November 2006
Dear Colleague:
Bundling of evidenced-based practices is one of the most successful patient safety strategies for improved outcomes. We have included a story of two hospitals’ success with bundling of measures to reduce hospital-acquired infections, plus Safety Institute case studies and resources from numerous national collaboratives. See also the Leadership Tools for CEOs.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- A business case for improved patient safety for hospitals and CMS
- Reductions in drug-resistant bugs and infection are key to selecting isolation methods: CDC's new guideline
- Inadequate handoffs, lack of knowledge and excessive workload among contributing factors for missed diagnoses in ED
- Low-cost screening tool useful for detecting adverse events in ICU
- Public launch of SCIP to educate consumers and surgical care teams
- One-third of wrong-site surgeries not prevented by current "site verification" protocols
- Accountability and staff feedback among the keys to success of BSI and VAP bundles in reducing infection
- Insufficient data prompts HHS to recommend higher level of respiratory protection for care of patients during flu pandemic
Safety tools
- AHA Collaborative – leadership tool for hospital CEOs
- AHRQ Handbook – human factors and ergonomics
- States' medication forms assist patients, physicians
- NIOSH report – workplace violence
- MGMA/AHA-HRET/ISMP tool – Assessing physician practices
A business case for improved patient safety for hospitals and CMS
Medicare and hospitals can both gain financially by improving safety. Medical errors have been estimated to cost the U.S. healthcare system more than $17 billion per year, and although Medicare has made extra payments for errors, a study of five types of adverse events (AE) found that for 48 to 80 percent of cases with an AE, hospitals received no additional payments.
The common perception is that healthcare providers are reimbursed for adverse events but whether that burden is borne by patients, employers, health plans, Medicare or Medicaid is not always clear. "Medicare payment for selected adverse events: building the business case for investing in patient safety," published in the September/October issue of Health Affairs, develops a business case for investing in hospital patient safety. The study describes the Medicare extra payments for five types of adverse events and how much extra cost is absorbed by hospitals. The five adverse events in this study include: decubitus ulcer, iatrogenic pneumothorax, postoperative hematoma or hemorrhage, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis.
The authors describe Medicare's extra payment for the five types of events as more than $300 million per year, accounting for 0.27 percent of annual Medicare hospital spending. Unfortunately, the extra payments cover less than a third of the additional costs incurred by hospitals for treating these adverse events. Further, the data indicate that hospitals generally do not receive additional compensation when an error occurs. The results support a business case for hospitals with substantial numbers of Medicare patients; they can financially benefit from improving patient safety. In 48 (post-operative sepsis) to 80 percent (decubitus ulcers) of the cases with an adverse event, hospitals received no additional Medicare payments and absorbed the extra costs.
Estimates of the excess Medicare payments made for each hospitalization in which an adverse event occurred were based primarily on the 2002 Healthcare Cost and Utilization Review's Nationwide Inpatient Sample. The patient safety indicators (PSIs) published by the Agency for Healthcare Research and Quality (AHRQ) were used to identify the adverse events during hospitalization.
The authors conclude that insights into understanding the costs of adverse events can lead to effectively designing patient safety programs that will help improve patient safety.
Medicare payment for selected adverse events abstract (.doc) (23 KB)
AHRQ Patient Safety Indicators (PSI)
Reductions in drug-resistant bugs and infection are key to selecting isolation methods: CDC’s new guideline
New CDC guidelines for prevention and control of antibiotic-resistant infections recommend the design of robust infection isolation and control programs customized to specific settings and local needs, including control measures based on infection rates. The guidelines emphasize the importance of administrative support of infection control practices, adequate funding and staffing, and facility-wide and unit-specific educational programs on drug resistance.
A key recommendation requires facilities to track infection rates and related data to monitor the impact of prevention and control efforts as part of a basic program. If these efforts are unsuccessful in reducing infection rates of a targeted resistant organism such as resistant Staphylococcus aureus (MRSA), a healthcare facility must reevaluate and incorporate additional measures such as testing patients at high risk for carrying drug-resistant bacteria and intensifying control efforts outlined in the guidelines. The goal is demonstrating a consistent decrease in the incidence of targeted resistant organisms.
The guidance document, "Centers for Disease Control and Prevention's (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for preventing the spread of multi-drug-resistant infections in healthcare settings," was released October 19, 2006.
CDC/HICPAC "Management of Multi-drug-Resistant Organisms In Healthcare Settings, 2006"
Related guidelines – see Premier Safety Institute Web site on Guidelines
Inadequate handoffs, lack of knowledge and excessive workload among contributing factors for missed diagnoses in ED
A recent study looked at the causes for missed or delayed diagnoses in the emergency department (ED), a patient safety concern with limited available causal information. The study, published in the September 2006 issue of Annals of Emergency Medicine, reviewed data from a random sample of closed malpractice claims files from four liability insurers that collectively covered more than 21,000 physicians, 46 acute care hospitals, and 390 outpatient facilities. The analysis focused on 429 claims of alleged missed or delayed diagnoses in the ED.
Contributing factors
The three most common contributing factors were mistakes in judgment (87 percent); lack of technical competence or knowledge (58 percent); and lapses in vigilance or memory (41 percent). Other leading contributing factors were patient-related factors such as atypical presentation, complicated medical history (34 percent); lack of appropriate supervision (30 percent); inadequate handoffs (24 percent); and excessive workload (3 percent). Most cases had multiple contributing factors; 85 percent had at least two, 61 percent had at least three, and 39 percent had at least four.
The top three missed or delayed diagnoses were fracture, infection and myocardial infarction. Two-thirds of the missed diagnoses involved more than one clinician, 27 percent of the errors had at least three, and 10 percent involved at least four clinicians.
Prevention strategies
The authors make a number of suggestions for prevention of missed or delayed diagnoses. These include:
- Targeting interventions such as use of algorithms at selected diagnoses with high potential for being overlooked.
- Considering decision support systems to assist with diagnosis and treatment determination. The authors note that conducting medical histories, physician exams, ordering and interpreting test results, ordering consultation, and creating follow-up plans were common, occurring in all but two (97 percent) of the missed diagnoses.
- Standardizing handoff procedures. (Handoff breakdowns were present in nearly 24 percent of missed diagnoses.)
- Increasing oversight of trainees' diagnostic evaluations in ED, especially during times of high workload or when atypical presentations or complicated medical histories are involved.
Emergency department abstract (.doc) (24 KB)
Low-cost screening tool useful for detecting adverse events in ICU
Adverse events (AE) in the intensive care unit can be rapidly identified using a screening method, known as a "trigger tool," developed by the Institute for Healthcare Improvement (IHI). This technique was first used to detect medication-related AEs. A recent study "A trigger tool to identify adverse events in the intensive care unit," published in the Joint Commission Journal on Quality and Patient Safety (October 2006), describes the use of 23 triggers associated with AEs in the ICU. Selected triggers frequently associated with AEs include a drop in hemoglobin, pulmonary embolism tests, and positive blood cultures.
Adverse events
Sixty-two intensive care units in 54 hospitals were involved in the study between 2001 and 2004. Charts were reviewed by non-physician reviewers and focused only on the 23 triggers. Additional examples of triggers include intubation or reintubation, code or code status change in the unit, readmission to ICU and nosocomial infection of any kind. If a trigger was detected, the relevant portion of the chart was reviewed and if an adverse event was found, it was classified based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The authors found a rate of 11.3 AEs per 100 ICU days. They also found that a small number of triggers led to the detection of the majority of the adverse events. A high percentage of AEs were associated with a decrease in hemoglobin by four points and the need for intubation or re-intubation.
Adverse medication-related events
The use of anticoagulants and sedatives were responsible for 24 percent of the adverse medication-related events. Narcotics, antibiotics, and insulin together were responsible for almost another 30 percent of medication-related adverse events. The authors conclude that using this focused review process to screen for AEs in the ICU can provide data to use in appropriately targeting patient safety measures and measuring the effectiveness of the interventions over time.
JQS Trigger tool abstract (.doc) (33 KB)
Public launch of SCIP to educate consumers and surgical care teams
The partner organizations of the Surgical Care Improvement Project (SCIP) held a national press conference in Washington, DC, on October 23, 2006, to introduce the program to consumers. At the public launch, Premier joined other supporting partners and the Steering Committee members, including the Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), American College of Surgeons (ACS), Association of periOperative Registered Nurses (AORN), and JCAHO. Speakers discussed the importance of patient participation in their healthcare and included Department of Health and Human Services Secretary Michel Leavitt, patient advocates from the National Partnership for Women & Families and clinicians from Franklin Square Hospital in Baltimore, MD.
The "Tips for Safer Surgery" contains information about how patients should talk to members of their surgical team before surgery; the "tip sheet" also describes what will be done to reduce risks during surgery. As part of the public launch, a letter was sent to members of surgical care teams in hospitals alerting them that their patients will have access to the "Tips for Safer Surgery" tip sheet. The SCIP partnership encourages surgical teams to begin conversations with patients about the SCIP quality measures that relate to them. More information about SCIP is available at the official Web site.
Tips for Safer Surgery (.pdf) (514 KB)
Letter from SCIP to members of surgical care team
(.doc) (194 KB)
SCIP official Web site: www.medqic.org/scip.
One-third of wrong-site surgeries not prevented by current "site verification" protocols
In an April 2006 study in Archives of Surgery, Kwaan and colleagues found that current wrong-site surgery verification protocols could have prevented only two-thirds of cases of wrong side/site, wrong procedure, wrong patient (WSPEs) surgeries and many protocols involve considerable complexity without clear added benefit. In 38 percent of cases, researchers found it unlikely that the universal protocol would have prevented WSPEs. Two examples of WSPEs included:
- A wrong-site case: The surgeon changed the side of the scheduled procedure for a patient with bilateral disease, the surgeon updated informed consent after patient was sedated, and the patient did not recall consenting to procedure performed; and
- A magnetic resonance image of the knee was printed at a referring hospital for an incorrect patient with the same name as the correct patient.
Site verification protocols required significant personnel time for multiple and enforced redundant checks without clear added benefit. Authors suggested that a 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.
In the September 2006 Archives of Surgery, Seiden and Barach report on the analysis of several national and state databases on wrong-side/wrong-site, wrong-procedure, and wrong patient adverse events (WSPEs), including an innovative anonymous Web-based reporting site for WSPEs developed by the authors. Their analysis suggests that although these are relatively rare events, they are substantially underreported and totally preventable. The incidence of 1,300 to 2,700 WSPE cases per year out of more than 75 million surgical procedures performed annually in the United States is more than 10 times greater than that accepted by the manufacturing industry's quality defect standard Six Sigma. The authors point out that the increased use of conscious sedation for surgical procedures in ambulatory and freestanding surgery centers will likely increase those numbers.
Distinguishing right from left
In explaining why these errors occur, Seiden and Barach suggested that patient identification systems that would ensure the right patient and right site are still experimental. They note that wrong-side procedures stem from bilateral symmetry of the body and common cognitive challenges that make it easy to confuse left and right. Clinicians grow accustomed to their right side being on their patients left side when facing a patient. However, the opposite is not true if the patient and the clinician are facing the same direction. This is especially challenging in the OR where the patient is covered in sterile drapes, the patient's position is changed during the procedure, or the table is rotated 180 degrees. This often requires significant mental effort to rotate the patient's body so that it is spatially congruent with that of the observer and its laterality is made clear. It is not surprising that such a cognitive demanding process could be subject to error, especially in a busy, distraction-rich OR environment. Although patient involvement and verification of operative site and procedure is recommended as a protection tool, many WSPEs occur after patient has verified the wrong site.
Recommendations to help reduce the occurrence of WSPEs include the following:
- Report and investigate all near misses and WSPEs to learn from them, although it is not required by any accreditation or professional society, including JCAHO, AORN and AAOS.
- Involve the entire healthcare team, including the patient and clerical scheduling personnel, in the identification of the correct surgical and intervention procedure.
- Perform human factors, failure mode and effects, and root cause analyses of all WSPEs to understand why our present systems are failing to stop these events.
- Develop and use a robust patient identification system such as bar coding or radio frequency tagging.
April 2006 study in Archives of Surgery (.doc) (24 KB)
September 2006 study in Archives of Surgery (.doc) (29 KB)
A voluntary, anonymous Web site is available for reporting WSPEs for all
healthcare providers to use at:
http://www.wrong-side.org.
Accountability and staff feedback among the keys to success of BSI and VAP bundles in reducing infection
One hospital system's journey with the use of evidence-based "bundles" is featured in a recent article, "Eliminating Nosocomial Infections at Ascension Health," highlighting the successes and challenges that led to more than 50 percent reduction of bloodstream infections (BSI) and ventilator associated pneumonia (VAP). Eliminating hospital-acquired infections was identified as one of the priorities for action for Ascension Health as part of its corporate goal of excellent clinical care with no preventable deaths or injuries by July 2008. Success was attributed to a number of factors, including having a physician champion, flexible multidisciplinary rounds, monthly feedback to staff, accountability to keep the effort high profile, and educating staff when there were misconceptions. One tip for success was starting a pilot with one physician, one nurse on one patient and spreading the process further, using the Web site to share successes. The experiences of two of Ascensions' hospitals, designated as alpha sites, were featured in the Joint Commission Journal on Quality and Patient Safety (November, 2006). It was noted that successful change comes slowly and requires persistence by the team implementing bundles.
The teams also noted that accurate data collection could often be challenging; yet it is important to the success of the program. For example, if checklists on insertion and data are missing on tracking forms, it is often difficult to determine compliance and rates of use of central line infections, suggesting that flexibility of staff is the primary characteristic to effect change for further reductions.
St. John Hospital and Medical Center, Detroit, MI, focused on developing the team process involving the central line bundle, which incorporates hand hygiene, aseptic techniques, and the use of maximum barrier precautions. They also saw the benefit of having the physical presence of the infection control professional in the intensive care unit to provide on-the-spot reinforcement of the initiative. They reduced BSI infections in their ICUs by 55 percent in the first year after implementing the IHI BSI bundle.
St. Vincent Hospital, Birmingham, AL, developed their bundle for ventilator patients based on IHI guidelines as well, including keeping the head of the bed at 30 degrees, deep vein thrombosis prophylaxis, peptic ulcer disease prophylaxis, oral care every two hours, and hand hygiene. Their VAP rate decreased from an average of 8.2 per 1,000 ventilator-days over a 13-month period to 3.3 per 1,000 patient days for 24 months. They attributed their overall success to the use of a multidisciplinary rounds team that coordinated the initiative.
Special offer - Subscription to 2007 Joint Commission Journal on Quality and Patient Safety
As a special offer to Premier Safety Share subscribers, Joint Commission Resources has granted permission for access to the full article featured in this story and is also offering a 20 percent discount for a 2007 subscription to the
Joint Commission Journal on Quality and Patient Safety. An annual subscription (12 issues) for both print and online issues is now only $240; online subscriptions are only $200. Please call 800.746.6578 and mention the promotional code PREMIER06 to take advantage of this limited-time offer. This offer is good through
January 31, 2007.
"Eliminating Nosocomial Infections at Ascension Health" (.pdf) (309 KB)
Joint Commission Journal on Quality and Patient Safety, visit:
http://www.jcrinc.com/subscribers/journal.asp?durki=32
Evidence based practices/bundling resources - Premier Safety Institute Web site
More information on IHI's bundling can be accessed at:
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/
ImprovementStories/WhatIsaBundle.htm.
Insufficient data prompts HHS to recommend higher level of respiratory protection for care of patients during flu pandemic
In late 2005, the World Health Organization and the U.S. Department of Health and Human Services (HSS) recommended simple surgical masks for the care of patients suspected of having flu during a pandemic, reserving N-95 respirators for use during aerosolized-generating procedures, such as intubation. In October 2006, HHS released "Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic October 2006," which recommends N-95 respirators for routine patient care, raising controversy among infection control and infectious disease experts.
Seasonal influenza viruses are transmitted by short-range droplets and are not considered airborne disease agents like M. tuberculosis. For years it has been recommended that workers wear traditional surgical masks if they are within three feet of a patient to prevent transmission of influenza. Based on past data and experience, HHS recommended that healthcare workers wear simple surgical masks designed to block large respiratory droplets for routine care of pandemic flu patients. The CDC has found no new scientific evidence on the question, but there is increased concern by some about the possibility of airborne transmission of flu viruses, particularly with "unknown" viruses that may cause a pandemic, leading to the revised interim guidance. This decision highlights the differences in how existing scientific evidence is interpreted and not all infection control and infectious disease experts agree with the recommendations. CDC has acknowledged the dilemma and indicated that studies are being funded to try to answer the questions. Since such studies will take several years to complete, the "Interim guidance document" was published October 19, 2006 with the intent of revising as data becomes available.
The guideline states that the use of N-95 respirators, (designed to stop 95 percent of small airborne particles), is "prudent" for healthcare personnel during other direct patient care activities (e.g., examination, bathing, feeding) and for support staff who may have direct contact with pandemic influenza patients. The guideline adds that if N-95 or other types of respirators are not available, surgical masks provide benefit against large-droplet exposure and should be worn for all healthcare activities involving patients with confirmed or suspected pandemic influenza.
Both the pandemic plan and the new guidance continue to recommend using an N-95 respirator or similar protection during procedures likely to generate airborne infectious particles, such as endotracheal intubation, and continue to emphasize other means such as such as hand hygiene and social distancing to prevent transmission of influenza.
October 2006: HHS Interim guidance surgical masks and respirators-influenza pandemic
HHS Web site, for more information: http://www.pandemicflu.gov/plan/tab6.html
Safety tools
AHA Collaborative – leadership tool for hospital CEOs
The Center for Healthcare Governance has developed a tool in collaboration with Clark Consulting's Healthcare Group called "Collaborative Leadership: A New Model for Developing Truly Effective Relationships Between CEOs and Trustees." The tool is designed to help hospital CEOs and their boards forge a stronger relationship. This CEO resource discusses what governance reform means in terms of how boards and CEOs work together to lead their healthcare organizations. It also provides an assessment tool and process that CEOs can use to take the lead in diagnosing their current relationship with their board, and to work together with board leaders to re-energize and strengthen the relationship to achieve maximum effectiveness and value. The tool was provided to all AHA members as the first in a series of Collaborative Leadership Tools. It can be completed online and CEOs and trustees can compare views on their working relationship. Access the tool at:
http://www.americangovernance.com/americangovernance/
ctool/email/email.html.
AHRQ Handbook – human factors and ergonomics
A new handbook that contains articles from Agency for Healthcare Research and Quality (AHRQ) funded researchers titled, "Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety," presents the most current knowledge on concepts and methods of human factors and ergonomics and their applications to help improve quality, safety, efficiency, and effectiveness in patient care. The handbook provides specific information on how to analyze medical errors with the fundamental goal of reducing errors and the potential harm that results. Contributors discuss the design of work environment and working conditions to improve satisfaction and well being, and the reduction of burnout and other ailments often experienced by healthcare providers and professionals. The handbook is available for a discounted price of $95.
States' medication forms assist patients, physicians
Arizona hospitals and health professionals have developed a medication safety tool that promotes communication between patients and their caregivers. "The Med Form" tool (.pdf) (405 KB) helps patients maintain a single, updated record of their medications, vitamins, immunizations and allergies to share with their healthcare providers. The Arizona Hospital and Healthcare Association's Safe & Sound Patient Safety Initiative, Arizona Medical Association, and Arizona Partnership for Implementing Patient Safety sponsored the form and it is available statewide in physician offices and hospitals. The Med Form is available in Spanish and English at http://www.themedform.com/.
A statewide initiative launched by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Medical Society is designed to help patients and healthcare providers reduce medication errors. The initiative involves helping patients discuss their medication history with physicians, and giving physicians better data on the medications their patients take. Key to the initiative is a medication list, Med List, which promotes health and safety by helping patients track the type of medication they use and the manner in which they use it. The Med List helps with medication reconciliation. Physicians can compare patient's current medication list with their medical record. Med List and other safe medication initiatives in Massachusetts are available online at: http://www.macoalition.org/initiatives.shtml#5.
NIOSH report – workplace violence
A NIOSH report released in September 2006, "Workplace Violence Prevention Strategies and Research Needs," summarizes discussions that took place during Partnering in Workplace Violence Prevention: Translating Research to Practice – a landmark conference held in Baltimore, MD, November 15-17, 2004. The report does not include a documented review of either the literature on workplace violence (WPV) in general or intervention effectiveness research in particular. Information in the report includes discussions of the scope of WPV, barriers to violence prevention, prevention programs and strategies, and research needs. The report discusses information on barriers and gaps that impede the development and implementation of WPV prevention programs, and summarizes the best workplace violence strategy/program practices presented by conference participants, general research needs and the importance of linking research findings to practical prevention efforts. The report (.pdf) (514 KB) also includes ideas about partners who should be involved in national, community, and company collaborations, and what they could be doing to address workplace violence.
MGMA/AHA-HRET/ISMP tool – Assessing physician practices
A tool developed by the Medical Group Management Association (MGMA) along with AHA's Health Research and Educational Trust (HRET) and Institute for Safe Medication Practices (ISMP) was launched on the Physician Practice Patient Safety Assessment (PPPSA) Web site. The tool was financed by a grant from the Commonwealth Fund. The tool is for physician practices to use to enhance awareness of patient safety issues, heighten awareness of characteristics that make a practice safer, and create a new reference point and baseline for practices to enhance and support patient safety. The tool can be completed electronically so users can receive a feedback report comparing themselves to other practices (percentile rankings on each question). Users also can receive a workbook with information and resources on how the practice can improve their performance. There is a $200 per practice fee to complete the assessment online and access the comparative report site. Download the file or use online at http://www.physiciansafetytool.org.
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
- 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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