Premier Safety Share
In this issue
Premier Safety Web site
December 2003
Dear Colleague:
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Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Surgeon-versus-hospital procedure volumes linked to mortality
- Errors discussed more openly at surgical than internal medicine staff meetings
- IOM panel calls information systems key strategy to improve patient safety
- Nearly half of California hospitals plan to implement CPOE
- Insulin and heparin among top drugs involved in patient harm
- Major change in nursing environment critical to patient safety
- Hastings Center: Discussion of patient safety ethics essential
- JCAHO 2005 infection control standards approved; Universal protocol resources released
Safety tools
- Toolkit - Ambulatory patient safety
- Disclosure policy guide Second in series from ASHRM
- OSHA bulletin - Disposal of contaminated blood tube holders
- Web-based training tool - OSHA resource for implementing incident command system
- Tips and resources - pesticide management in hospitals
- Checklist - Magnetic resonance safety
Surgeon-versus-hospital procedure volumes linked to mortality
A recently released study published in the New England Journal of Medicine found that individual surgeon experience -- rather than a hospital's volume -- of specific procedures was more likely to impact patient mortality. Although a considerable body of research has established a direct correlation between hospital volume and surgical mortality, the link between surgeon volume and patient outcomes had remained uncertain until the latest findings.
The study, led by investigators at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., used data from the national Medicare claims database for 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections from 1998 through 1999. The researchers studied mortality rates for patients before discharge and within 30 days following the procedure. For all eight procedures, surgeon volume was inversely related to operative mortality. The researchers found that surgeon volume accounted for "a large proportion of the apparent effect of the hospital volume," but the effect varied based on the procedure. In the case of aortic-valve replacement, for example, surgeon volume accounted for 100 percent of the effect of hospital volume, while it accounted for 24 percent of the effect of hospital volume for lung resection. Overall, low-volume surgeons saw higher mortality rates than their high-volume peers, regardless of the surgical volume of the hospital in which they practiced.
The researchers concluded that patients often can improve their survival chances, even at high-volume hospitals, by selecting surgeons who perform the operations frequently. They note that hospitals should focus on highlighting "processes of care [that are] under the control of surgeons," rather than just emphasizing the "allocation of resources among hospitals." In addition, since the effect of surgeon volume on hospital mortality rates varied based on the difficulty and technical skill required for the procedure, researchers suggest that hospitals may want to limit "selected operations ... to a smaller number of surgeons" to improve patient mortality for these procedures.
- Abstract of study (29 KB)
Errors discussed more openly at surgical than internal medicine staff meetings
Only a small percentage of cases presented at internal medicine morbidity and mortality conferences involve adverse events and errors, according to a report in the December 3, 2003, issue of the Journal of the American Medical Association (JAMA). In a review of 332 cases at four US teaching hospitals, only 37 percent of 100 cases reviewed at medical staff morbidity and mortality conferences discussed medical errors, compared to 72 percent of 232 cases at surgical conferences.
The study involved cases presented at morbidity and mortality conferences between July 2000 and April 2001 at four US teaching hospitals. Trained physician observers were asked to identify and rate adverse events and errors that were discussed at the conferences. Case presentations at medical conferences were about three times longer than presentations at surgery conferences, and medical conferences devoted more time to guest speakers and less time to audience discussions.
Seventy-two percent of surgery case presentations involved an adverse event, compared with just 37 percent of internal medicine case presentations. The researchers also found differences in how errors were discussed. Compared to surgical conferences, errors at medicine conferences were less likely to be discussed and less likely to attribute a particular cause for each error. Discussion leaders at both types of conferences infrequently used explicit language to indicate that an error was being discussed and often did not discuss any personal experiences with the same error. The authors suggest that this may be related to the differences in residency requirements. Specifically, the Accreditation Council for Graduate Medical Education requires surgeons to discuss all deaths and complications on a weekly basis, compared to the requirement for internal medicine for periodic clinicopathologic correction conferences without specific reference to adverse events.
IOM panel calls information systems key strategy to improve patient safety
In a newly released report, the Institute of Medicine (IOM) has called for a national health information infrastructure, similar to that used by the aviation industry, to improve the quality and safety of patient care. The IOM Committee for Data Standards for Patient Safety report recommended all healthcare organizations implement electronic health record systems, built upon industry-wide standards for data, to prevent errors by giving caregivers immediate access to patient information and decision-support tools, and to learn from errors that occur. The IOM also singled out the Premier-CMS hospital quality demonstration project as a model for standards-based data systems. The report recommends that all healthcare settings establish comprehensive safety programs:
- Comprised of standardized data formats and terminology;
- Informed by a culture of safety'; and
- Involving adverse event and near miss detection and analysis. The panel suggested that the federal government lead and fund a public-private partnership to develop national data standards, and called on Congress to authorize the Department of Health and Human Services to spearhead such a partnership.
In its discussion of practical approaches to moving forward with standards-based data systems, the IOM report singled out the Premier-CMS hospital quality demonstration project. Premier collects and aggregates hospitals' data elements, the report describes, subjecting each participating facility's raw data to vigorous and reliable peer comparison. The extensive data management procedures employed by Premier suggest that there are "ample opportunities to simplify data collection by hospitals and to streamline data management, the IOM report noted.
The Premier and Centers for Medicare and Medicaid Services (CMS) project, which pays quality-improvement incentive bonuses at participating institutions, along with the National Quality Forum’s hospital initiative, were cited in a letter in the Health Affairs policy journal as examples that demonstrate that our healthcare system has the tools needed to help initiate change. The open letter recommends that pay-for-performance should become a top national priority and that Medicare should lead in this effort with its priority being hospital care. Co-signers of the letter include Donald Berwick, Nancy-Ann DeParle, Kenneth Kizer, Uwe Reinhardt and Gail Wilensky.
- The report may be ordered at
http://books.nap.edu/catalog/10863.html - Health affairs letter (53 KB)
Nearly half of California hospitals plan to implement CPOE
In September 2000, the California Legislature required all hospitals in the state to submit a plan to the Department of Health Services (DHS) that would substantially reduce medication-related errors. The plan was to include technological solutions and be implemented no later than January 1, 2005. A detailed examination of the plans submitted by hospitals to comply with this legislation is available in a report titled Legislating Medication Safety: The California Experience.
The report describes the technologies, strategies, and methods hospitals plan to use to reduce medication-related errors.
Two major themes emerged from the analysis of the plans. The first was that many hospitals go beyond the minimum legislative requirements. Technology solutions were widely embraced, with a third of the hospitals indicating that they will use four or more technology methods. The most popular technology planned (46 percent) is computerized physician order entry (CPOE), which enables a prescribing clinician to enter a medication order directly into a software application. The software is designed to detect errors or situations that can lead to an error. A second, less optimistic theme is that many hospitals plan only limited efforts to evaluate the effectiveness of their strategies. Most hospitals will rely on self-reporting as the primary method of error detection. The hospitals also do not describe the level of participation they will require or expect from their physicians. CPOE error reduction is dependent on the strength of the software and the level of physician participation. The analysis of the California plans as they relate to CPOE shows promise in reducing medication-related errors, but the ability of hospitals to ensure that clinicians use the systems appropriately remains an unsettled issue.
Insulin and heparin among top drugs involved in patient harm
According the United States Pharmacopoeias (USP) fourth annual MEDMARX report, the vast majority (98.3 percent) of the 192,477 errors reported to their voluntary database in 2002 resulted in no harm, compared with 97.6 percent the prior year, and 49 percent of the errors did not reach the patient. Meanwhile, insulin, morphine and the blood-thinner heparin were the medications most often involved in errors resulting in harm to patients.
The report noted that both the number of errors and number of participants increased. A spokesperson for US Pharmacopeia also indicated that the increase in reported errors could be due to better internal reporting procedures at the hospitals and a change in culture at those facilities that encourages the reporting of medication errors.
The most common errors were those of omission (25.6 percent), in which the prescribed medication did not reach the patient; dosage or quantity (25.5 percent); and prescription (18.5 percent), in which a medication was incorrectly prescribed.
The types of errors most likely to result in harm involved wrong administration (such as inappropriately crushing tablets), wrong route (such as intravenous versus intramuscular injection), or an unauthorized drug, in which the wrong medication was administered. Insulin, morphine and the blood-thinner heparin were the medications most often involved in errors resulting in harm to patients. Older patients, defined as those 65 and over, were twice as likely to be harmed by a medication error, and more than half of the deaths linked to medication errors involved geriatric patients. Older patients usually have more serious medical problems requiring complicated drug regimens. This makes them more vulnerable to harmful drug mistakes. A total of 405 hospitals and 77 outpatient and other facilities participated in the database in 2002, a 31 percent increase from the previous year.
- More information on the MEDMARX annual report and how to order: http://www.usp.org/medmarx/dataReport/
Major change in nursing environment critical to patient safety
The work environment of nurses must be transformed to better protect patients from medical error, according to a recently released report from the Institute of Medicine of the National Academies. The report calls for changes in how nurse-staffing levels are established and mandatory limits on nurses' work hours as part of a plan to reduce problems that threaten patient safety. The plan would strengthen the work environment in four areas: management, work-force deployment, work design and organizational culture. Studies referenced in the report show that increased infections, bleeding, and cardiac and respiratory failure are associated with inadequate numbers of nurses. Nurses also defend against medical errors. For example, a study in two hospitals found that nurses intercepted 86 percent of medication errors before they reached patients. Electronic copies of "Keeping Patients Safe: Transforming the Work Environment of Nurses" are available at the National Academies Press site. This report aligns with the consensus standards for measuring nursing care in hospitals expected to be released by the National Quality Forum (NQF). The NQFs 13 measures are based on evidence that demonstrates nursing influence on patient outcomes, hospital costs, and the atmosphere of care.
- For more details on the IOM report, go to http://www.iom.edu/report.asp?id=16173.
- Copies will be available in early 2004 from the National Academies Press, 202.334.3313 or 800.624.6242.
- For more information on the NQF measures see article in the October 2003 edition of Safety Share.
Hastings Center: Discussion of patient safety ethics essential
The final report of a two-year research project launched in response to the landmark IOM report on medical error, To Err Is Human, has been released. The Hastings Center has announced the publication of “Promoting Patient Safety: An Ethical Basis for Policy Deliberation.” The new report seeks to foster clearer and better discussion of the ethical concerns that are integral to the development and implementation of sound and effective policies needed to address the problem of medical errors. It is intended for policymakers, patient safety advocates, healthcare administrators, clinicians, lawyers, ethicists, educators, and others involved in designing and maintaining safety policies and practices within healthcare institutions. Among the topics discussed in this report:
- The values, principles, and obligations underlying patient safety efforts.
- The tensions between "individual" and "system" accountability, between error "reporting" and error "disclosure," and between overall safety improvement within institutions and the rights and welfare of individual patients in these institutions.
- The practical implications of defining "responsibility" retrospectively, as praise or blame for past events; or prospectively, as it relates to professional obligations and goals.
- The shortcomings of tort liability as a means of building cultures of safety, learning from error, encouraging truth telling, or compensating patients and families; contrasted with alternative models of dispute resolution, including mediation and no-fault liability.
- The needs of patients, families, and clinicians affected by harmful errors and how these needs may be addressed within systems approaches to patient safety.
- The potential conflicts between the protection of patient privacy required by HIPAA and efforts to use patient data for the purposes of safety improvement, and how these conflicts may be resolved.
- Download the Hastings report (352 KB)
-
or go to
http://www.thehastingscenter.org
JCAHO 2005 infection control standards approved; Universal protocol resources released
Revised infection control standards
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) approved revised standards to help prevent the occurrence of healthcare-associated infections. The 2005 standards retain many of the concepts embodied in existing standards, but sharpen and raise expectations of organization leadership and of the infection control program itself. The requirements for ambulatory care, behavioral healthcare, home care, hospital, laboratory and long-term care organizations will take effect January 2005.
The revised standards are the result of the work of an expert group of infection control practitioners, hospital epidemiologists, physicians, nurses, risk managers and other healthcare professionals, along with significant input from accredited organizations participating in a field review. Since the work of these groups began, two new issues emerging antimicrobial resistance and the management of epidemics and emerging pathogens have been identified. Requirements addressing those topics will be sent to all accredited organizations next month for field review. The revised standards are designed to raise awareness that healthcare associated infections are a national concern that can be acquired within any care, treatment or service setting, and transferred between settings, or brought in from the community. Therefore, prevention represents one of the major safety initiatives that a healthcare organization can undertake. The revised standards focus on the development and implementation of plans to prevent and control infections, with organizations expected to:
- Incorporate an infection control program as a major component of safety and performance improvement programs.
- Perform an ongoing assessment to identify its risks for the acquisition and transmission of infectious agents.
- Effectively use an epidemiological approach that includes conducting surveillance, collecting data, and interpreting the data.
- Effectively implement infection prevention and control processes.
- Educate and collaborate with leaders across the organization to effectively participate in the design and implementation of the infection control program.
Medical community supports surgery protocol
The nation's medical, nursing, and healthcare leadership associations and organizations have joined the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in a new nationwide effort to eliminate wrong-site, wrong-procedure, and wrong-patient surgeries. Such occurrences are widely viewed as entirely preventable. By December 2, more than 40 organizations endorsed a new Universal Protocol to standardize pre-surgery procedures for verifying the correct patient, the correct procedure, and the correct surgical site. The Universal Protocol will become effective on July 1, 2004 for all Joint Commission-accredited hospitals, ambulatory care surgery centers and office-based surgery sites. The Joint Commission Web site provides numerous resources on the Universal Protocol
- JCAHO IC Standards and field review topics (34 KB)
- Organizations endorsing universal protocols (26 KB)
- Universal protocol resources:
http://www.jcaho.org/accredited+organizations/
patient+safety/universal+protocol/wss_universal+protocol.htm
Safety tools
- Toolkit - Ambulatory patient safety
- Disclosure policy guide – Second in series from ASHRM
- OSHA bulletin - Disposal of contaminated blood tube holders
- Web-based training tool - OSHA resource for implementing incident command system
- Tips and resources - pesticide management in hospitals
- Checklist - Magnetic resonance safety
Toolkit- ambulatory patient safety
Gundersen Lutheran Medical Center (GLMC) has been involved in the recently completed Safety Collaborative for the OutPatient Environment (SCOPE) collaborative and is willing to share the toolkit utilized during its work. A "mini-collaborative" was formed within GLMC involving seven primary care sites. Local improvement teams were formed and worked on projects. Over the course of the year, some significant improvement in medication list accuracy, allergy list accuracy, and safe prescription writing practices was observed. GLMC plans to publish its results in the future. Project officials noted that the toolkit was developed with the thought: "What would be useful for a small practice with one nurse and one physician spending an hour a week attempting to improve their practice?" If any of the tools are used, GLMC would appreciate feedback on the elements of difficulty of implementation, the time element or cost.
- Download the toolkit (6.1 MB)
- or go to: http://www.gundluth.org/SCOPE
Disclosure policy guide Second in series from ASHRM
As healthcare organizations continue to work toward more open communication with patients, the American Society for Healthcare Risk Management has issued a new monograph that analyzes the value, structure and challenges in developing a disclosure policy. Titled Disclosure of unanticipated events: Creating an effective patient communication policy," the monograph covers considerations for developing policies and procedures in specific settings such as acute care, long-term care and pediatric care. It also examines the effect of disclosure policies on litigation. The monograph is the second in a series of three papers on the topic of disclosure to be issued by ASHRM. The third paper will be available in early 2004.
- Download the monograph (410 KB)
- or go to http://www.hospitalconnect.com/DesktopServlet
OSHA bulletin - Disposal of contaminated blood tube holders
OSHA recently published a bulletin reiterating the agency's policy on disposal of contaminated needles and blood tube holders following blood-drawing procedures. OSHA's bloodborne pathogens standard prohibits the removal of needles from medical devices and removal of contaminated needles from blood tube holders following a blood drawing procedure. The safety and health information bulletin details those requirements and also includes an “Evaluation Toolbox that supplies guidance on the evaluation, selection, and appropriate use of engineering controls. The bulletin also provides the most recent sharps injury data from the Exposure Prevention Information Network. OSHA developed this “Information Regarding the Disposal of Contaminated Needles and Blood Tube Holders Used for Phlebotomy to provide relevant information regarding its policy on the prohibition of contaminated needle removal from medical devices. This Safety and Health Information Bulletin is not a standard or regulation, and creates no new legal obligations. The Bulletin is advisory in nature, informational in content, and is intended to assist employers in providing a safe and healthful workplace.
- Download the bulletin (39 KB)
- or go to http://www.osha.gov/dts/shib/shib101503.html
Web-based training tool - OSHA resource for implementing incident command system
OSHA has a Web-based training tool on implementing an incident command system as part of emergency response preparedness. The tool, available at http://www.osha.gov/SLTC/etools/ics/index.html, provides guidance on planning for an incident command system and addresses applicable OSHA standards.
Tips and resources - pesticide management
A survey of top U.S. hospitals finds that many major hospitals are regularly spraying toxic pesticides, unnecessarily risking the health of patients, staff and visitors. The survey results are detailed in a new report, Healthy Hospitals: Controlling Pests Without Harmful Pesticides. (11-pesticides) The report, released by health advocate groups Health Care Without Harm (HCWH) and Beyond Pesticides, offers tips and resources for how hospitals can manage pests while also protecting the health of people and the environment.
- Download the report (614 KB)
- The report is also available at:
Checklist - Magnetic resonance safety
The American College of Radiology has developed a white paper on
Magnetic Resonance safety. The paper is an educational tool designed to
provide consensus-based, valid and medically credible information and
features detailed, useful checklists.
- Download the white paper (197 KB)
- or go to
http://www.acr.org/dyna/?doc=committees/mr_safety/safe_mri.html
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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 Premiers Perspective Online database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.