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March 2003

Dear Colleague:

We hope you enjoy our free safety newsletter.

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

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Sincerely,

Gina Pugliese, Editor
Vice President, Premier Safety Institute

News

 

Safety tools

 

Premier launches Web safety resources for preventing back injuries

Healthcare industry workers sustain nearly five times more overexertion injuries than any other type of worker and are among six of the top 10 professions at greatest risk for back injury, according to the U.S. Department of Labor. The Premier Safety Institute now offers a Web-based clearinghouse of back injury prevention tools, policies, and resources to prevent this costly and preventable occupational hazard.

While back injuries are the most common cause of workforce absenteeism, such injuries among patient care personnel also compounds the current critical U.S. nursing shortage and seriously diminishes the nation’s ability to provide quality care. Such injuries also drain financial resources from the economy as well. Claims involving back strain may cost up to $85,000 if corrective surgery is required. Worker’s compensation absorbs approximately $1.7 billion from the nearly 67,000 claims from healthcare workers suffering from back injuries.

Since many of the back injuries result from improper patient lifting, risk managers, safety directors, occupational health directors, and other healthcare administrators need assistance with assessing their facilities’ risks and implementing policies and procedures to deal with the problem. Developed and maintained by the Premier Safety Institute, the new Web site “module” includes a wealth of information designed to help healthcare facilities develop a comprehensive safety program.

The new “Back Injury Prevention” module of the safety Web site, will offer visitors over a dozen different tools and resources such as action plans, sample policies and procedures, training and education guidelines, equipment lists, lifting techniques, checklists, cost benefit analyses, and case studies and success stories.

In the January issue of OSHA Quick Takes, for example, the Occupational Safety and Health Administration (OSHA) cited a dramatic decline in worker injury and illness rates at a West Virginia intermediate nursing care facility following mandatory use of patient lifting devices. The facility's lost workday injury and illness rate dropped to 5.5 in 2001 from 24 in 1997. According to OSHA, the facility reported no lifting-related injuries throughout 2002.

Downloads and links

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IHI and BMJ launch Web site on quality and safety

The Institute for Healthcare Improvement (IHI) and the British Medical Journal Publishing Group (BMJ) launched a new web site enabling health care professionals to collaborate for health care improvement. Qualityhealthcare.org is accessible free of charge with initial emphasis on patient safety and improvement methods.

Site organizers say QualityHealth.org will enable health care professionals in all parts of the world to recommend improvements that they have implemented, discuss their use and impact, exchange ideas on refinements and applications, and track progress over time with online tools. "It will build on the extraordinary potential that the Internet offers for creating global communities interested in specific topics…enabling the latest improvements to be shared immediately throughout the world," said Dr. Donald Berwick, President and CEO of IHI.

A key feature of the new site permits health care professionals to track progress over time with an online “Improvement Tracker.” The tool will enable visitors to gauge whether the changes their teams test actually lead to improvements by establishing measures, setting an aim, and tracking data over time. The Improvement Tracker automatically graphs data and helps visitors create customized reports of their improvement project.

QualityHealthCare.org offers specific content areas. The first two address patient safety and improvement methods. Subsequent content areas, which will appear in coming months, include chronic conditions, critical care, office practices, end-of-life Care, leadership, HIV/AIDS, workflow, and workforce development. Each of these content areas is “hosted” by a leading expert in the field who will oversee the content and moderate regular online discussions of timely and important topics. Renowned medical errors expert Lucian Leape, M.D., adjunct Professor of Health Policy at the Harvard School of Public Health, will host the initial content area on patient safety and improvement methods.

Each content area offers diverse sources of information on issues such as: how to improve; measures; changes; improvement stories; tools; resources; literature, and frequently asked questions.

Downloads and files

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JCAHO reviews infection control standards

A panel of infection control experts gathered at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) headquarters in early February to review infection control standards and discuss the recently published Sentinel Event Alert on hospital-acquired infections (HAIs).  The advisory group of 20 experts began the latest review of the current Infection Control standards, a process expected to continue through the first half of 2003.

The JCAHO explained that the Sentinel Event Alert #28 was issued because the number of patients acquiring infections in the healthcare setting remains high, despite the small number of infection-related case reports it typically receives. The JCAHO further noted that numerous high-profile media reports of incidences of patient deaths resulting from healthcare-associated infections might indicate that such cases are seriously underreported.

The Sentinel Event Alert emphasizes that patient death or permanent injury/loss of function as a result of a nosocomial infection indeed meets the criteria for reviewable sentinel events. Consequently, the JCAHO is interested in identifying strategies learned from the experiences of those reporting such sentinel events. The value of the root cause analysis, required for each reportable sentinel event, JCAHO explains, may lead to system changes.

Dr. John Burke, a physician at LDS Hospital, Utah, noted in a recent article on nosocomial infections in the New England Journal of Medicine (February 13, 2003) that a root cause analysis would not be helpful in identifying the cause and source of some infections. Burke points out that epidemiologic methods, frequently case control studies, are powerful tools that have been used to identify causes and sources of infection over long time periods. Infection control experts agree that the challenge is knowing which tools (case controls or root cause analyses) to use for different cases and what criteria should be used to define a sentinel event that meets the JCAHO definition. Safety, quality improvement, and infection control staff at many hospitals are working together to define which events are most appropriate and the events to consider will vary among hospitals based on their patient populations and other factors.

JCAHO recommends that organizations manage all identified cases of death and major permanent loss of function attributed to a nosocomial infection as sentinel events, and has published a number of strategies that institutions have initiated following their analyses of an infection-related sentinel event. However, JCAHO strongly recommends that healthcare organizations comply with new hand hygiene guidelines established by the Centers for Disease Control and Prevention. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings and to demonstrate that organizations can help prevent the spread of germs from one patient to another by improving hand hygiene.

Downloads and links

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CDC's hand hygiene guideline spurs controversy

Alcohol-based hand agents have been welcomed by clinicians because of evidence supporting their effectiveness and key role in improving compliance, and are the centerpiece of the hand hygiene guidelines released by the Centers for Disease Control and Prevention (CDC) in October 2002.  Although immediate, widespread use of these agents in healthcare was expected, implementation has slowed because of perceived conflicting regulations from the Occupational Safety and Health Administration (OSHA), the National Fire Protection Association (NFPA) and the Centers for Medicare and Medicaid Services (CMS).

In the February 2003 issue of Infection Control Today® the team from the Premier Safety Institute - Gina Pugliese, Judene Bartley and Dr. Tammy Lundstrom - argue for speedy implementation of new rules and a common-sense approach to interpretation of potentially conflicting regulations from OSHA, NFPA and CMS.

The issues being debated:

  • OSHA handwashing requirements -The October 2002 CDC guidelines are consistent with the OSHA Bloodborne Pathogen Standard, which some may perceive only permit soap and water as an acceptable handwashing method. Waterless alcohol-based products are, in fact, an acceptable method for hand hygiene in the absence of visible dirt or exposure to blood or other potentially infectious material.
     
  • NFPA flammability issues - In the absence of scientific data about the risk of fire associated with dispensers of alcohol-based hand products, the benefits of prevention of infections in patients and workers clearly outweighs the risk, the authors argue.  The NFPA’s current regulations do not specifically address the use of alcohol-based hand sanitizers, and many states advocate common-sense approaches to dispenser placement in corridors and patient rooms.
     
  • CMS corridor obstruction issues - The CMS has hinted that alcohol gel dispensers may violate the agency’s "4 inch rule” prohibiting wall attachments to project into a corridor because they could obstruct traffic or contribute to a fire. “It is highly unlikely that the intent of this rule was to interfere with the quality of patient care or worker safety,” according to the authors. Moreover, the authors urge organizations to consult with state health facility planning departments about the dispensers, many of which may already meet the 4-inch rule.

Downloads and links

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NQF releases final safe practices and quality measures

The National Quality Forum (NQF) recently released 26 "safe practices" that should be universally utilized in applicable health care settings to reduce harm resulting from processes, systems, or environments of care. Noting that adverse events are a leading cause of death and injury, the NQF report identifies safe practices in five specific categories: promoting a culture of safety; matching healthcare needs with service delivery capabilities; facilitating information transfer and clear communication; adopting safe practices in specific clinical settings or for specific processes of care; and increasing safe medication use.

The NQF also endorsed eight new measures to be included in the first set of 39 national voluntary consensus standards for measuring quality of hospital care. Hospital performance measures are routinely used, but there has been no standardized, uniform measures intended for public reporting, according to the organization. These measures allow comparison of the quality of care in acute hospitals across the nation in several categories. NQF endorsement of the performance measures allows these measures to be more easily used by Medicare and other federally funded healthcare programs.

Downloads and links

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CDC and military report few serious adverse vaccination events

By the end of February 2003, the Department of Defense (DoD) and the Centers for Disease Control and Prevention (CDC) reported few moderate-to-serious adverse events since the program started on January 24. More than 8,000 DoD healthcare workers, over 100,000 military operational forces and 7,350 civilian healthcare workers have received the smallpox vaccine.

CDC reported the first moderately serious event among civilian healthcare workers (generalized vaccinia) resolved with return to work after fifteen days.. A 39 year-old nurse had been vaccinated in the past and the rash appeared to be resolving. A second adverse event - angina or chest pain - is not known to be causally associated with smallpox vaccinations. No potentially life-threatening events to be caused by smallpox vaccination have occurred, and only 23 individuals have reported non-serious adverse events. The most common signs and symptoms include fever, rash, malaise, pruritus, hypertension and pharyngitis. The CDC said adverse events are not necessarily associated with the vaccination and may be incidental. CDC data were revised March 3, 2003, with two additional reports of serious eye infections out of 12,690 vaccinated civilian healthcare workers. These infections were treated and resolved. The agency plans to continue publishing regular smallpox vaccination surveillance reports in its Morbidity and Mortality Weekly Report.

Relatively few of the more than 108,000 smallpox vaccinations completed by the DoD experienced even minor adverse reactions. As of February 12, 2003, the Military Vaccine Agency characterized only four cases as moderate to serious reactions. Two cases of possible encephalitis, one case of rash (generalized vaccinia) and one case involving an eye infection have resolved, as have the small number of mild skin-related reactions not classified as generalized vaccinia. The Department of Defense said the soldiers experiencing the more severe reactions have recovered and returned to duty. See the military summary.

On a related note, the CDC unveiled a Hospital Smallpox Vaccination Monitoring System (HSVMS) to help hospitals monitor and track workers who receive the smallpox vaccine. A fact sheet and a frequently asked questions sheet are available to explain its implementation. The Web-based application is a free service to hospitals and supports the CDC smallpox vaccination program. It is designed to capture data such as symptoms reported by vaccine recipients, fitness for duty and workdays lost, and produces summary and overview reports of the hospital's experience. See the CDC vaccination site.

The Final recommendations for using Smallpox Vaccine in a Pre-Event Vaccination Program were also released by CDC at the end of February.

Download and links

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FDA antibiotic labeling rule addresses MD role in patient education

The U.S. Food and Drug Administration (FDA) announced in February that a final rule outlining new labeling regulations designed to help reduce the development of drug-resistant bacterial strains is available in the Federal Register. The new rule requires a statement in the labeling encouraging physicians to counsel patients about the proper use of antibiotic drugs and the importance of taking them as directed. (See FDA summary). For more information on antimicrobial resistance, refer to CDC’s twelve-page brochure Addressing the problem of antimicrobial resistance.

The FDA said the final rule is designed to reduce the inappropriate prescription of antibiotics for children and adults with common ailments such as ear infections and chronic coughs. The agency said prescribing antibiotics to children with viral infections could hasten the development of bacterial strains that are antibiotic-resistant. In older adults, the use of antibiotics to treat chronic coughs when sputum thickens is a common example of the over-prescription of antibiotics. Recent reports have warned of increasing antibiotics resistance in common microorganisms, such as streptococcus.

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Adverse events common after hospital discharge

A recent study in the Annals of Internal Medicine looked at adverse events occurring after hospital discharge. By examining a teaching hospital’s 400 patients discharged to home after a general medicine hospital stay, the authors reported that 76 individuals experienced an adverse event - defined as injuries occurring as a result of medical management - after hospital discharge. Researchers concluded that 23 of these patients had preventable adverse events and 24 had adverse events that could have been made less severe by appropriate medical management.

Most adverse events were related to drugs or procedures and did not result in permanent disability. Researchers noted that the transition from hospital to home is a potentially vulnerable period, and implored the medical community to explore ways of reducing adverse events during this transition.

Downloads and links

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Safety tools

 

Law guide - smallpox vaccine injury

Healthcare providers and environmental health, safety, and security managers should be aware of a guide addressing legal and risk management issues for hospitals related to the smallpox vaccine. The Smallpox Vaccine Injury and Law Guide, written by Edward P. Richards, J.D., M.P.H., and Katharine C. Rathbun, M.D., M.P.H., is a continuously updated resource that discusses how the medical risks of smallpox vaccine can legally impact a healthcare facility.

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Assessment guide - facility disaster risk assessment tool

The American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE) recently released guidelines for assessing the vulnerability of a building's air, water, and food systems affected by disasters. The report, Risk Management Guidance for Health, Safety and Environmental Security under Extraordinary Incidents, covers several issues related to infrastructure and environmental risks during disaster events, including food, mail, and personnel security and safety; transportation; childcare; and building access.

Download ASHRAE's report (220 KB)

An executive summary may be downloaded from the ASHRAE Web site:
http://xp20.ashrae.org/about/extraordinary.pdf

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Complete program - Medication safety strategic plan, case studies, resources

A set of tools designed to reduce medication errors and help hospitals take a system-based approach to address such errors was released December 10, 2002, at the 37th American Society of Health-System Pharmacists Midyear Clinical Meeting. The tools - Pathways for Medication Safety - were developed by the AHA, the Health Research and Educational Trust and the Institute for Safe Medication Practices with support from The Commonwealth Fund.

Organized in a modular format to suit different organizations and professionals, the three main Pathways components help hospital leaders and professionals incorporate medication safety into an organization's strategic plan; identify specific error-prone processes and devise safe alternatives using a process flow diagram; learn from case scenarios and the ISMP's 10 Key Elements of Medication Use System; and prepare to implement a bedside bar-coding system for administering medications. Pathways for Medication Safety is free. More than a dozen tools cover a range of topics from error reporting, chemotherapy and medication safety. Below is a sample of tools that are available in the appendices.

  1. An executive rounds tool describing how a culture of safety can be fostered (92 KB).
  2. A sample medication error reporting form designed to collect and analyze actual and potential medication errors (97 KB).
  3. A checklist/action plan for the safe use of high-alert medications (182 KB).
  4. A sample policy detailing a blame-free adverse drug event reporting program (116 KB).
  5. A patient safety tool helping patients understand their rights and responsibilities regarding safe medication use (81 KB).

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Checklist - wrong-site surgery

Wrong-site surgery affects the patient and surgeon and results from poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, or a simple mistake in communication between the patient and the surgeon. According to an advisory statement released by the American Association of Orthopaedic Surgeons (AAOS), wrong-site surgery is not confined to orthopaedic surgery. The AAOS has published recommendations for eliminating as well as managing the discovery of a wrong-site surgery. It also provides a patient safety checklist (55 KB) that can be used preoperatively to help eliminate potential errors.

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Guidance - CPOE evaluation and case studies

A January 2003 report expands the information base available to hospital leaders regarding computerized physician order entry (CPOE). CPOE has the potential to reduce medication errors and adverse drug events and improve the quality of care. An estimated five percent of hospitals now have CPOE, but many more are considering this investment. The report also explores CPOE implementation, costs, challenges, benefits, and lessons learned. The study was done on behalf of AHA by First Consulting Group and is available to the public at the AHA site:

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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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