May 2007
Dear Colleague:
The Safety Institute has launched a new Web site on Tubing misconnections and added to the Culture of Safety site the newly released benchmarking data from AHRQ on the patient safety culture survey.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Premier receives major industry honor for environmental leadership fifth consecutive year
- Social distancing and infection control are basis of pandemic flu guidance for public-home setting; masks and respirators secondary
- FDA approves first H5N1 influenza vaccine
- AHRQ releases safety culture survey benchmarking data from 382 hospitals; results show strong teamwork but room for improvement with handoffs
- House members call for unique medical device identification to improve patient safety
- AHRQ report: Most adverse drug events in hospitals not caused by errors
- OSHA requires blunt-tip suture needles for surgery
- 'Location, location, location': Inconveniently placed dispensers adversely impact hand hygiene
Safety tools
- AHA – CEO leadership tools
- CDC – QuickStats on training ER staff for emergency preparedness
- AHRQ tools – Podcast on reducing BSI; safety tips; emergency response planning
- RFID – Web-based resource center available
- The Joint Commission – FAQs on tissue storage
- CDC – HAI summary and slide set
Premier receives major industry honor for environmental leadership fifth consecutive year
The Premier healthcare alliance received a major healthcare industry environmental honor for the fifth consecutive year, recognizing its national leadership in helping healthcare organizations advance environmental sustainability to lower costs, promote quality and preserve the communities they serve.
Hospitals for a Healthy Environment (H2E) – a collaborative healthcare industry effort to promote environmental sustainability – presented the 2007 "Champions for Change" award to Premier at its annual Environmental Excellence Awards program held May 14 in Minneapolis, MN. Premier, the first hospital group purchasing organization (GPO) to earn the prestigious award, now becomes the first GPO to receive the honor five years in a row.
Central to its receipt of the Champions for Change award were Premier's extensive efforts to help hospitals address critical environmental health issues by reducing or eliminating environmentally harmful products and processes, such as those related to toxic waste and mercury use. These environmental and public health issues pose a growing industry concern, as questions continue to surface about the long-term effects of products containing mercury, phthalates and other hazardous substances identified by the Environmental Protection Agency.
Another selection factor was the Premier Safety Institute's suite of educational offerings – both for Premier member healthcare institutions, as well as the industry at-large. The Safety Institute provides Web-based tools and resources for establishing "green" programs and practices. Green Corner, another Premier Web resource, showcases hospital and supplier success stories about green initiatives that contribute to a safer, healthier community. Premier's corporate information technology team used the same green Web-based tools and resources it provides healthcare institutions to help Premier recycle and safely dispose of more than 5 tons of excess IT equipment over the past two years.
More than 137 Premier member healthcare organizations are current H2E Partners, and have pledged to make changes in their facilities that will protect the health of the environment and the communities they serve. Premier joins Catholic Healthcare West and Covenant Health Systems along with 20 other organizations in receiving the Champions for Change award this year. The Champion for Change Award is given to organizations that take a leadership role in improving environmental performance in healthcare. Other Premier members have also earned distinction as honorees for other H2E awards, recognizing efforts in waste reduction, total mercury elimination and less toxic and safer healthcare practices.
Safety News link to press release
Safety Institute's EPP Web-based tools and resources
Safety Institute's Green Corner
Social distancing and infection control are basis of pandemic flu guidance for public-home setting; masks and respirators secondary
Very little is known about the benefits of wearing facemasks and respirators to help control the spread of pandemic influenza, according to the Centers for Disease Control and Prevention (CDC) in a newly released interim guidance document. CDC advises that the use of masks and respirators may have a role, but it is secondary to social distancing and infection control practices.
These interim recommendations are based on the best judgment of public health experts who relied in part on information about the protective value of masks in healthcare facilities. The guidance stresses that during an influenza pandemic a combination of actions will be needed including:
-
Practicing hand hygiene;
- Minimizing the likelihood of exposure by distancing people who are infected (or likely to be infected) with influenza away from others;
- Treating infected people with antiviral medications;
- Volunteering to stay home when caring for family members who are ill; and
- Encouraging people to avoid crowded places and large gatherings.
When used in conjunction with such preventive steps, masks and respirators may help prevent some spread of influenza. CDC Director Julie Gerberding, M.D., emphasized in a press conference that during an influenza pandemic, no single action will provide complete protection and many people may choose to use masks for an extra margin of protection even if there is no proof of their effectiveness. Gerberding noted that while studies are underway to learn more, the guidance was designed to be a "best estimate" based on what is currently known, and to help guide people's decisions regarding the use of masks.
Guidance recommendations: In the absence of clear science, the steps below offer a "best estimate" to help guide decisions. They will be revised as new information becomes available.
Consider wearing a facemask if:
- You are sick with the flu and think you might have close contact with other people.
- You live with someone who has the flu (you therefore might be in the early stages of infection) and need to be in a crowded place. Limit the amount of time you spend in these crowded places and wear a facemask while you are there.
- You are well and do not expect to be in close contact with a sick person but need to be in a crowded place. Limit the amount of time you spend in these crowded places and wear a facemask while you are there.
Consider wearing a respirator if:
- You are well and you expect to be in close contact with people who are known or thought to be sick with pandemic flu. Limit the amount of time you are in close contact with these people and wear a respirator during this time. These recommendations apply if you must take care of a sick person at home.
Download Interim Community mask use – pandemic influenza (.pdf) (105 KB)
More pandemic influenza resources from the Safety Institute
FDA approves first H5N1 influenza vaccine
The first vaccine to prevent the H5N1 influenza virus (avian or bird flu) has been approved by the FDA. The vaccine could be used if the current H5N1 virus develops the capability to efficiently spread from human to human, causing the disease to spread rapidly. According to the FDA, this vaccine may provide early limited protection in the months before a vaccine tailored to the specific pandemic strain of the virus could be developed and produced.
Manufactured by Sanofi Pasteur, Inc., the vaccine will not be sold commercially but purchased by the Federal government to be kept in the U.S. Strategic National Stockpile for distribution by public health officials if needed. The vaccine, from a human strain, is intended for immunizing people age 18 through 64 who are at increased risk of exposure to the H5N1 influenza virus. The vaccine consists of two intramuscular injections given approximately one month apart. The most common side effects were pain at the injection site, headache, general ill feeling and muscle pain, but it was generally well tolerated. Results of the clinical study conducted to collect safety information and information on recipients' immune responses showed that 45 percent who received the two-dose regimen developed antibodies at a level that is expected to reduce the risk of getting influenza. Antibodies in the remaining individuals did not reach that level but information on other influenza vaccines suggests that less than optimal antibody levels may still have the potential to help reduce disease severity and influenza-related hospitalizations and deaths.
Although no human cases of H5N1 have been reported in the United States, more than 300 people worldwide have been infected since 2003 and more than half of them have died. H5N1 influenza has remained primarily an animal disease but should the virus acquire the ability for sustained transmission among humans, people will have little immunity and the potential for an influenza pandemic would have grave consequences for global public health.
Premier Safety Institute Safety topic – Pandemic influenza
AHRQ releases safety culture survey benchmarking data from 382 hospitals; results show strong teamwork but room for improvement with handoffs
More than three-fourths (78 percent) of hospital staff believe there is a positive environment of teamwork within their patient care units, but nearly half (45 percent) indicate there is room for improvement in the area of handoffs and transitions across units. The Agency for Healthcare Research and Quality recently released the results of the 2007 Hospital Survey on Patient Safety Culture Comparative Database Report.
The report presents results from the first compilation of aggregated national data from AHRQ's Hospital Survey on Patient Safety Culture. The data include information from 382 U.S. hospitals and survey responses from 108,621 hospital staff. The report found a number of strengths among hospitals as well as areas for patient safety culture improvement. The database report provides the first national benchmarks for hospital staff assessments about patient safety issues, medical errors, and event reporting from a wide range of hospitals that participated in the AHRQ hospital safety culture survey. The report presents results by hospital characteristics such as bed size, teaching status, ownership, and geographic region. It also offers results by respondent characteristics such as respondent work area/unit, staff position and interaction with patients.
Hospitals can use the results in the 2007 report as one basis for comparison in their efforts to establish, improve, and maintain a culture of patient safety in their institutions.
Another round of voluntary data collection is planned to update the database with results from additional hospitals and evidence of change in the initial hospital set. Information on eligibility, registration, and data submission are available at the AHRQ Web site. Select the link under "Year 2 Comparative Database." The deadline for data submission is June 30, 2007.
Premier Culture of Safety – More information on the Customized Excel™ Data Tool
AHRQ Web site: http://www.ahrq.gov/qual/hospculture
House members call for unique medical device identification to improve patient safety
Citing the need to improve patient safety and healthcare efficiency, 26 House members, led by Reps. Mike Doyle (D-PA) and Pete Sessions (R-TX), asked the FDA to require a national unique device identification (UDI) system. The letter from the Advancing Patient Safety (APS) coalition urges FDA Commissioner Andrew C. von Eschenbach to move forward as soon as possible on a national UDI system.
"A national UDI would improve patient safety, reduce medical errors, enhance device recall processes, and improve device adverse event reporting," the lawmakers said. "We believe that our nation's health care system will benefit by having a defined UDI system with a global nomenclature that complements the FDA National Drug Code system."
The APS coalition, of which Premier is a member, is advocating for a national UDI system.
APS coalition letter from Congress to FDA
AHRQ report: Most adverse drug events in hospitals not caused by errors
The Agency for Healthcare Research and Quality (AHRQ) recently released a report that describes the types of patients seen with adverse drug events (ADEs) in U.S. hospitals, and details of the types of ADEs reported. The report is based on 2004 data from the Healthcare Cost and Utilization Panel's (HCUP) Nationwide Inpatient Sample. The data indicated that ADEs were found in approximately 3.1 percent of all hospital stays. ADEs are separated into two main categories: adverse effects of properly administered drugs; and drug poisoning, which includes accidental overdoses, wrong drugs given or taken in error, or drugs taken inadvertently. Care was taken to exclude hospital stays associated with illicit drug use or with evidence of intentional harm, self-inflicted or otherwise.
Most ADEs (90.3 percent) were attributed to the side effects of properly administered medications. The medications were properly administered in therapeutic and prophylactic dosages but patients experienced an adverse event such as an allergic or hypersensitivity reaction. Only 8.6 percent of ADEs were attributed to patients receiving an incorrect medication or dose in the hospital or from patients accidentally taking an incorrect dose or the wrong medication before being admitted. Slightly more than 1.1 percent of the ADEs were classified as neuropathy or dermatitis due to medications.
The most common general causes of ADEs across the adverse effects and poisoning categories were analgesics, antipyretics, and antirheumatics (medications used to treat pain, fever, inflammation and arthritis). Those most commonly associated with adverse effects included:
- Corticosteroids (11.6 percent);
- Anticoagulants (9.4 percent);
- Antineoplastic agents and immunosuppressant agents used to prevent rejection of organ transplants (9.6 percent);
- Opiates such as codeine and morphine (5.7 percent); and
- Analgesics and antipyretics (4.6 percent).
Medications most associated with drug poisoning were benzodiazepine tranquilizers (9.7 percent), opiates (7.3 percent), and aromatic analgesics (5.1 percent) such as acetaminophen.
Compared with all inpatients, the patients with ADEs categorized as adverse events such as an allergic or hypersensitivity reaction were generally over age 65, (mean age of 63.3 years), while the mean age of patients with ADEs categorized as drug poisoning was 47.4 years with most in the age range of 18 to 64.
AHRQ HCUP report (.pdf) (228 KB)
OSHA requires blunt-tip suture needles for surgery
The leading cause of percutaneous injuries to surgical personnel is sharp-tip suture needles. A bulletin promoting the use of blunt-tip suture needles was jointly published recently by the CDC, National Institute for Occupational Safety and Health (NIOSH), and the Occupational Safety and Health Administration (OSHA), drawing attention to the importance of using blunt-tip needles to protect surgical personnel against needlestick injuries.
The bulletin emphasizes that surgical personnel, for their own safety, should use blunt-tip suture needles instead of sharp-tip suture needles when blunt-tip needles are clinically appropriate in such situations as suturing less dense tissues like muscle and fascia.
OSHA's Bloodborne Pathogens standard requires engineering controls and work practices to eliminate or minimize employee exposure. This means that if an effective and clinically appropriate safety-engineered sharp exists, an employer must evaluate and, when appropriate, implement the device. The use of a safer device is not required if its use would compromise patient safety or medical integrity. If the use of a safer device is not feasible, this must be documented in the facility's Exposure Control Plan.
The American College of Surgeons (ACS) supports the use of blunt-tip suture needles for suturing fascia, noting that all published studies to date have demonstrated that the use of blunt suture needles can substantially reduce or eliminate needle-stick injuries from surgical needles. This statement has been endorsed by the Association of Perioperative Registered Nurses (AORN), the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists.
CDC-OSHA Bulletin (.pdf) (170 KB)
Sharps FAQs – Blunt suture needles, safety scalpels and physician compliance
'Location, location, location': Inconveniently placed dispensers adversely impact hand hygiene
A recently developed tool by Medical University of South Carolina Children's Hospital identifies those factors that have a negative impact on hand hygiene, including poor location, height and visibility of dispensers and paper towel trash containers. Factors that discourage use of hand hygiene resources are related primarily to hand hygiene dispenser placement. The tool is used for safety improvement efforts.
The ergonomics-based tool is described in a March, 2007 Joint Commission Journal on Quality and Patient Safety article, "How 'User Friendly' Is the Hospital for Practicing Hand Hygiene? An Ergonomic Evaluation." The tool, dubbed "SWAG," which refers to the four main hand hygiene resources (sinks, waste receptacles, alcohol-based hand rub dispensers, and gloves), was implemented in hospitals' intensive care units and in 59 individual patient rooms.
Researchers reviewed the principles of physical and cognitive ergonomics, and propose that hand hygiene resources should be located where they are:
- Clearly visible;
- Within easy reach with unobstructed access;
- Placed at comfortable heights;
- Require minimum effort to be used; and
- Placed in standard locations in all patient rooms.
The SWAG tool has two sections, one a structural assessment, the other a periodic assessment to determine whether resources are replaced in a timely manner. The tool is very simple and new users can be trained in 10 minutes. Results found deficiencies in the structural layout of hand hygiene resources that hinder their usage, including poor visibility, difficulty of access, placement at undesirable height, lack of redundancy, and wide spatial separation of resources that are used sequentially. The ABHR dispensers were found to be located on the opposite side of the patient's bed from the glove dispenser, causing the healthcare worker to walk around the bed after washing their hands to put on gloves. Research also revealed a lack of timely replenishment of hand hygiene resources. The study authors conclude that "the provision of hand hygiene resources based on ergonomic principles should be a key component of any mulitfaceted strategy to improve hand hygiene."
Hand Hygiene – An Ergonomic Evaluation abstract
(.doc) (28 KB)
Safety Institute Hand Hygiene guideline
Safety tools
AHA – CEO leadership tools
The second in a series of collaborative leadership tools for CEOs, "Clarifying Expectations: A First Step in Developing Truly Effective Relationships Between CEOs and Trustees," is available from AHA's Center for Healthcare Governance, in partnership with Clark Consulting-Healthcare Group. This new tool (Tool 2) focuses on clarifying trustees' and CEOs' mutual expectations. It includes a simple exercise for helping trustees and CEOs refine the way they work together. Successful collaboration allows CEOs and boards to clearly define their leadership partnership, as well as define, share and establish their mutual expectations for working together. It also includes information on the sources of misunderstandings and typical expectations and describes the roles of and relationships between the CEO and the board.
- Tool 2 is available at
http://www.americangovernance.com/
americangovernance/resources/CLT/CLTtool2.html. - Tool 1: "Collaborative Leadership: A New Model for Developing Truly Effective Relationships between CEOs and Trustees" can be accessed at:
http://www.americangovernance.com/
americangovernance/resources/CLT/CLT.html
CDC – QuickStats on training ER staff for emergency preparedness
The CDC has provided advance data from vital and health statistics demonstrating wide variations in terrorism preparedness training. A study by Niska et al., "Training for terrorism-related conditions in hospitals: United States, 2003-04; No. 380," used data to determine which hospital characteristics are associated with providing terrorism preparedness training to clinical staff. The report and many updates on Emergency Preparedness may be downloaded from the Safety Institute's Emergency Preparedness Web site.
AHRQ tools – Podcast on reducing BSI; safety tips; emergency response planning
Podcast information on reducing catheter-related bloodstream infections
A recent AHRQ audio newscast series featured an interview with Peter Pronovost, M.D., Ph.D., of The Johns Hopkins University School of Medicine. Dr. Pronovost discussed his research about interventions to reduce bloodstream infections in hospital ICUs caused by central venous catheters. Patients in the United States spend about 18 million days in the intensive care unit per year and in more than 50 percent of the cases, an ICU patient will have a central venous catheter inserted. Unfortunately, approximately 80,000 patients each year develop catheter-related bloodstream infections, and about 28,000 of them will die from the infection. AHRQ podcast:
http://www.healthcare411.org/podcast.aspx?id=197
Evidence-based safety tips, emergency response
planning tool
The Agency for Healthcare Research and Quality (AHRQ) has released
10 evidence-based patient safety tips for hospitals
(.pdf) (142 KB). The tips cover many different aspects of a patient stay in a hospital or healthcare system. They include promoting a culture of patient safety, building teamwork, limiting shifts for medical residents and interns, taking positive advantage of senior ICU nurses, and adopting interventions to reduce cases of ventilator-associated pneumonia and catheter-related urinary tract infections. The 10 tips are all from evidence-based research and include suggestions that can be put into immediate practice. Each tip provides a synopsis of key data or findings from AHRQ-supported research to help organizations recognize the benefit of changing their current practices.
Emergency response planning tool
AHRQ has released a questionnaire that hospitals and other healthcare facilities can use to plan and evaluate their readiness for a public health emergency involving a chemical, biological, radiological, nuclear or explosive event. The 43-question document is divided into eight categories: administration and planning; education and training; communication and notification; patient (surge) capacity; staffing and support; isolation and decontamination; supplies, pharmaceuticals, and laboratory support; and surveillance. AHRQ is not administering nor will be compiling data from this questionnaire. The Web-based tool (http://www.ahrq.gov/prep/cbrne/) includes an Administrator's Guide, a Respondent's Guide, an Operations Manual, and a Deployment Package that contains all the files and folder structure to set up a Survey Administrator's site, a Survey site, a SQL Server™ database, and a log for run time exceptions.
RFID – Web-based resource center available
The Health Industry Business Communications Council (HIBCC) launched a RFID (radio frequency identification) Resource Center www.hibcc.org/AUTOIDUPN/RFID.htm in April 2007. HIBCC is a non-profit organization that facilitates electronic communications by developing appropriate standards for information exchange among all healthcare trading partners. The RFID Resource Center includes an implementation guide describing the use of HIBC (Health Industry Bar Code) Standards with RFID, an overview of RFID technology (including its potential applications and costs), a white paper, "RFID In Healthcare: Benefits, Limitations & Recommendations," and other related articles.
The Joint Commission – FAQs on tissue storage
As of April 7, 2007, The Joint Commission added a new extensive list of
frequently asked questions (FAQ)
(.doc) (65 KB) to its Web site on "Tissue Storage or Issuance" under the standard "Provision of Care." Multiple aspects are addressed. The new information explains what the Joint Commission is looking for in adverse tissue reaction policies, such as the reporting of potential disease transmission to the recipient when notified by the donor source facility and reporting adverse patient reactions to the donor source facility. These actions must be carried out and the tissue's unique identifier must also allow the organization to easily trace the records when notified of a problem by either the donor facility or the patient's physician. Tracing the tissue records includes the complete chain of events, including who handled the tissue, how it was transported, stored and processed, dates and times such activities occurred.
CDC – HAI summary and slide set
The CDC has published a national estimate of the number of healthcare-associated infections (HAI) and HAI-related deaths in the United States in a March-April issue of Public Health article, "Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002." The authors concluded that the method they used for estimating the number of HAIs made the best use of existing national data. Data were obtained from the National Nosocomial Infections Surveillance (NNIS) System (1990-2002), the National Discharge Survey (2002), and the American Hospital Association Survey (2000). Study findings are summarized in a PowerPoint presentation.
Back to Safety tools | Back to top
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
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 © 2007 Premier, Inc.
You may forward this newsletter to your colleagues. If you would like to reprint any of these stories, please cite the "Safety Share newsletter, Premier, Inc." as your source and send an email to safety_institute@premierinc.com and alert us. Thank you.
