drug interactions a risk among elderly in outpatient settings
- Studies find CPR often performed incorrectly by healthcare workers
Safety tools
- EPA guidance - Safer needle, sharps disposal in public areas
- Practice brief - Health information manager role in patient safety
- NIOSH Alert - Hazardous pharmaceutical waste management resources
- ASHRM CD -Tool kit for physician office risk managers
- OSHA memo - Annual fit-testing of respirators for tuberculosis
Healthcare-associated infections likely to join other public safety/quality data reporting
Experts and stakeholders from healthcare facilities, public health, professional and trade associations, industry, and consumers at a national conference in early February discussed the potential benefits of public reporting of healthcare-associated infections, along with other safety and quality data reporting initiatives. The "Mandatory Public Reporting Consensus Conference on Healthcare-Associated Infections" was sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC) in partnership with the Centers for Disease Control and Prevention, the American Hospital Association, Consumers Union, the National Quality Forum, and the Society for Healthcare Epidemiologists of America.
Attendees, along with representatives from the states that currently have public reporting (Illinois, Pennsylvania, Florida and Missouri) discussed the merits of public reporting, including the importance of consumer's needs, increased attention to the program and support for more resources for prevention efforts. They also advised that any state initiative be accompanied by funding to support implementation and urged that there be agreement on types of infections to be reported, standardized definitions and methodologies, types of patients with a focus on high risk patients, valid risk adjustments, consistency with medical advancements, and alignment of reporting with national initiatives. Attendees were asked to rank the type of infections that should be reported and voted catheter-associated bloodstream infections as number one, followed by surgical site infections and ventilator associated pneumonia, respectively.
Efforts are already underway in most hospitals to combine infection data with other data on quality and adverse outcomes. Nearly 84 percent of attendees reported that hospital-associated infection data is currently part of hospitals' overall quality/safety improvement initiatives. Although attendees strongly agreed about the need for using existing measures, such as surgical site infections, they stressed that the current practice of reporting apparently similar performance measures wastes resources if the metrics are not aligned. The audience expressed concern that state-by-state infection-related measures could amplify this problem. Attendees voted unanimously to move toward national versus state-driven measures. The conference appeared to achieve full consensus that as healthcare-associated infection reporting issues move forward, the goal should ultimately be a national standard.
Information on proceedings is available from: http://www.apic.org.
Worker fatigue, surgical fires, multi-dose vials among JCAHO's 2006 proposed patient safety goals
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is requesting review of a list of draft goals and "requirements" from which its 2006 national patient safety goals (NPSG) will be chosen. The draft goals are grouped in setting-specific categories appropriate to the patient care population. JCAHO introduced its first set of NPSG in January 2003 as a focused effort to improve patient safety in accredited organizations, and updates them annually based on recommendations from its Sentinel Event Advisory Group.
Existing goals; new requirements: Many existing goals are proposed for retention, but include new requirements. For example, existing Goal 3 - "improving the safety of using medications" - proposes several new requirements, including one to eliminate the use of multiple dose medication vials, when possible. The goal adds another requirement stating that if multi-dose vials are used, appropriate steps should be taken to minimize the risk of infection transmission between patients. Other related requirements for this goal include labeling all medications, medication containers and/or other solutions on and off the sterile field. Other existing goals with new requirements include:
- Improving effectiveness of communication;
- Reducing risk of patient harm resulting from falls;
- Reducing risk of influenza and pneumococcal disease in older adults;
- Improving the safety of using infusion pumps; and
- Accurately and completely reconcile medication across the continuum of care.
New goals: Newly proposed draft goals require organizations to achieve and maintain an organization-wide culture of safety, encourage patients' active involvement in their own care, and prevent patient harm associated with healthcare worker fatigue. Other possible setting-specific goals include:
- Preventing healthcare-associated decubitus ulcers;
- Reducing the risk of harm associated with emotional and behavioral crisis;
- Reducing the risk of harm from abuse or exploitation in the healthcare organization;
- Ensuring the safety of assisted living facility residents with dementia and other mental health disorders; and
- Reducing the risk of surgical fires.
In this field review, the JCAHO wants information regarding the relevance, the relative priority, the clarity, the ability to measure compliance, the time needed to implement, and the cost of implementation of each potential goal and requirement under consideration. JCAHO also seeks comments on expanding the application of existing Goals or Requirements to additional programs. Comments are due by February 25.
Draft 2006 for critical access and hospitals (109 KB) (.pdf)
Draft 2006 for ambulatory care (98 KB) (.pdf)
Nearly half of adverse events in Minnesota's new mandatory reporting register are surgically-related
The first report on the 27 reportable events, "Adverse Health Events in Minnesota Hospitals," required by the Minnesota Hospital Association's Patient Safety Registry, has been released by the Minnesota Department of Health. Nearly half of the events noted in the report, expected on an annual basis, are related to surgical events. The 27 events are based on the National Quality Forum list of events, such as wrong-site surgery, that hospitals should always strive to prevent. Information on the determination of why the event happened and what is being done to prevent the event from happening again is included in the report that summarizes data from July 2003 to October 2004. Consumers and patients are cautioned that the events listed in the report represent a small percentage of the total procedures and admissions in Minnesota hospitals. The public is encouraged to use the information in the report to identify their areas of interest, and question their hospital or healthcare provider about what is being done to prevent this type of event.
Categories of reportable events include surgical, environmental, patient protection, care management, product or devices and criminal events. Thirty of 145 Minnesota hospitals reported 99 serious medical errors, one crime, and a physical assault during the 15-month reporting period. Over half of the reported mistakes occurred during surgery, the most frequent being leaving a foreign object such as a sponge or a needle in a surgical patient. Twenty of the reported events were linked to patient deaths and four to serious disabilities. The state said 115 hospitals did not report any events. Minnesota will report data on outpatient surgery centers in 2006.
Minnesota Adverse Health Event Report (.pdf) (270 KB)
Minnesota Adverse Health Events Web page:
http://www.health.state.mn.us/patientsafety
Extended work hours increase intern risk of car crashes
Medical interns who work shifts of longer than 24 hours are more than twice as likely to have a car crash leaving the hospital and five times as likely to have a "near miss" incident on the road as medical interns who work shorter shifts. This conclusion is the result of a study published in the January 13, 2005, issue of the New England Journal of Medicine (NEJM).
Interns completed surveys in which they recorded work hours, frequency of shifts of more than 24 hours work hours, documented motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleeping and driving safety records on a monthly basis from April 2002 to May 2003. The study was conducted before new standards limiting duty hours were implemented.
Interns who worked five or more extended shifts in a month were at a significantly increased risk of falling asleep while driving or while stopped in traffic, according to study results. The article, "Extended Work Shifts and the Risk of Motor Vehicle Crashes Among Interns," is the third in a series of studies on the impact of extended work hours and fatigue on interns conducted by the Divisions of Sleep Medicine at the Brigham and Women's Hospital and the Harvard Medical School in Boston. The first two studies were published in the October 28, 2004, issue of NEJM. All three were co-funded by AHRQ and CDC's National Institute for Occupational Safety and Health and stem from a project led by Charles A. Czeisler, Ph.D., M.D.
Abstract Extended Work Shifts and Risk (.doc) (26 KB)
For more information on sleep deprivation and safety, go to the Harvard Work Hours, Health and Safety Web site at: http://workhours.bwh.harvard.edu/.
New guidelines aim to reduce performance measurement workload
The Consumer-Purchaser Disclosure Project, a coalition of more than 25 of the nation's leading consumer, employer and labor organizations, has announced guidelines to promote rapid, industry-wide adoption of performance measures to help patients compare the relative quality and cost of care provided by the nation's hospitals, physicians and healthcare systems. The "Guidelines for Purchaser, Consumer and Health Plan Measurement of Provider Performance" encourage organizations providing ratings of healthcare quality to:
- Use National Quality Forum-endorsed measures for those measures that are available, or measures approved by federal agencies or national accrediting bodies;
- Regularly review all supplemental measures used;
- Publicly disclose how the provider rating methods were obtained; and
- Coordinate data collection with others measuring quality.
The Disclosure Project considered many issues when developing the guidelines. They reviewed challenges to the standardization of performance assessment such as defining uniform performance measures, making ratings meaningful and available to the public and obtaining collection of provider-level data with the minimum burden for the providers.
Consumers Guidelines (.pdf) (47 KB)
Premier Safety Institute's resources for selected guidelines.
Private room requirement among proposed AIA/FGI guidelines; Comment deadline extended
Patient safety and cost implications of single rooms as a minimum requirement of newly constructed hospitals will demand extensive public review among all other changes in the 2006 edition of the AIA/FGI Guidelines for Design and Construction of Hospital and Health Care Facilities. Other changes include a new chapter on the Environment of Care, refinement of the infection control risk assessment and ventilation in endoscopy procedure rooms. The Facility Guidelines Institute is extending the public comment period until February 28, 2005, 5 p.m. EST. Comments will be accepted on proposed changes or additions to the 2001 document only.
Download the proposed changes and access the electronic comment form: Go to www.aia.org and click the "Call for Comments."
Proposal forms direct link: www.aia.org/aah_gd_hospcons.
Review the single room study files on the Premier Safety Institute's Construction resources Web site.
Isolating ICU patients does not reduce MRSA transmission, study finds
The widely practiced approach of isolating intensive-care patients infected with methicillin-resistant Staphylococcus aureus (MRSA) does not reduce cross-infection, according to a study published in the January 22, 2005, issue of The Lancet. MRSA infection acquired in hospitals is a serious problem because it is resistant to most antibiotics, and is often fatal.
Jorge Cepeda and colleagues from University College London Hospitals and the Royal Free Hospital in Great Britain did a prospective one-year study in the intensive-care units of these two London teaching hospitals. During one six-month study period, patients in the study population identified as positive for MRSA were hospitalized in single rooms. During another six-month period, patients with MRSA were not isolated in single rooms. Admission and weekly screens were used to determine the incidence of MRSA colonization. Staff followed standard precautions and were monitored for adherence to hand hygiene with both groups. The study authors observed no significant difference in the rates of MRSA acquisition during the two periods.
The researchers cautioned that this finding should not be applied to general hospital wards, and needs further confirmation from larger studies. In a comment paper in the same issue of The Lancet, Charles Huskins, M.D., and Donald Goldmann, M.D., discuss methods that are used throughout Europe and the United States to control MRSA and the control steps, such as improving hand hygiene compliance and proper use of gloves, that should be taken.
Isolation in single room - Lancet abstract. (.doc) (20 KB)
Comment on isolation study - Lancet. (.pdf) (45 KB)
Premier Safety Institute's Hand Hygiene module.
Harmful drug interactions a risk among elderly in outpatient settings
Potentially harmful drug-drug and drug-disease combinations are a risk among the elderly to varying degrees in the outpatient setting, according to a new study from the Agency for Health quality and Research (AHRQ). Elderly patients were prescribed at least one medication that could have caused a harmful drug-disease interaction in more than 2.5 percent of outpatient visits. The likelihood that a patient was prescribed a medication that had the potential for a harmful drug-drug interaction was slightly less than 1 percent in visits that involved two or more prescriptions.
Using data from 1995 to 2000, the study assessed the likelihood that a patient would receive a prescription for a medication that could have a harmful drug-drug or drug-disease interaction in the outpatient setting. Six drug-drug and 50 drug-disease combinations considered to be harmful to the elderly were the focus of the study published in the February issue of the Journal of the American Geriatrics Society. The researchers conclude that targeting drug combinations that have a high prevalence and potential for harm offers a practical approach to improving prescribing and patient safety.
The relationship of medications to patient safety in all settings is of particular importance, and prior studies demonstrate the correlation of medications and falls in the elderly. The Premier Safety Institute's fall prevention module provides numerous resources addressing the role of medications, other risk factors, checklists, an annotated bibliography, and more.
Download the abstract, "Suboptimal Prescribing in Elderly Outpatients: Potentially Harmful Drug-Drug and Drug-Disease Combinations." (.doc) (24 KB)
A print copy of the article is available by sending an e-mail to ahrqpubs@ahrq.gov.
Premier's Safety Institute's Fall prevention module www.premierinc.com/quality-safety/tools-services/safety/topics/falls/.
Studies find CPR often performed incorrectly by healthcare workers
Many caregivers are not performing cardiopulmonary resuscitation (CPR) correctly - specifically, inadequate chest compression - according to a recent study evaluating the quality of CPR in more than 200 individuals in two different studies. The finding stems from two studies published in the January 19, 2005, issue of The Journal of the American Medical Association (JAMA). The studies targeted two common improper CPR techniques - not pushing hard enough or frequently enough on the chest to restart the heart, and breathing air (via mouth or tubes) into the lungs too often. Failure to follow several guidelines was common, according to the studies.
The American Heart Association hosted a January 2005 conference in which a group called ILCOR (International Liaison Committee on Resuscitation) met to review, evaluate and interpret peer-reviewed, published scientific evidence for each specific task force topic. ILCOR includes seven international resuscitation organizations: the American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada (HSFC), Resuscitation Council of Southern Africa (RCSA), the Australia and New Zealand Council on Resuscitation (ANZCOR), and the InterAmerican Heart Foundation (IAHF). ILCOR aims to prepare an International Consensus on CPR and ECC Science with Treatment Recommendations (CoSTR). This document will provide the scientific basis from which each resuscitation council will compile individual Council Guidelines and practitioner recommendations.
The AHA has announced that it will develop guidelines from the CoSTR document. The revised AHA guidelines will be published in the journal Circulation in December 2005. Texts and training materials will follow the publication of council-specific guidelines.
JAMA CPR abstracts (.doc) (28 KB)
Complete studies are available for a fee at:
http://jama.ama-assn.org/cgi/content/full/293/3/305 and
http://jama.ama-assn.org/cgi/content/full/293/3/299
Safety tools
- EPA guidance - Safer needle, sharps disposal in public areas
- Practice brief - Health information manager role in patient safety
- NIOSH Alert - Hazardous pharmaceutical waste management resources
- ASHRM CD -Tool kit for physician office risk managers
- OSHA memo - Annual fit-testing of respirators for tuberculosis
EPA guidance - Safer needle, sharps disposal in public areas
The Environmental Protection Agency (EPA) has new guidance about how the general public should handle used syringes/needles and other sharps generated at home or other non-healthcare locations. The guidance suggests that syringe users dispose of used syringes in ways that keep the sharps out of the general trash, with a goal of protecting workers along the solid waste "stream" and at land fills. The new EPA guidance is published in two brochures:
- Protecting Your Community from Sharps: Options for Safe Disposal of Sharps. (.pdf) (590 KB)
- Protect Yourself, Protect Others: Safe Options for Needle Disposal. (.pdf) (1.2 MB)
Practice brief - Health information manager role in patient safety
Health information managers are directly involved in clinical quality issues and outcomes through
quality management programs, according to the January practice brief titled, "The HIM Role in Patient
Safety and Quality of Care." Issued by the American Health Information Management Association, the
document discusses the legal and regulatory environment, data standards, and return on investment in
technology. Health Information Managers also affect quality through improved medical record documentation,
accurate coding, and index integrity. The author concludes that the health information managers' ability
to affect patient safety is great, particularly through data reporting. As the coordinators of data quality,
the health information managers are the "overseers" of consistent and accurate quality data. To read the
complete article, go to:
http://library.ahima.org/xpedio/groups/public/
documents/ahima/pub_bok1_025487.html.
(Article citation: Hjort, Beth. "The HIM Role in Patient Safety and Quality of Care (AHIMA Practice Brief)."
Journal of AHIMA 76, no.1 (January 2005): 56A-G.).
NIOSH Alert - Hazardous pharmaceutical waste management resources
The NIOSH Alert "Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings"
is available on Premier's Safety Institute Web site under the "Resources" section of the pharmaceutical waste management
module. Additional information on hazardous waste management (content of which is free except the actual database) contains
reference articles, state and federal regulations, etc., and can be found at
www.pharmecology.com.
Download the "HazDrugAlert"
(.pdf) (841 KB), or go to:
https://premierinc.com/quality-safety/tools-services/safety/topics/
pharma-waste/
ASHRM CD -Tool kit for physician office risk managers
The American Society for Healthcare Risk Management (ASHRM) has a CD-ROM tool kit created for the various
healthcare professionals who work in the physician practice area. Risk managers can use it to conduct an on-site
survey of a practice for auditing purposes and also as a baseline tool to develop additional checklist items. Key
areas covered in the tool kit include principles of documentation; what to report to the insurance claims representative;
medical practice office systems risk prevention strategies; qualities of effective patient relations for office staff;
and risks and strategies related to effective telephone communication. The tool kit also can be used as a pre-assessment
tool to identify potential risk areas. The tool kit contains Adobe Acrobat® and PowerPoint® files. A
sample tool kit
(.pdf) (340 KB) has been made available and the complete kit can be purchased at
http://www.ashrm.org/ashrm/resources/
products.html#toolkits.
OSHA memo - Annual fit-testing of respirators for tuberculosis
The recently passed Consolidated Appropriations Act for fiscal year 2005 includes an appropriations restriction. This restriction states that during FY 2005, employers may not be inspected or cited for the requirement to do annual fit testing of respirators for occupational exposure to tuberculosis. OSHA can still cite for the non-annual fit testing requirements of 29 CFR 1910.134 as it relates to tuberculosis, including the provisions of 29 CFR 1910.134(f)(2) for the lack of initial fit testing or whenever a different respirator face piece is used. The standard interpretation is described in an OSHA memo (.doc) (33 KB) and also states that only annual fit testing of respirators used for protection against tuberculosis are exempt from citations All other requirements of the respiratory protection standard, including annual fit testing, may continue to be cited for respirator use against other hazards, such as Severe Acute Respiratory Syndrome (SARS) or other bioaerosols.
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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
- John Deem, managing editor
- 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.
