May 2006
Dear Colleague:
We highlight a number of high profile issues in this month’s newsletter, including:
- respiratory protection for influenza,
- drying alcohol-based hand rubs to avoid sparks, and
- bed safety assessment, not measurement.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Drying hands after use of alcohol hand rubs reduces risk of sparks from static
- Universal Protocol will not prevent all wrong-site surgeries
- Board of directors' engagement in quality linked to improved hospital performance
- Government stresses need for local and individual disaster plans
- IOM report on mask use provides opportunity to focus on assessment-based respiratory protection
- Medication Reconciliation collaborative shares tools, lessons
- Experts caution rigid interpretation of FDA guidance on bed safety; call patient assessment 'key'
- Community hospitals challenged by 80 percent nursing vacancy rate, lack of critical care beds
Safety tools
- California sponsored training videos – pandemic influenza
- JCAHO – New patient safety practices online resource
- Handwashing video for children
- OSHA – online handbooks on glutaraldehyde and mold
Drying hands after use of alcohol hand rubs reduces risk of sparks from static
Joint Commission Resources (JCR) recently reported that a healthcare worker at a Michigan hospital received a small (2 cm) burn to the hand and redness to her wrist after an electrostatic discharge (ESD) ignited alcohol-based hand rub on her hands. The employee had just applied the hand gel when the nurse call system rang. She reached for the handset and, upon contact, received an electrostatic shock that caused a bright flash. The minor injury to the employee was limited to the hand. It is believed that the source of the ESD may have been the fully carpeted environment.
The hospital nurse call system was found to be functioning properly. The hospital instituted an action plan, including educating staff on appropriate use of alcohol-based hand rub according to manufacturer labeling and recommendations, particularly thorough drying of hand gel before beginning a task.
Improving hand hygiene compliance is a major quality and safety initiative in healthcare today. A rare incident such as this is an opportunity to remind staff about safety measures to reduce potential risks associated with the use of alcohol-based hand rubs and other sources of ignition. These include rubbing hands until completely dry before beginning a task, placement of dispensers at correct distances from ignition sources in accordance with JCAHO recommendations and proper storage of containers according to CMS requirements.
JCR news:
http://www.jcrinc.com/generic.asp?durki=12614
FAQ on placement of dispensers
JCAHO recommendations and CMS requirements:
http://www.ashe.org/ashe/codes/handrub/
Universal Protocol will not prevent all wrong-site surgeries
A recent study by Kwaan and colleagues in the April 2006 issue of Archives of Surgery found that current site-verification protocols could have prevented only two-thirds of cases of wrong-site surgery and many protocols involve considerable complexity without clear added benefit. The researchers identified 25 non-spine wrong-site operations among 2.8 million operations at more than 28 institutions –an incidence of 1 in 112,994. Researchers also investigated the characteristics and cases of wrong-site surgery and characteristics of site-verification protocols.
Medical records were available for review in 13 of the 25 cases. Patient injury was temporary and minor in 10 of the 13 cases; the median indemnity payment for all of the non-spine wrong site surgeries in the cohort was $12,000.
It was determined that of the 13 non-spine cases reviewed, 9 involved ambiguity or error that preceded the arrival of the patient at the operating room area on the day of surgery. For five of the 13 cases (38 percent), it was judged as unlikely that the universal protocol would have prevented them. For example, in one case, a magnetic resonance image of the knee was printed out at the referring hospital for the incorrect patient with the same name as the correct patient. In another case, the surgeon decided to change the side of the scheduled procedure for a patient with bilateral disease in the preoperative holding area. The surgeon obtained updated informed consent after the patient had been sedated and the patient did not recall consenting to the procedure. Two cases involved multiple lesions and there was uncertainty on the part of the patient and the surgeon regarding which lesion was to be removed. Site marking would not have prevented these errors.
Significant variability was found in processes in which cases required site marking (all cases, as required by JCAHO, or only cases involving laterality), who should perform the marking (surgeon, nurse or patient), and how the marking should be performed (writing initials or "yes"). The researchers noted that many protocols required significant personnel time for multiple and enforced redundant checks (up to 20 checks per patient) without clear added benefit. They suggest that simplification of protocols would improve adherence and efficiency and allow surgical teams to focus their limited time and energy on prevention of more common and harmful errors.
The authors also explained that rates of wrong-site surgery differ among specific procedures, potentially explaining why a study of hand surgeons showed wrong-site surgery to be four times more common than the rate found in this study.
Abstract, Kwaan et al. Archives of Surgery 2006 (.doc) (24 KB)
Tools for wrong-site surgery protocols
Board of directors' engagement in quality linked to improved hospital performance
CEOs and board chairs are well attuned to public reporting of quality measures but most are not familiar with the two Institute of Medicine (IOM) landmark reports on quality and safety – "To Err is Human" and "Crossing the Quality Chasm." A recent survey asked CEOs and/or board chairs from 30 hospitals in 14 states to rank their familiarity, satisfaction and level of engagement in a number of quality issues on a scale of 1 to 10 (highest). The results indicated CEOs had more familiarity with IOM reports, with CEOs' mean ranking of 7.4, compared to 4.16 for all board members and 4.9 for board chairs. Both the CEOs and board chairs had a high level of understanding of publicly reported quality data, with mean rankings of 8.0 for both. CEOs and board chairs reported that about one third of board meetings are devoted to discussing quality issues. Board chairs tended to be more confident than CEOs that they were using the right measures to drive quality improvement and effectively integrating quality and strategic planning.
Approximately half of the respondents indicated that CEO variable compensation was linked to quality (a mean amount of compensation 15 percent). Two thirds of all respondents reported using patient satisfaction surveys.
For CEOs, a composite knowledge of quality measure was found to be significantly correlated with board engagement and was positively related to both the rate of progress in improvements and assessments of a culture that supports progress.
The authors suggested a number of strategies to enhance the engagement of hospital boards in quality, including: (1) increasing education on quality to increase the board's quality literacy; (2) improving the framing of an agenda for quality; (3) more quality planning, focus, and incentives for leadership and governance for quality improvement; and (4) greater focus on the patients.
Abstract, Maulik et al. JC Journal of Quality and Safety, April 2006 (.doc) (25 KB)
Government stresses need for local and individual disaster plans
The "National Strategy for Pandemic Influenza: Implementation Plan" from the federal government stresses that governments, businesses, schools, and hospitals must all have individual plans to deal with a pandemic like one that may be caused by bird flu. The updated pandemic preparation plan offers little new information and asserts that states, cities, and businesses should not be expected to be rescued by the federal government. The new plan provides detailed advice beyond the healthcare focus of the "HHS Pandemic Influenza Plan," released last November by the Department of Health and Human Services (HHS). That plan focused largely on HHS' efforts to procure vaccines and antiviral drugs to blunt the pandemic's potential impact.
The new implementation plan describes more than 300 critical actions that the government will take, many of which have already been initiated, and outlines what non-federal agencies should do for pandemic preparedness. Individual plans have been drafted by various federal agencies and are expected to be released over the next several weeks. The report divides planning and response efforts into eight areas: federal government planning; federal government response; international efforts; transportation and borders; protecting human health; protecting animal health; law enforcement and public safety; and institutions. The plan also has an appendix with advice for schools, the business sector, families, and individuals. The latest plan is intended to explain the steps that federal agencies; will take to deal with a pandemic. The document lists several other methods to reduce the spread of the virus:
- Social distancing measures, such as advising people to stay at least 3 feet apart;
- Using more telecommuting or teleconferencing for work;
- Closing schools;
- Canceling non-essential public gatherings;
- Restricting long-distance travel; and
- "Snow-day restrictions" – suggestions or mandates by community authorities that everyone stay home for two incubation periods (about four days for seasonal flu viruses).
Other recommendations advise colleges to consider which dormitories could be used to quarantine the sick, and advise flight crews to use surgical masks for coughing travelers. The response plan anticipates that as much as 40 percent of the work force could be off the job, focusing on minimizing the damage. The report also addresses the importance of private sector businesses continuing to function in the face of absenteeism, but no one is actually charged with verifying whether the vital businesses are, in fact, compliant.
A special issue of U.S. News and World Report devoted to emergency preparedness highlighted similar planning in a recent Health Summit, summarizing lessons learned from localized disasters such as Hurricane Katrina and the SARS outbreak. The summit detailed the responsibilities of each federal agency as well as issues relating to vaccine development, stockpiling of antiviral medications, communication plans, international and domestic monitoring, and screening people who enter the country. Suggested resources include emergency disaster plans from Harvard Medical school and the Red Cross.
Download the National strategy briefing book and fact sheet the from Premier Safety Institute's Influenza online resource.
Transcripts from the U.S. News & World Report Health Summit:
http://www.usnews.com/usnews/health/emergencyprep/
Harvard Medical School's three-step plan (.pdf) (44 KB)
Red Cross disaster plan (.pdf) (668 KB)
HHS disaster planning kit:
http://www.ready.gov/america/get_a_kit.html
IOM report on mask use provides opportunity to focus on assessment-based respiratory protection
A recent Institute of Medicine (IOM) report confirmed that disposable masks and N95 respirators cannot be effectively reused. The report provides the opportunity to restate the need for assessment to determine types of respiratory protection needed. Masks, not N-95s, are appropriate for most patient interactions.
Assuming that supplies may run short in an influenza pandemic, the U.S. Department of Health and Human Services (HHS) asked the IOM to assess the possibility of reuse of disposable masks and N95 respirators. A panel of experts concluded that there is no practical way to clean disposable masks and N95 respirators to permit safe reuse. However, a mask or respirator can be used more than once by the same person, provided either is still in good condition. The IOM panel also called for HHS to sponsor research on how well masks, respirators, and other filtering materials protect against influenza viruses, as well as developing methods to decontaminate masks and respirators without damaging them. Committee co-chair John C. Bailar, professor emeritus, University of Chicago, stated that respiratory protection through the use of face coverings is only one of many strategies that will be needed to slow or halt a pandemic outbreak of influenza.
Pandemic influenza: In its pandemic influenza plan released in November 2005, HHS recommended that healthcare workers employ the same infection control practices for pandemic flu as for other human influenza viruses. In Supplement 04 of the plan, precautions include wearing a surgical or procedure mask when caring for influenza patients, and a N95 respirator only when performing aerosol-generating procedures such as endotracheal intubation, suctioning, or aerosolized nebulizer treatments.
The use of masks for respiratory protection is reinforced in the World Health Organizations' (WHO) influenza pandemic preparedness plan. The WHO's clarification also recommends that healthcare workers who will be within three feet of patients infected or suspected to have pandemic influenza use masks during general care and use N95s for aerosol-generating procedures.
Reuse: The IOM panel concluded that if a N95 respirator will be reused by the same person, it should be protected with a medical mask or a clear plastic face shield to prevent surface contamination. Users should store the respirator carefully between uses and should clean his or her hands before and after handling. Manufacturers pointed out that several models of masks can be used repeatedly by the same person until they become damaged, moist, soiled or hard to breathe through. Again, users should clean hands before and after handling.
Infection control experts point out that the primary mode of transmission of typical influenza viruses is by large droplet within short distance. As such, the use of standard masks and handwashing remains the primary method to prevent transmission.
IOM report – Facemasks & Pandemic Flu and additional information from the Premier Safety Institute's Influenza online resource.
HHS Pandemic Influenza Plan:
http://www.hhs.gov/pandemicflu/plan/
Medication Reconciliation collaborative shares tools, lessons
Fifty hospitals collaborated in a patient safety initiative developed by and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. A toolkit was developed as part of this collaborative to support hospitals' adoption of safe practices for reducing medication errors – including recommendations for medication reconciliation and strategies for putting the recommendations into practice, checklists, tests of change, flow charts, same hospital policies and forms, patient medication cards, and staff education materials. Hospitals nationwide are using these tools to comply with the JCAHO's National Patient Safety Goals and the Institute for Healthcare Improvement's 100,000 Lives Campaign. The safe practice recommendations, many of the implementation strategies, and sample tools are available for download from the Massachusetts Coalition for the Prevention of Medical Errors.
This collaborative was summarized in the article, "Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies," published in the January 2006 issue of the Joint Commission Journal on Quality and Patient Safety.
Massachusetts coalition
http://www.macoalition.org/Initiatives/RMToolkit.shtml
Abstract, JCAHO Medication reconciliation (.doc) (24 KB)
The abstract can be purchased at:
http://www.jcrinc.com/subscribers/journal.asp?durki=32.
JCAHO National Patient Safety Goals – Medication errors:
http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/
Experts caution rigid interpretation of FDA guidance on bed safety; call patient assessment 'key'
A joint regulatory advisory released by the American Society for Healthcare Engineering (ASHE) and the American Society for Healthcare Environmental Services (ASHES) urges its members to continue placing patient assessment before bed measurements when implementing strategies to prevent life-threatening bed entrapment. The advisory was released in response to the FDA's "Guidance for Industry and FDA Staff – Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment."
The FDA Dimensional Guidance document provides additional guidance to the current body of knowledge on bed rail entrapment. In September 2002, the Joint Commission on Accreditation of Healthcare Organizations issued Sentinel Event Alert #27 – "Bed Rail-Related Entrapment Deaths." The alert reported that over a 10-year period, JCAHO received reports of seven deaths or injuries related to bed rails; three of these reports were from hospitals. As a result, hospitals examined the issue of bed rail entrapment within patient safety or risk management programs, addressed patient risk assessment, clinical staff training, and appropriate changes to the beds to close gaps resulting in reduced risk of entrapment. The JCAHO recommended re-evaluation of beds for entrapment potential, though no guidance existed at that time regarding gap measurement or appropriate sizing of mattresses. With the release of the FDA Dimensional Guidance document, which has now established critical dimensions and a measurement procedure, AHA/ASHE is alerting healthcare providers to maintain their focus on patient assessment as they review and use this guidance for hospital bed measurement.
Since the 2002 alert, hospitals have effectively managed the risk of entrapment without an undue focus on bed measurement. ASHE/ASHES recommend that policies and procedures that were developed using a risk assessment process continue as the primary strategy, and only then consider bed measurement to protect the patient. Bed measurement should be considered in full context of gains in patient safety and hospitals and not divert attentions from patient assessment. Clinical evaluation identifying a vulnerable patient should result in appropriate mitigation strategies to provide a safe bed environment.
Hospitals are encouraged to work with their patient safety committee to review their organizations' policy and procedures regarding bed rail entrapment and determine if revisions are necessary. Many hospitals have standing task forces on patient restraint and prevention of patient falls that may also be addressing entrapment risks on an ongoing basis. In addressing entrapment, task force members should include nursing, risk management, facilities management, materials management, environmental services, physical therapy, infection control, and administration. Points for the task force to consider are:
- Creation of a purchasing specification requiring all new hospital beds meet the dimensional criteria of the FDA Dimensional Guidance document.
- Determination that clinical procedures are in place to assess patients for vulnerability to entrapment.
- Provision for current mitigation techniques (such as bumpers, pads, netting, etc) that are effective and available for all types of beds that may used for the care of patients vulnerable to entrapment.
- Reference materials to assist in completing the risk assessment.
Download the ASHE/ASHES advisory (.pdf)
(72 KB)
or go to http://www.ashe.org.
Download FDA Guidance (.pdf) (860 KB)
Download Clinical Guidance (.pdf) (461 KB)
JCAHO Sentinel Event Alert #27 – Bed Rail-Related Entrapment Deaths
http://www.jointcommission.org/SentinelEvents/
SentinelEventAlert/sea_27.htm
Community hospitals challenged by 80 percent nursing vacancy rate, lack of critical care beds
The American Hospital Association (AHA) has released results of a survey of more than 1,000 community hospital leaders on workforce shortages, emergency department diversions; rising costs and disaster readiness.
According to the AHA survey, there are 118,000 registered nurse vacancies nationally – an 8.5 percent vacancy rate in 2005, compared with an 8.1 percent rate reported in 2004. Half of the hospitals leaders reported their emergency departments "at or over capacity," mostly due to a lack of staffed critical care beds. Gaps in emergency department specialty coverage were reported by 42 percent of survey respondents. Almost one-third reported that medical liability issues are affecting their hospitals' ability to provide services, particularly obstetrics. Hospitals also continue to face significant increases in the costs of pharmaceuticals and other supplies.
State Hospitals Chart Pack 2006 (.ppt) (252 KB)
Safety tools
California sponsored training videos – pandemic influenza
California is one of many states that have initiated pandemic influenza planning. Its online resources and information can be found at the California Distance Learning Health Network (CDLHN), a non-profit organization of the Graduate School of Public Health at San Diego State University. The section on pandemic influenza resources includes the U.S. national strategy for pandemic influenza and World Health Organization avian influenza updates. A summit designed to inform California leaders in business, education, local government, healthcare, social services and other sectors to better prepare California for influenza pandemic is available as a Webcast. The summit presents the current threat of avian influenza and the risk of a human influenza pandemic and several training videos related to mass vaccinations and disease investigation.
JCAHO – New patient safety practices online resource
The Joint Commission International Center for Patient Safety has a new online resource that links to resources related to sentinel events and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals. The site, "Patient Safety Practices," contains tools and resources addressing issues related to the causes and types of adverse events, U.S. and International Patient Safety Goals and free access to many of their articles from a variety of journals, including the "Environment of Care." http://www.jcipatientsafety.org/psp
Handwashing video for children
An eight-minute video on proper handwashing technique titled "Last Clean Chance" has been produced by the Mecklenburg (NC) County Health Department. The science fantasy thriller is set in a bio-research lab. The video involves a doomsday scenario in which a virus is leaked into the lab space. Tailored for the young viewer, the video teaches a valuable skill and reminds us that handwashing is the number one way to prevent the spread of disease. Access the video and information online at
http://www.charmeck.org/Departments/Health+Department/
Communications/Last+Clean+Chance.htm.
OSHA – online handbooks on glutaraldehyde and mold
Two new handbooks are available online from Occupational Safety and Health Administration (OSHA): "Best Practices for the Safe Use of Glutaraldehyde in Health Care," which helps employers and employees understand and control exposures to glutaraldehyde, a chemical used to disinfect and clean heat-sensitive medical, surgical and dental equipment – http://www.osha.gov/Publications/glutaraldehyde.pdf; And "Preventing Mold-Related Problems in the Indoor Workplace," which offers recommendations to owners, managers, and occupants on how to fix mold problems in buildings – http://www.osha.gov/Publications/preventing_mold.pdf.
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, CUA, Web master
- Jena Abernathy, Executive sponsor
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.
Safety Share © 2006 Premier, Inc.
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