Premier Safety Share
In this issue
Premier Safety Web site
September 2003
Dear Colleague:
We have added evidence-based guidelines for safety and infection control from CDC, AHRQ and others to our Web site.
We hope this newsletter is useful. Please encourage your colleagues to subscribe to Safety Share so they don't miss any issues. Search our archives for topics featured in past issues.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Litigation stifles hospitals' efforts to improve patient safety
- September marked by new preparedness efforts, resources
- Patients’ satisfaction linked to staff attitudes, skills
- Bar coding, CPOE top two technologies to improve patient safety
- Communications as part of medical school curriculum
- Multi-dose vials addressed in WHO guideline
Safety tools
- Interactive tools from IHI: FMEA and ADE trigger tool
- Sharps disposal container evaluation and implementation guide available
- Mercury-safety resource from OSHA
- Restraint-seclusion – An award-winning guide
- Harvard Quality Colloquium Safety conference – CD-ROM of audio presentations
- Influenza patient education materials from CDC
Litigation stifles hospitals' efforts to improve patient safety
Fear of litigation either stifles hospital efforts to improve patient safety or drives them underground, according to the latest article in a journal series that harnesses the power of individual case presentations to educate healthcare providers about medical errors.
The article, "Patient Safety and Medical Malpractice: A Case Study," appears in the August 19, 2003, issue of the Annals of Internal Medicine. In an effort to promulgate practical assistance to hospitals in promoting cultures that support higher quality care and patient safety, all the current and upcoming articles in the series are available free of charge. Future articles in the series will include cases studies of ICU, outpatient, and diagnostic errors, along with house staff work-hour limits, communication and teamwork, and the role of media in patient safety. All the articles in the series are available through the California HealthCare Foundation (CHCF).
"Patient Safety and Medical Malpractice: A Case Study" is seventh in the series called "Quality Grand Rounds." The case study features a physician who had to make a split-second judgment call about how to manage a critically ill patient. The patient sustained serious neurological damage, although the doctor's actions were not negligent. The article explores both the plaintiff-patient and defendant-physician's points of view.
The case study points out that the legal system's fundamental flaw is more than just high costs for providers, but also its tendency to overcompensate some patients while under-compensating others. A no-fault approach to medical injury may be the answer, the article points out. In a no-fault system, the injured patient would only have to demonstrate that medical management, as opposed to the disease process, caused a disability. There is not a need to prove negligence, according to the study. Similar programs in workers' compensation and vaccine liability operate at less than one-half the cost of tort litigation, largely by minimizing the role of lawyers, according to the authors.
All the articles in the series are available at www.chcf.org. http://www.chcf.org/topics/view.cfm?itemID=19726
September marked by new preparedness efforts, resources
Observance of the September 11 terrorist attacks on the United States is being marked by a number of updates and provision of additional resources for healthcare providers, from homeland security to home preparation. Four resources are available for download:
- Homeland Security blueprint -- The sharing of information
by federal authorities to state and city governments is critical to
effectively execute and unify homeland security efforts, according to
a recently released GAO report. The
report details the initiatives that have been undertaken to improve
information sharing and whether federal, state, and city officials
believe that the current information-sharing process is effective. The
development of the Homeland Security blueprint is being called
“enterprise architecture.” The plan is to issue the enterprise
architecture in September 2003 and begin implementation in November
2003.
- HHS bioterrorism preparedness fact sheet -- A new Health
and Human Services (HHS) fact sheet titled, "Public Health Emergency
Preparedness: Transforming America's Capacity to Respond," is now
available. The fact sheet describes
extensive activities over the last two years to expand preparedness
for a possible bioterrorism incident, especially the ongoing efforts
to improve emergency medical response capacity at the federal, state
and local levels.
- NIOSH fact sheet for home preparedness -- The National
Institute for Occupational Safety and Health (NIOSH) provides an
easy-to-read fact sheet on respirator use and selection as part of
emergency preparedness at home. Some employers and consumers are
considering purchasing escape hoods or other respirators to protect
themselves against potential terrorist threats, including biological
and chemical substances. This guidance will provide information on
what respirators are, how they work, and what is needed for a
respirator to provide protection.
Download the factsheet or visit
http://www.cdc.gov/niosh/npptl/npptlrespfact.html.
- RAND offers steps for protecting yourself in a terrorist attack -- The RAND research organization has published a study identifying simple steps individuals can take to protect themselves in a terrorism attack. A report summarizing the study includes a quick guide and foldout reference card listing key steps to take for individuals subjected to chemical, radiological, nuclear and biological attacks. The steps include quickly finding clean air in the event of a chemical attack, avoiding inhaled dust following a radiological attack and radioactive fallout from a nuclear attack, and getting medical aid and minimizing further exposure to biological agents. Download the Quick Guide. More report details and ordering information can be found at http://www.rand.org/hot/press.03/09.10.html.
- Download GAO report (595 KB)
- Download HHS Bioterrorism Fact sheet (163 KB)
- Download NIOSH Fact Sheet (70 KB) or go to http://www.cdc.gov/niosh/npptl/npptlrespfact.html
- Download Rand Quick Guide (1.6 MB)
Patients’ satisfaction linked to staff attitudes, skills
A survey of nearly 2 million patients suggests that a hospital staff's ability to work as a team and its overall workplace demeanor are keys to whether patients will recommend that hospital to others. This month's Press Ganey Satisfaction Report asserted that patients who answered its satisfaction surveys gave the highest satisfaction scores to questions regarding the skill of their physicians and the courtesy of nurses. The lowest scores involved satisfaction with the quality of the food and room temperature. However, both food quality and room temperature ranked penultimate and last, respectively, as factors in determining whether patients recommended the hospital. The surveys also find that satisfaction declines with a longer hospital stay, and can differ by patient age. The study analyzed satisfaction questionnaires received from hospitalized patients in 2001. Data represented nearly two million questionnaires from 1,137 U.S. hospitals. An average of 1,547 patients per hospital completed the questionnaires, which included 49 standard questions.
- Download the satisfaction report (254 KB)
Bar coding, CPOE top two technologies to improve patient safety
Bar codes used in medication administration, and computerized physician order entry, were the top two technologies believed to improve patient safety, according to the 2003 Patient Safety Survey conducted by the Healthcare Information and Management Systems Society (HIMSS). The most frequently identified metric used to measure patient safety is a decrease in medication errors. The survey suggests that nurses play a critical role in promoting patient safety in healthcare. Nearly all of the respondents who indicated that their facility had a formal patient safety committee also had at least one member of the nursing department on the committee. Nurse executives and patient safety officers were identified as most likely to lead the patient safety initiative at their organization, according to the survey, which was sponsored by McKesson Corp.
Of those healthcare organizations with a patient safety committee, 79 percent have a pharmacy representative, 95 percent have a nursing representative, and 41 percent have a member of the information technology department. The web-based survey of health professionals was conducted from April 11, 2003 through June 2, 2003.
- Download the Patient Safety Survey (520 KB)
Communications as part of medical school curriculum
A recently released study on the effects of communications training on medical students found that using an established educational model significantly improved third-year medical students' overall communications competence, as well as their skills in relationship building, organization and time management, patient assessment, and the negotiation and shared decision making-tasks important to positive patient outcomes. The standardized curriculum incorporated core skills, including determining the reasons for the patient’s visit, eliciting and understanding the patient’s perspective, sharing information and providing education, negotiating and agreeing on a plan and achieving closure. The students exposed to the standardized curriculum outperformed those students in the comparison group in their clinical examinations. The study was released in the September 3, 2003 issue of the Journal of the American Medical Association.
- Download communications study (27 KB)
Multi-dose vials addressed in new WHO needle injection guideline
An additional guideline – a World Health Organization (WHO) bulletin focused on needle injection safety – has been added to the 40-plus guidelines on the Premier Safety Institute guideline resources Web site. As a special feature, the Safety Institute has compiled the multidose vial information from the CDC vascular access and WHO needle injection guidelines. A single electronic source for the major safety and infection prevention guidelines from CDC and other organizations (e.g., Association for Professionals in Infection Control and Epidemiology, Society of Healthcare Epidemiologists of America) is now available on Premier’s Safety Institute Web site. Among the 40 guidelines are prevention of specific infections (e.g., urinary tract infections, surgical site infections), environmental safety, sterilization and disinfection, personnel health, antimicrobial resistance, and CDC surveillance definitions and annual surveillance reports.
Safety tools
- Interactive tools from IHI: FMEA and ADE trigger tool
- Sharps disposal container evaluation and implementation guide available
- Mercury-safety resource from OSHA
- Restraint-seclusion – An award-winning guide
- Harvard Quality Colloquium Safety conference – CD-ROM of audio presentations
- Influenza patient education materials from CDC
Interactive tools from IHI: FMEA and ADE trigger tool
Two interactive tools designed to help make care safer are available from the Institute for Healthcare Improvement at http://www.qualityhealthcare.org/.
The Failure Modes and Effects Analysis (FMEA) tool is a method for analyzing any process to see where it is likely to fail; to see how changes you are considering might affect the safety of the process; and to track changes in the Risk Priority Number (or RPN) of the process over time.
The Trigger Tool for Measuring Adverse Drug Events (ADEs), developed with Premier, is a simple yet powerful method of identifying and tracking the number of medication errors in your hospital – using a retrospective review of patient records to look for sentinel clues or "triggers" that indicate a medication error has occurred.
- For both tools, go to http://www.qualityhealthcare.org/.
Sharps disposal container evaluation and implementation guide available
In the July 2003 issue of its journal, Health Devices, ECRI presents ratings of eight sharps disposal containers designed for patient rooms or patient treatment areas. Although most of the models tested met ECRI's basic requirements for preventing sharps injuries, several models had design flaws that could increase the risk of a sharps injury. According to ECRI, containers that are poorly designed or improperly placed – or that are allowed to become overfilled – could actually increase the risk of a user suffering a sharps injury. In addition to describing ECRI's model-specific findings, the journal includes an implementation guide that offers practical advice on the safe use of sharps containers. Also included is a discussion of an alternative to disposable sharps containers – contracting with a company that supplies reusable sharps containers and replaces these containers for the hospital.
- A press release on the evaluation and implementation guide, including a link to an order form, is available at: http://www.ecri.org/Newsroom/PR_Detail.asp?DN=20030828_73
Mercury-safety resource from OSHA
The Occupational Safety and Health Administration (OSHA) recently revised its safety and health topics Web page on mercury. This resource provides information on such topics as the health effects of mercury exposure; reducing occupational exposures, including thorough training and personal protective equipment; and applicable OSHA standards and guidelines.
- Volume 2 of the Healthcare Hazard Control System includes analyses on mercury hazards for further reference. Go to: http://www.osha.gov/SLTC/mercury/index.html
Restraint-seclusion – an award-winning guide
A joint publication of the AHA Section for Psychiatric and Substance Abuse Services, American Psychiatric Association, American Psychiatric Nurses Association, and National Association of Psychiatric Health Systems has received an APEX 2003 Award for publication excellence. The 42-page “Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health” received the award in the category of One-of-a-Kind Publications-Medical. The award recognizes excellence in graphic design, editorial content, and the ability to achieve overall communications excellence.
Harvard Quality Colloquium Safety conference –CD-ROM of presentations
Presentations from the Quality Colloquium conference at Harvard University, held August 24-27, 2003, are now available for purchase. Premier was a co-sponsor of the Colloquium, along with other prestigious organizations including the Agency for Healthcare Research and Quality (AHRQ), the Joint Commission on Accreditation of Healthcare Organizations, (JCAHO), the Institute for Safe Medication Practices (ISMP), and the National Patient Safety Foundation (NPSF).
The Colloquium featured a special pre-conference session on patient safety officer training, along with general conference sessions on error reduction and quality enhancements; the role of technology; informatics; competition for quality and six sigma process improvement. Case studies of successful programs, as well as practical initiatives for plans and providers, also were presented. A streaming video of the keynote presentation by George C. Halvorson, chairman and CEO, Kaiser Foundation Health Plan, Inc., titled, “Epidemic of Care: A Call for Safer, Better and More Accountable Health Care,” is available, along with a CD-ROM that includes video of all speakers plus synced PowerPoint presentations. The CD-ROM costs only $295. Three or more CD-ROMs can be purchased for $225 each; 10 or more CD-ROMs cost $195 each.
- The CD-ROMs can be purchased at http://www.qualitycolloquium.com/.
- More details on the speakers from the conference and purchase information are in the press release (110 KB).
Influenza patient-education materials from CDC
The National Immunization Program, Centers for Disease Control and Prevention (CDC) posted the majority of its influenza patient-education materials on its 2003-04 "Flu Gallery" web site. This season's flu campaign emphasizes protecting yourself and the ones you love by getting a flu vaccine. You'll find materials for parents, Spanish speakers, those at high risk for flu complications, and immunization providers. Materials are free and can be downloaded easily.
The materials include the following:
- One brochure -- "Influenza and Your Child: Information for Parents;" prints double-sided -- one side in English, one side in Spanish.
- Four 8-1/2" x 11" flyers, all available in English and Spanish: (1) "Flu Vaccine Facts & Myths"; (2) "To Protect Yourself and Those You Love"; (3) "When Should You Get Your Flu Vaccination?" and (4) "Who Is at High Risk for Flu Complications?" (Black and white only).
- Three posters; all available in English and Spanish: (1) "Community Immunity: 'Dominos'"; (2) "Protect Your Kids from Flu"; and (3) "Top Three Reasons to Get Your Flu Vaccine."
Other materials include the Vaccine Information Statements for inactivated influenza vaccine and live intranasal influenza vaccine; buttons; pediatric dosage chart; cover letter (English only); stickers (English only); three-sided stand-up table tent (English only); and flu logos for print materials or web sites.
- To access "Flu Gallery" materials, go to: http://www.cdc.gov/nip/flu/gallery.htm
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Editorial team
Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, associate editor
Donna Bernstein, MPH, marketing consultant
John Hall, BSJ, contributor
Derek Kleckner, BA, Web master
Judith Luca, RN, BSN, contributor
About Premier
Premier, Inc. is a healthcare alliance entirely owned by 200 of the nation's 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.