March 2006
Dear Colleague:
Has your hospital joined SCIP yet? Sign up now for the CMS Surgical Care
Improvement Project (SCIP) and be recognized as a participating hospital on the
CMS-SCIP official Web site. Visit our SCIP resources and
related guidelines.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Clostridium difficile rates double; experts debate cause and control measures
- States review best methods for adverse event data reporting, analysis, feedback and improvement
- Online medical error reporting provides rich safety tracking data; strategies needed to increase reporting by physicians
- Consumer partnership assures success in reducing antibiotic use and proper disposal
- Nurse staffing and work hours explored in
new safety study - Influenza update: New rapid blood test for avian flu; CDC releases first exclusive worker influenza immunization guideline
- Premier Safety Institute launches Web site on Culture of Patient Safety
Safety tools
- The unSUMMIT on Bedside Barcode Technology
in Practice - Guidelines – Surgical antimicrobial
prophylaxis – SCIP - Medication safety tool – ambulatory care
- Green Link – New Premier newsletter to aid "green" purchasing and practices
- AHRQ toolkit – Hospital process
redesign strategies - IHI white paper – perinatal care
Clostridium difficile rates double; experts debate cause and control measures
Diarrhea caused by Clostridium difficile has been a recent hot topic in both the mainstream press and scientific literature. Most recently, McDonald and colleagues used the National Hospital Discharge Survey (NHDS), a sample of almost 500 U.S. acute care hospitals in which over 300,000 patient records per year are abstracted, to determine the incidence of Clostridium difficile-associated disease (CDAD) as coded in discharge records. They found the incidence of CDAD doubled from 61/100,000 between 1996 and 2003 and is five-fold higher among those 65 or older. See full summary for story and references.
The Safety Institute interviewed Russell Olmsted, MPH, an epidemiologist at St. Joseph Mercy Hospital, Ann Arbor, MI, following his extensive review of recent CDAD literature. Olmsted's review addressed the changing epidemiology of this microbe, the risk factors that may increase or reduce transmission (e.g., antibiotic usage, role of alcohol based sanitizers, hand hygiene, and use of gloves), the role of patient placement, and environmental controls measures.
Olmsted shared his key findings, which include:
- Antibiotic usage First and foremost, use antibiotics judiciously; evaluate use of fluoroquinolones, other antibiotics, and additional medications such as proton pump inhibitors if an endemic rate is high or a cluster is suspected.
- If feasible, discontinue the antibiotic(s) the patient was receiving prior to onset.
- Precautions Use Contact Precautions for patients with known or suspected CDAD according to current CDC guidelines:
- Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms with other patients (cohorted) with C. difficile-associated disease.
- Perform hand hygiene using either an alcohol-based hand rub or soap and water.
- Outbreak: If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with C. difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria.
- Use gloves when entering patients' rooms and during patient care.
- Use gowns if soiling of clothes is likely.
- Dedicate equipment whenever possible.
- Continue these precautions until diarrhea ceases.
- Environmental cleaning and disinfection Implement an environmental cleaning and disinfection strategy:
- Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
- Use an Environmental Protection Agency (EPA)-registered hypochlorite-based disinfectant for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: alcohol-based disinfectants are not effective against C. difficile and should not be used to disinfect environmental surfaces.)
- Follow the manufacturer's instructions for disinfection of endoscopes and other devices.
- Infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings.
Complete story, references and links at:
http://www.premierinc.com/quality-safety/tools-services/safety/topics/cdad/
States review best methods for adverse event data reporting, analysis, feedback and improvement
Findings from a recent National Academy for State Health Policy (NASHP) summit, "Maximizing the Use of State Adverse Event Data to Improve Patient Safety," addressed adverse event data integrity, event report analysis, and data feedback dissemination. This Commonwealth Fund-sponsored report outlines states' opportunities and challenges they may experience when attempting to improve their adverse-event reporting system.
Adverse event reporting systems can help improve patient safety through the analysis of the adverse events, implementation of best practices, and the lessons learned to prevent recurrences. Challenges to the collection of relevant data include incomplete reporting, statistical problems, and identifying the best reporting formats to use. The NASHP report describes the key findings of the data collectors, analysts, and users who met to try and identify ways to improve reporting, tools to be used for event report analysis and dissemination, and opportunities for improvement.
Lessons learned and tools developed It is important for states to consider new national developments that may influence their systems such as the Patient Safety Event Taxonomy (PSET) endorsed by the National Quality Forum (NQF). The NQF also recently released a consensus report, "Standardizing Patient Safety Taxonomy." The NASHP report concluded that focusing on the quality improvement aspects of adverse reporting systems, as well as providing information to providers that helps them improve their care, may lead to a greater incentive to report adverse events. NASHP is creating a toolbox on its Web site that will include policies, practices, forms, reports, and methods used across state reporting systems.
National Academy for State Health Policy (NASHP) Web site:
http://www.nashp.org
NASHP report (.pdf) (426 KB)
Patient Safety Event Taxonomy (PSET) (.pdf) (699 KB)
NQF Taxonomy (.pdf) (781 KB)
Toolbox Web site: http://www.pstoolbox.org/
Online medical error reporting provides rich safety tracking data; strategies needed to increase reporting by physicians
Results from a multi-year survey of 92,000 events reported by 26 acute care hospitals using a secure electronic medical adverse event/error reporting system provide rich and real-time data to track safety improvements. Meanwhile, the results also have revealed additional strategies needed to increase reporting by physicians, who provided fewer than 2 percent of the reports.
The 26 hospitals in this study used the same electronic event reporting system (e-ERS) located on all hospital computers and accessible to all employees for purpose of reporting medical errors. The study was conducted between January 1, 2001, and September 30, 2003, with a mean duration of e-ERS use of 21 months. A total of 2.5 million patient days were analyzed and reporting rates varied widely across hospitals (nine to 95 reports per 1,000 inpatient-days). The study was published by Milch and colleagues at Tufts-New England Medical Center in the December 22, 2005, issue of the Journal of General Internal Medicine.
Any hospital employee could submit a report after a secure login and although reporting was not anonymous, reports were peer-review protected at each hospital site and accessible only to pre-specified hospital personnel. For example, in most hospitals, the chief medical officer and quality improvement executives had access to all reports; ward leaders (nurse managers and attending physicians) had access to and responsibility for all events that occurred on their ward and pharmacy leaders had access to all medication-related events.
The greatest percentage of reports came from registered nurses (47 percent), followed by pharmacists and pharmacy technicians (16 percent), lab technicians (10 percent), unit clerks/secretarial staff (10 percent), LPNs and nursing assistants (3 percent), and physicians (1.4 percent). Other reports came from medical assistants, security personnel, social workers, and risk case managers.
Among 80 percent of reports that identified level of impact, 53 percent were events that reached a patient ("patient events"), 13 percent were near misses that did not reach the patient, and 14 percent were hospital environment problems. Thirty two percent of the patient events caused temporary harm, 0.8 percent life threatening or permanent harm, and 0.4 percent contributed to patient deaths.
Authors noted that high reporting rates in an institution may not necessarily represent poor patient care, but rather an institutional culture that encourages reporting of errors and adverse events, integrates reporting into quality improvement processes, and focuses on system-level changes instead of individual blame and punitive actions.
The proportion of very serious adverse events in this study, although small, was not negligible – slightly more than 1 per 1,000 admissions. If this rate is applied to the entire population of 33.7 million inpatients in non-federal acute care U.S. hospitals, the authors estimated 34,000 patients per year could be seriously or permanently injured or die during hospitalization because of an adverse event.
Nearly 70 percent of events that reached the patient produced no harm, and one quarter of all reports were either environmental safety issues or near misses. Thus, an e-ERS was helpful in capturing system defects (latent errors) and near misses that may not have been detected by reviews of patient charts or medication records and assist with the identification of ‘‘root causes'' of errors and adverse events.
This study provided further evidence that an e-ERS could help overcome two of the roadblocks to improving safety of medical care identified by Donald Berwick.
First, by making errors and adverse events reporting accessible to all hospital employees, as well as easy to review and track, they become more visible to clinicians, hospital administrators, government officials, and the public. Second, a reporting system that allows for reporting of near misses and problems in the safety of the hospital environment may help uncover "root causes" such as some system errors that may not be identified by retrospective review. Additionally, a Web-based e-ERS allows for real-time event notification and oversight, and for concurrent tracking of rates over time – tasks not easily performed with a paper-based system. Over the past two years, England's National Patient Safety Agency has introduced a national system for identifying and reporting adverse events in healthcare; in the absence of such a national system in the United States, hospital-wide e-ER systems may be important in the reporting, measuring, and tracking of adverse events and medical errors.
Physicians should take a leading role in quality efforts to reduce medical errors and adverse events. The factors associated with the low reporting rates by physicians and in some hospitals require further evaluation. Quantros, Inc., a strategic partner of Premier, acquired DrQuality, the event reporting system used in the study. This reporting system is part of Premier's Safety Advisor.
Journal of General Internal Medicine abstract (.doc) (28 KB)
This reporting system is part of Premier's Safety Advisor.
For more information, go to:
http://www.premierinc.com/all/informatics/advisor/safety/
Consumer partnership assures success in reducing antibiotic use and proper disposal
The state of Michigan recently launched a successful new campaign that engages consumers in helping to decrease antibiotic resistance and properly dispose of antibiotics to save the environment. The campaign, "Antibiotic Roundup," generated hundreds of consumer inquiries within the first two days of its January 25 launch. This first-ever statewide program focused on antibiotic resistance reduction and provides everyone in the community with an opportunity to help "save our antibiotic lifeline" and the environment. The program runs through April 25, 2006. The Michigan Antibiotic Resistance Reduction (MARR) coalition, the CDC Foundation and a large pharmacy chain collaborated in launching the initiative. The MARR Coalition is a non-profit organization dedicated to preserving consumers' antibiotic lifeline through education, research and collaborative partnerships.
Michigan residents were asked to bring old or unused antibiotics to a local pharmacy for disposal and in return, received educational materials on the development of antibiotic resistance and a free gift from a large Michigan pharmacy chain. This "antibiotic amnesty" program saves the environment as well, since the disposal of drugs down a drain or toilet is minimized. The collected drugs are being properly incinerated in cooperation with the EPA.
When medicines, including antibiotics, are flushed down the toilet or washed down a drain, they typically go to one of two places – a septic tank or a sewer that drains into a wastewater treatment plant. Different types of drugs can harm the beneficial bacteria that break down waste in a septic system or treatment plant, and could damage the ability of the system to treat wastes. Many medicines pass through treatment systems intact, or partially treated and are released to the environment (lakes, rivers or groundwater) with the treated wastewater. Additionally, some medicines contain minute quantities of mercury. When released into aquatic systems, microorganisms can convert mercury into methylmercury, which builds up in the food chain to dangerous levels for humans and wildlife, which consume potentially contaminated fish species at the top of the food chain. More information is available from Premier Safety Institute's Pharmaceutical waste management Web site.
The Michigan Antibiotic Roundup launch was publicized in newspapers, television and radio across the country; the MARR Web site received over 400 hits in one 48-hour period. This program is also partly supported by the U.S. Environmental Protection Agency (EPA) Region 5, Food and Drug Administration (FDA), Meijer Pharmacies, Michigan State legislative leaders and others.
Michigan Antibiotic Resistance Reduction (MARR):
http://www.mi-marr.org/
List of antibiotics (.pdf) (295 KB)
Antibiotics – frequently asked questions:
http://www.mi-marr.org/faqs.html
Michigan Surgeon General recording:
http://www.mi-marr.org/documents/Antibiotic60.mp3
Premier Safety Institute's Pharmaceutical Waste Web site.
Nurse staffing and work hours explored in
new safety study
A recent study of intensive care nurses found an association between prolonged working hours and increased risk of errors; the risks doubled among nurses working more than 12.5 hours in a 24 hour period.
Data for this study were obtained from a random sample of critical care nurses in the United States. Nurses who volunteered and were eligible for the study collected information about the hours worked (both scheduled and actual hours), the time of day worked, overtime hours, days off, and sleep-wake patterns. Space was provided for descriptions of any errors or near errors that might have occurred. On days off, the nurses completed only those questions about sleep-wake patterns, mood, and caffeine intake. For more information, see the document, "Effects of critical care nurses' work hours on vigilance and patients' safety."
A total of 502 critical care nurses in 6,017 work shifts were included in the study. All the nurses worked full time in a critical care unit. Forty four percent of the work shifts were scheduled for 12 hours, with 67 percent exceeding 12 consecutive hours. Ten percent worked more than 16 hours at least once during the study. Of those nurses that worked longer than scheduled, 16 percent were mandatory and 10.5 percent were reported as "coerced voluntary overtime."
Thirty eight percent of the nurses reported making at least one error during the study period. The majority of errors (56.5 percent) and near errors (28.2 percent) involved administration of medications. Other errors reported were procedural (19.6 percent), charting (1 percent), and transcription (0.8 percent) mistakes.
Longer shift durations increased the risk of errors and near errors and were associated with decreased vigilance. In particular, the risk for making an error almost doubled when nurses worked 12.5 or more consecutive hours. Nurses who worked more than 12.5 consecutive hours were more likely to struggle to stay awake at work than those who worked fewer hours.
The authors note that although 12-hour shifts are popular, the findings from this study support recommendations to minimize the use of 12-hour shifts or at least limiting nurses' work hours to no more than 12 consecutive hours during a 24-period.
Effects of critical care nurses' work hours abstract (.doc)
(25 KB)
Influenza update: New rapid blood test for avian flu; CDC releases first exclusive worker influenza immunization guideline
Rapid H5 diagnostic test-avian The Food and Drug Administration (FDA) approved a new rapid test for diagnosing the H5 avian flu strain in humans following an unusually quick two-week review. The test, "Influenza A/H5 (Asian lineage) Virus Real-time RT-PCR Primer and Probe Set," developed by the Centers for Disease Control and Prevention (CDC), can detect an H5 virus within four hours, versus two to three days using previous testing technology. Two genetic lineages of influenza A/H5 viruses exist: Eurasian (Asian) and North American. The primer and probe set test is designed to detect highly pathogenic influenza A/H5 viruses from the Asian lineage associated with recent laboratory-confirmed infections of avian influenza in humans in East Asia and, most recently, Turkey and Iraq. Numbers of cases continue to grow; as of March 1, 2006 the World Health Organization (WHO) reported 174 confirmed human cases of avian influenza A (H5N1); among them, 94, or 54 percent, were fatal. The CDC is distributing the new test to U.S. laboratories and has shared the test technology with the World Health Organization. Testing for influenza A/H5 virus is indicated when a patient has symptoms of severe respiratory illness and a risk of exposure and is done in consultation with local or state health departments.
Seasonal influenza vaccination Although the Advisory Committee on Immunization Practices (ACIP) publishes guidance each year on influenza immunization, including healthcare workers (HCW), ACIP and the Healthcare Infection Control Practices Advisory Committee (HICPAC) this year released a joint "Influenza Vaccination of Health-Care Personnel" guideline that focuses solely on HCWs and strongly recommends the offering of influenza vaccination to all personnel. This seasonal influenza immunization program addresses all staff, students, volunteers, and licensed practitioners working with patients, clients, and residents at high risk for influenza-related complications. Specific information is provided on the importance of education, record keeping, monitoring and developing strategies for enhancing rates. The guideline offers the following detailed methods for improving vaccination rates and classifies specific recommendations on an evidence-based weighted classification scheme (1A, 1B, the strongest recommendations for implementation; 1C regulatory requirements; and II, which is suggested for implementation based on theoretical basis.) Offering influenza immunization to all eligible personnel classified as a 1A recommendation:
- Offer annually to all eligible HCP to protect staff, patients, and family members and to decrease HCP absenteeism (category IA).
- Offer vaccination to HCP at the work site and at no cost as one component of employee health programs (category IB).
- Educate HCP regarding the benefits of influenza vaccination and the potential health consequences (category IB).
- Monitor HCP influenza vaccination coverage and declination at regular intervals during influenza season and provide feedback of rates to staff and administration (category IB).
- Obtain a signed declination from HCP who decline influenza vaccination for reasons other than medical contraindications (category II).
- Use the level of HCP influenza vaccination coverage as one measure of a patient safety quality program (category II).
MMWR Lab Assay (.doc) (35 KB)
Premier Safety Institute launches Web site on Culture of Patient Safety
The Survey on Patient Safety Culture was developed by the Agency for Healthcare Research and Quality (AHRQ) and released in November 2004 in partnership with Premier, Inc., the Department of Defense and the American Hospital Association. The survey tool is being used to assess the safety culture of a hospital as a whole or specific units within hospitals, to track changes in patient safety over time, and to evaluate the impact of patient safety interventions.
Developed initially by Premier with assistance from AHRQ/Westat, the Excel™ customized data tool is available free of charge on the Web site and has been updated in cooperation with AHRQ. It allows users to easily input raw data, create graphs and tables to display results, analyze safety culture dimensions needing attention or further analysis, share findings electronically, and benchmark results.
"The excel data tool is particularly useful for smaller healthcare settings," said Gina Pugliese, R.N., M.S., vice president of the Premier Safety Institute. Moreover, she noted, the tool will help support the state Quality Improvement Organizations' (QIOs) work with small, rural and critical access hospitals as part of the Centers for Medicare and Medicaid's 8th Scope of Work (SOW) initiative. "QIOs are always looking for ways to accelerate the pace of improvement by promoting organizational change and the use of redesigned care processes, and our tools and related resources will assist them in supporting activities to improve safety culture in healthcare settings," Pugliese added.
Many downloadable resources and sample tools and interventions for the development of a culture of safety are available at the new Culture of Patient Safety Web site within the overall publicly accessible Premier Safety Institute site. Resources include the AHRQ survey tool in multiple formats (including the Spanish version developed by Premier), audio conference materials, benchmarking data and more than 40 different resources for improving the development of a culture of safety.
Link to official announcement, Culture of Safety Press release
Premier Safety Institute Culture of Patient Safety Web site:
http://www.premierinc.com/quality-safety/tools-services/safety//culture/
Safety tools
The unSUMMIT on Bedside Barcode Technology
in Practice
The unSUMMIT on Bedside Barcode Technology in Practice, planned April 24-26, 2006 in Hollywood, FL, will provide essential information about patient safety and Barcode Point of Care (BPOC) technology. The agenda includes panel discussions and Q&A sessions delivered by peers and industry experts including James P. Bagian, M.D., Michael Cohen and Dr. Kenneth Barker. Jeff Patchett, director, Pharmacy Technology, Premier, will moderate a session entitled "Medication Distribution Uprooted." The program is designed to help clinicians and administrators interested in safeguarding the medication administration process and should equip pharmacy, nursing and informatics professionals with practical tools for building a strong bedside barcode scanning practice. The conference registration form and information are available at: http://www.unsummit.com/homepage.html.
Use code number 06UNS001 to receive a 20 percent discount off of the registration fee.
Guidelines – Surgical antimicrobial prophylaxis – SCIP
Access to guidelines on surgical antibiotic prophylaxis have been added to the Premier Safety Institute's Guidelines Web site. These resources are useful for participants in the Surgical Care Improvement Project (SCIP), a national quality improvement project designed to improve surgical care in hospitals. The following information on SCIP and more is available at:
http://www.premierinc.com/quality-safety/tools-services/safety//
news/scip-11-11-05.jsp.
- "Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project"; Dale W. Bratzler and Peter M. Houck, for the Surgical Infection Prevention Guidelines Writers Workgroup (SIPGWW), Oklahoma Foundation for Medical Quality, Oklahoma City, OK, and Centers for Medicare and Medicaid Services, Seattle, WA. This advisory statement provides an overview of issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection, initiation and discontinuance of prophylactic antimicrobials.
Download "Antibiotic Prophylaxis for Surgery." - "Antibiotic Prophylaxis in Cardiac Surgery – Duration of prophylaxis"; Report from the Society of Thoracic Surgeons Workforce on Evidence Based Surgery; © 2005 The Society of Thoracic Surgeons. This guideline provides for one recently CMS approved exception for discontinuance of antibiotic prophylaxis.
View "Antibiotic prophylaxis in Cardiac Surgery."
Medication safety tool – ambulatory care
An easy-to-use medication safety guide (.pdf) (2.5 MB) has been developed by AHRQ researchers. The guide is designed to help outpatient physician practices incorporate safer systems for medication sample prescribing and dispensing. The checklist format helps users rate their current medication use processes (prescribing, dispensing, administering, counseling, and monitoring) so plans for improvements can be prioritized and implemented. The guide also addresses processes in technology and safety, office environment, error management, workplace conditions, safety education, and safety perceptions. Researchers developed the guide in response to an AHRQ study that found standards for medication safety among 31 physician practices were suboptimal and unacceptable.
Green Link – New Premier newsletter to aid "green" purchasing and practices
Green Link is the latest addition to Premier's award-winning Environmentally Preferable Purchasing (EPP) program. The newsletter provides news and success stories about topics such as reduction of medical waste, computer recycling, green cleaning programs, conversion to reusable products, laboratory chemical recycling, energy efficient lighting and light bulb recycling. Premier's EPP program is a collaboration of the Premier Safety Institute and Premier's group purchasing services. The program is part of Premier's commitment to helping healthcare facilities with their environmental efforts, including waste minimization and the elimination of the use of mercury.
For its efforts, Premier was the first hospital group purchasing organization to earn the Champion for Change Award from Hospitals for a Healthy Environment (H2E), and has now won the award for three consecutive years. H2E is an industry-wide collaborative effort that educates healthcare professionals about pollution prevention opportunities and assists hospitals in reducing mercury use and minimizing waste. For a copy of Green Link and more information about Premier's EPP program, visit the Premier Safety Institute Web site at www.premierinc.com/safety or call 704.733.5865.
AHRQ toolkit – Hospital process redesign strategies
Hospitals that wish to redesign their processes of care to make them safer and more efficient now have a new toolkit available from The Agency for Healthcare Research and Quality (AHRQ). The toolkit (.pdf) (260 KB) presents strategies for comprehensively redesigning and transforming processes of care in a hospital. It details how healthcare systems can redesign (including the planning steps needed for such transformation) and presents strategies for translating information gathered into proposed projects for implementation. Many of the techniques included in the toolkit can be used to guide process improvements without embarking on comprehensive system transformation.
IHI white paper – perinatal care
Reviews of perinatal care have consistently pointed to failures of communication among the care team and documentation of care as common factors in adverse events that occur in labor and delivery. Such failures also have been shown to be prime factors leading to malpractice claims. A new white paper from the Institute for Healthcare Improvement (IHI), "Idealized Design of Perinatal Care," (.pdf) (230 KB) is an innovative project based on the principles of reliability science and the IHI's model for applying these principles to improve care. The Idealized Design model focuses on comprehensive redesign to enable a care system to perform substantially better in the future than the best it can do at present.
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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
- Derek Kleckner, BA, 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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