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Dear Colleague:
We end the year with news on key research and milestones on improving patient safety, including tracking adverse events, increasing EMR use, and peer support after adverse events.
It is National Flu Immunization Week - keep yourself, family and patients safe and get your flu shot.
SafetyShare is brought to you by the Premier Safety Institute, as part of Premier’s core role, to improve the health of communities.
We wish you a healthy and happy holiday season!
The Editorial Team
Gina Pugliese, editor
Judene Bartley, associate editor
Cathie Gosnell, contributor
Judith Luca, contributor
John Hall, contributor
David Huntley, webmaster
Blair Childs, senior vice president and advisor
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Recent results of a study from the Institute for Healthcare Improvement (IHI) on the development and evaluation of a more robust approach for detecting adverse events in hospital patients using an enhanced IHI Global Trigger Tool methodology found high levels of agreement on the presence and severity of adverse events with the use of well-trained reviewers using a two-stage review process.
The IHI Global Trigger Tool for measuring adverse events is a method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. The Trigger Tool methodology includes a retrospective record review of a random sample of patient records using "triggers" (or clues) to identify possible adverse events. Hospitals can use the Trigger Tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. Triggers relate to care processes, surgical procedures, medication administration, and care in an intensive care unit (ICU), perinatal department, or emergency department.
Methodology In this new study, researchers refined the Global Trigger Tool methodology by using a retrospective record review with a two-stage process. Four clinicians, followed by a second review by two physicians and then a consensus process, conducted the initial review. A two-step process was also used for evaluation. Agreement among all reviewers was measured for the presence and severity of adverse events. Initially, reviewer agreement ranged from 38.5 percent to 76.9 percent. After reviewer training, agreement ranged from 66.7 percent to 93.9 percent. Researchers concluded that using trained reviewers increases agreement on identifying an adverse event and its severity. Record review is a more expensive method of finding adverse events, but has been found to identify more adverse events than either a voluntary reporting system or an incident-based reporting system. Authors conclude that the use of the Global Trigger Tool methodology in retrospective chart review with a two-stage review process is easy to use and together with trained reviewers accurately identifies adverse events and their severity.
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A recent survey of medical and surgical residents found that if crucial information is not transferred during "handoffs" communication, major patient harm, including significant worsening of clinical status, prolonged hospitalization, disability or death, could result. The authors conclude that best practice "handoff " communications occur in a quiet, uninterrupted setting that allows questions to be asked and that a standardized format may be useful.
The Joint Commission added the implementation of a standardized approach to "handoff " communications, including an opportunity to ask and respond to questions to their 2006 National Patient Safety Goals. These survey results indicate that best practice recommendations for handoffs are not being observed; despite specific guidelines that have been developed to promote safe handoff practices, they remain a significant source of patient harm.
Results This new study surveyed medical and surgical resident physicians at a teaching hospital about their handoff practices and the frequency with which they perceive problems with handoffs lead to patient harm. The study, published in the October 2008
Joint Commission Journal on Quality and Patient Safety, reports the results of the 161 study respondents at Massachusetts General Hospital (MGH) and describes situations in which problematic handoffs are more likely to occur and factors that may interfere with the smooth transfer of crucial information. More than half of the residents reported at least one incident of handoff-related patient harm during their month-long inpatient rotations. Approximately 12 percent of residents said handoffs resulted in major patient harm, including significant worsening of clinical status, prolonged hospitalization, disability or death. The residents reported that if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely. The overall quality of handoffs was rated "fair" or "poor" by 31 percent of the residents.
Recommendations While 94 percent of handoffs were conducted face-to-face, only 26 percent of residents reported that handoffs usually or always took place in a quiet setting, with 37 percent reporting one or more interruptions during the receipt of handoffs. More than half of the residents felt that problematic handoffs reduced their ability to provide complete and accurate information to patients, family members and other healthcare professionals. The authors recommend compiling better information for handoffs and conducting them in a quiet, uninterrupted setting that allows questions to be asked. They also suggest that the implementation of a standardized handoff format may be useful.
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Joint Commission accredited hospitals have steadily improved the quality of patient care in critical areas over a six-year period of data collection. According to The Joint Commission’s (TJC)
annual report, hospital quality measures related to conditions such as heart attacks, heart failure, pneumonia or selected surgeries provide scientific evidence of improved patient care through 2007.
Surgical care quality: A number of improvements cited included three evidence-based measures taken from 2005 to 2007, which showed continual progress and improvement on the three measures. Measured over all surgeries, "timely discontinuance of antibiotic" improved the most, showing a 12.1 percent gain from 2005 (73.5 percent) to 85.6 percent in 2007. "Timely start of antibiotic" improved 7.7 percent, moving up from 81.8 percent in 2005 to nearly 90 percent (89.5) in 2007. "Selection of appropriate antibiotics" had already achieved high levels in 2005, gaining nearly 3.6 percent from 91.3 to 94.9 percent in 2007.
Heart failure: Providing discharge instructions to heart failure patients improved dramatically from 30.9 percent to 77.5 percent.
Pneumonia: Providing pneumococcal screening and vaccination to pneumonia patients also more than doubled, moving from 30.2 percent in 2005 to 83.9 percent by 2007.
The annual report also provides updates on hospitals' compliance with 18 requirements of the nine 2007 National Patent Safety Goals.
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A comprehensive review of root cause analysis (RCA) reports of inpatient suicides and suicide attempts in Veterans Affairs (VA) hospitals found that 70 percent of completed and attempted suicides were from hanging, cutting and overdosing. Recommendations included eliminating doors when not required by code as well as sharps, among other environmental interventions. Since nearly half of the incidents occurred on units other than the inpatient psychiatry unit, especially the ER, hospitals were also urged to develop systematic protocols for evaluating and managing suicidal patients.
Approximately 1,500 suicides occur in inpatient hospital units nationwide each year, with one-third occurring while the patient is on 15-minute checks. Previously published reports state that veterans are twice as likely as non-veterans to die of suicide. RCA reports have been mandatory by The Joint Commission for suicides or attempted suicides for more than 10 years. In an effort to determine the underlying causes and environmental factors involved in patient suicides and suicide attempts, all related RCA reports submitted to the
VA National Center for Patient Safety (NCPS) from December 1999 and June 2006 were reviewed.
Analysis: During this nearly seven-year period, there were a total of 185 inpatient suicides and attempted suicide events, with nearly 80 percent suicide attempts. There were 42 successful suicides. Fifty-two percent of the total number occurred while the patient was on an inpatient psychiatry unit. The distribution of primary methods (70.4 percent) were hanging (31.4 percent), cutting with a sharp object (20.1 percent), and intentional drug overdose (18.9 percent). Other methods included strangulation (8 percent) and jumping (8 percent). Doors and wardrobe cabinets accounted for 41.4 percent of the hanging anchor points, and bedding accounted for 39.7 percent of the noose material. Razor blades were used in 36.8 percent of cutting cases, and balconies and walkways were used for 57.1 percent of the cases of jumping.
Recommendations: Seventy-six percent of the 143 inpatient suicide attempts reviewed involved the environment of care. Authors recommend modifying inpatient units by such measures as: 1) eliminating doors when not required by Code; 2) removing doors on wardrobe cabinets and replacing rods and hangers with shelves; 3) eliminating belts, shoelaces and safety razors; 4) eliminating access to drugs that could be used for an overdose; and 5) conducting environmental rounds using active observations skills and a comprehensive checklist of potential environmental hazards. As noted, hospitals should also develop systematic protocols for evaluating and managing suicidal patients.
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The Centers for Disease Control and Prevention (CDC) released updated guidelines for cleaning, disinfecting and sterilizing medical devices and cleaning and disinfecting the environment. With the last version published more than two decades ago in 1985, this 2008 revision has many significant changes that include:
- Design of disinfection technology for use on complex medical, equipment, e.g., endoscopes
- Efficacy of products on newer pathogens, e.g., Norovirus, SARS
- New products, e.g., hydrogen peroxide, peracetic acid and combination of both
- Eliminated products, e.g., iodophors, as high level disinfectants, due to lack of efficacy against bacterial spores (note: iodophors are still effective antiseptics)
- Reduction of exposure time for high-level disinfection, down to five minutes for some formulations (e.g., ortho-phthalaldehyde) under specific conditions
- Confirmation of lack of any evidence that disinfectants are becoming resistant to organisms, similar to what we see with antibiotics used on patients
Bleach dilutions clarified with household measurement terms
The glossary in the CDC guidelines provides bleach dilutions using household measurement terms and equivalent parts per million (ppm) that can be used to translate recommendations for use in the patient care setting for environmental decontamination after cleaning, e.g., for
Clostridium difficile. The Premier Safety Institute has expanded the information to include the use of chlorine bleach as a sanitizing agent in dietary settings consistent with EPA U.S Govt regulations (21 CFR Part 178).
Bleach
Solution |
Dilution
Exact |
Chlorine
(ppm) |
Dilution
approximate |
Household
(ppm)
Approximate |
Application |
| 5.25% - 6.15% |
Concentrate |
52,500 -
61,500 |
Concentrate |
52,500 -
61,500 |
*Patient Care |
| 5.25% - 6.15% |
1:10 |
5,250 -
6,150 |
1.5 cups / 1 gallon |
~6000 |
*Patient Care |
| 5.25% - 6.15% |
1:100 |
525-615 |
0.25 cup / 1 gallon |
~600 |
*Patient Care |
| 5.25% |
1:200 |
263 |
1 tablespoon / 1 gallon |
<200 |
*Dietary |
| 5.25% - 6.15% |
1:1000 |
53-62 |
1 teaspoon / 1 gallon |
~50 |
*Dietary |
* See specific recommendations in Guidelines
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Office-based physicians are gradually increasing their use of electronic medical records (EMR). CDC's 2006 National Ambulatory Medical Care Survey (NAMCS) found 29.2 percent of office-based physicians reported using a full or partial EMR system, which represented a 22 percent increase in 2006 from the previous year and a 60 percent increase since 2001.
The recently released CDC report, "Electronic Medical Record Use by Office-Based Physicians and Their Practices: United States, 2006," also examined physician plans to install new EMR systems or replace their current systems within three years.
Features of a full system Minimal features for a full EMR system include four key features: the use of computerized orders for prescriptions; computerized orders for tests; reporting of test results; and clinical notes. Only 12.4 percent of surveyed physicians reported using a full EMR system in 2006 – a small 3.1 percent increase from the reported 9.3 percent using a full EMR system in 2005. A partial EMR includes a system that is part paper. Use of EMR was higher among health maintenance organizations and increased with the size of the practice. Use of a full EMR system was higher among physicians in multi-specialty practices. The survey indicated 23.9 percent of office-based physicians planned to install new EMR systems or replace their current system within three years.
Of the physicians who report using fully electronic medical record systems, 63.7 percent reported using reminders for guideline-based interventions or screening tests, with 52.9 percent using the computerized prescription order entry, and only 46.5 percent using the computerized test order entry feature in their EMR system. Authors concluded that since these are the features most likely to result in improved management and quality of care, continued efforts are needed to increase the adoption rate of comprehensive EMR systems.
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VA study authors found that use of the VA National Surgical Quality Improvement Program (NSQIP) model was applicable to Private Sector (PS) hospitals and that implementation of the model in PS hospitals would reduce adverse postoperative outcomes, including a reduction in 30-day postoperative morbidity.
Study population 128 VA medical centers and 14 PS hospitals participated in the
Patient Safety in Surgery (PSS) Study involving 184,843 patients undergoing major general or vascular surgery. Seventy percent of the patients were from VA hospitals and 30 percent were from PS hospitals. There were differences in the baseline characteristics and types of procedures between the VA and PS hospitals, but little difference in perioperative complications, with seven of the top 10 comorbidities common to both groups. The two groups also shared nine of the top 10 predictors of postoperative mortality and eight of the top 10 most common 30-day postoperative morbidities, with superficial wound infection being the most common.
Results Statistical analysis found that valid risk-adjusted outcomes for diverse hospitals and hospital groups could be compared using the NSQIP database. Over the three-year study period, an 8.7 percent reduction in overall postoperative morbidity was observed, including a 9.1 percent reduction in surgical site infections and a 23.7 percent decrease in renal complications. No significant change was observed in the mortality rate.
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The Peer Support Team model provides structured peer-based support services for healthcare providers after an adverse event. The Peer Support program was developed and implemented at Brigham and Women's Hospital to address the emotional impact of adverse events on healthcare professionals following the apology and open communication between a doctor and a patient.
The emotional impact of adverse events on healthcare professionals has been described in the literature but seldom are there reports of any support services or programs to assist these healthcare providers. The literature suggests that over 90 percent of the results of a healthcare experience are a function of the systems in which the caregivers work. Authors conclude that instead of looking to assign individual responsibility for an adverse event, one should first look at the systems that may have compromised the quality of care.
The PST model provides structured, peer-based support services for healthcare providers after an adverse event. By having such a model in place, healthcare providers can avoid pursuing more formal forms of support services through the Employee Assistance Program (EAP) or mental health services. An internal survey at the hospital indicated only 10 percent of healthcare providers who were offered or found formal support services actually used them. The Peer Support Service provides a safe environment that allows open communication and provides compassion. Being able to relate to an individual with a common clinical background provides credibility and helps overcome the stigma of therapy. The service is handled separate from of the quality assurance (QA) process, and eliminates the fear of lawsuits. Authors said the care providers on the PST must be respected for their clinical skills, able to listen without judgment, and be supportive of the organization. Support from the medical culture also is critical. The PST at Brigham and Women’s Hospital is available 24 hours a day, seven days a week and is sponsored by the chief medical officer and the chief nursing officer. It is used for many types of events from personal crisis and adverse events to offering support during malpractice litigation.
The authors concluded that sustainable improvement of support services for care providers following adverse medical events depends on the integration of a supportive and compassionate work environment with systems-based thinking. This balance creates the opportunity for
being the change rather than
doing the change.
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Safety Tools
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With vaccination rates continuing to be less than optimal, experts are trying the popular Internet video site YouTube to reach a wider audience. A YouTube video documentary features the personal stories of parents who have lost or nearly lost a child to the flu. "Why Flu Vaccination Matters" was developed by Centers for Disease Control and Prevention (CDC) together with Families Fight Flu (FFF), a non-profit organization dedicated to educating people about the importance of vaccinating children against the flu every year. More immunization resources are available.
Quick summary of resources
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The U.S. Department of Health & Human Services (USDHHS) recently made public an inventory of the measures that are currently being used by the divisions in HHS for quality measurement, improvement and reporting. The department's goal is to advance the effective use and harmonization of quality of care measures. This is the first time a comprehensive list of quality measures used by the department has been posted in a single location. The department's transparency about the quality measures being used lays the foundation for the measurement enterprise and local users to build and improve upon.
http://www.qualitymeasures.ahrq.gov/hhs/hhsmeasures.aspx
The HHS measure inventory is accessible through the National Quality Measures Clearinghouse™ (NQMC) Web site. Use
the link and the drop-down box at the site to identify measures by HHS Division. You can view specified measure attributes by clicking the "More" link next to the measure title. For further analysis, the entire inventory of HHS
Measures is available for download in
Excel. This file will soon be enhanced with additional
functionality such as sorting by condition, setting, or
measure domain.
Download: or go to:
http://www.qualitymeasures.ahrq.gov/hhs/HHS.Quality.Measures.Inventory.xls
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The U.S. Pharmacopeia (USP) has announced a new drug safety tool designed to help patients, caregivers, pharmacists, physicians and others in avoiding medication errors that may occur because of drug names that look alike and/or sound alike. The new tool, "Drug Error Finder," is a searchable database of almost 1,500 commonly used drugs reported to be involved in medication errors due to brand and/or generic drug names that look or sound alike and reported to USP's MEDMARX® or to USP's Medication Errors Reporting Program. Using the Drug Error Finder is simple: just type in the name of the drug of interest. The tool will generate a list of medications that have been confused with that drug, as well as the severity attributed to the reported errors involving the drug (ranging from Category A for "potential for error " to Category I for "death"). To access the database on USP’s Web site, visit
www.usp.org/hqi/similarProducts/drugErrorFinderTool.html.
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In an instant, an explosion or blast can wreak havoc, producing numerous casualties with complex, technically challenging injuries not commonly seen after natural disasters such as floods or hurricanes. The Centers for Disease Control and Prevention, in collaboration with partners from the Terrorism Injuries Information, Dissemination and Exchange Project, as well as other experts in the field, have developed fact sheets for healthcare providers that provide detailed information on the treatment of blast injuries. These fact sheets address background, clinical presentation, diagnostic evaluation, management and disposition of blast injury topics. The fact sheets may be viewed and downloaded for use in the treatment of blast injury patients, in the training of clinical staff or to disseminate to others. These fact sheets will soon be available in Spanish, Chinese, and French at
http://www.bt.cdc.gov/masscasualties/blastinjuryfacts.asp.
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- David Huntley, BA, Web master
About Premier Inc., 2006 Malcolm Baldrige National Quality Award recipient Serving more than 2,100 U.S. hospitals and 53,000-plus other healthcare sites, the Premier healthcare alliance and its members are transforming healthcare together. Owned by not-for-profit hospitals, Premier operates one of the leading healthcare purchasing networks and the nation's most comprehensive repository of hospital clinical and financial information. A subsidiary operates one of the nation's largest policy-holder owned, hospital professional liability risk-retention groups. A world leader in helping healthcare providers deliver dramatic improvements in care, Premier is working with the United Kingdom's National Health Service North West and the Centers for Medicare & Medicaid Services to improve hospital performance. Headquartered in San Diego, Premier has offices in Charlotte, N.C., Philadelphia and Washington. For more information, visit
www.premierinc.com.
SafetyShare © 2008 Premier, Inc.
You may forward this newsletter to your colleagues. If you would like to reprint any of these stories, please cite the "SafetyShare newsletter, Premier, Inc." as your source and send an email to
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