Safety Share

May 2005

Dear Colleague:

DELETE THIS EMAIL. Yes, you read correctly. ALL issues of Safety Share are archived on our Web site by date and topic, and are available, whenever you need the information.

Gina Pugliese, editor
Vice President, Premier Safety Institute


Safety tools

OR surgical preps ban raises concerns and recent compromise

A recent ban of alcohol-based surgical skin prep solutions in Nebraska after a hospital OR fire prompted healthcare experts to submit an amendment to the National Fire Protection Association (NFPA) suggesting language for safe use of flammable antiseptic solutions, including a "time out" by the OR team to ensure the surgical site is dry before using an ignition source such as cautery.

The prohibition issued March 31 affecting all hospitals and ambulatory care facilities was a result of an interpretation of the existing standard by Nebraska officials that would prohibit use of flammable solutions when use of cautery or electrosurgery was anticipated. Noncompliance with the ban could jeopardize a facility's certification and licensure.

Because the letter indicated support from the Centers for Medicare and Medicaid (CMS), healthcare officials expressed concern that the ban could spread to other states. Nebraska’s Department of Health and Human Services issued a follow-up letter May 6, changing its original position of an outright prohibition to a compromise solution as the result of concern for all patient safety risks. (See "late breaker" below.)

The first response to the ban was a regulatory advisory from the American Society for Healthcare Engineering (ASHE) stating that NFPA 99 did not prohibit use of alcohol-based prep solutions with the use of cautery, and recommending that healthcare facilities be allowed to continue using these preps consistent with product labeling instructions. CMS disagreed with this interpretation, prompting the need to update the NFPA 99 through a "tentative interim amendment" (TIA) that provides guidance on safer use of the alcohol-based products, rather than banning all flammable solutions.

Elimination of alcohol-based prep solutions may increase the risk for surgical site infections. According to the CDC Guidelines for Prevention of Surgical Site Infection "no studies have adequately assessed the comparative effects of these preoperative skin antiseptics on SSI risk in well-controlled, operation-specific studies." Experts believe the complete removal of alcohol in any form constitutes an unacceptable risk for increased surgical site infection and to date, has never been attempted. The most common practice is using aqueous formulations with alcohol skin wipes, alcohol alone, or tinctures of iodophors or chlorhexidine gluconate (CHG). The clinical community does not know the unintended consequences of complete alcohol removal because of potential risks of SSI.

The TIA recommends that 1) the surgical site is dry before use of cautery or other sources of ignition, 2) steps be taken to prevent pooling of solution under surgical drapes, and 3) solution-soaked materials be removed from the area before proceeding with electrosurgery. A "time out" by the team before starting surgery provides one additional level of safety.

The earliest the TIA could be approved, following internal NFPA approval and public comment, is July 2005.

Until the NFPA 99 is revised, healthcare organizations should develop protocols based on the elements of the proposed TIA. If an organization is cited, this protocol could be used as the basis to request a waiver of specific life safety code provisions from CMS until the proposed TIA is adopted or rejected by NFPA. If granted, this waiver could allow continued usage of alcohol-based surgical prep solutions.

Late breaker
The Nebraska Department of Health and Human Services letter issued May 6 to all Nebraska hospitals and ambulatory surgical centers recognizes the infection control risks resulting from an outright ban of flammable liquid germicides. All organizations are advised that such products can be used safely when manufacturer’s instructions are followed. If surveyed by the state, a deficiency will need to be cited even if there has been no patient harm resulting from use of flammable liquid germicides. However, this deficiency does not constitute a serious "Immediate Jeopardy" situation that would affect licensure. An acceptable corrective plan in response to the deficiency must include the manufacturer’s recommendations and specific measures as outlined in the TIA. This letter essentially provides ‘breathing room’ until the TIA is approved and adopted by CMS. All hospitals should have protocols in place to reduce fire risks from flammable liquid germicides that include at a minimum the recommendations from the TIA.

Downloads and links

Related news: Regulatory advisory (3/21/05)

CDC Guidelines on surgical site infections
Premier Safety Institute guidelines module

ASHE TIA (.pdf) (190 KB), or
ASHE Web site:

Related news: CMS permits hand-sanitizer dispensers in hospital exit corridors (3/28/05)

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Deep-vein thrombosis reduced with computer alerts

A computerized system that alerts physicians to provide preventive treatment to patients at risk for deep-vein thrombosis appears to be successful in reducing development of thrombosis or pulmonary embolism in hospitalized patients. Researchers at Brigham and Women's Hospital felt that prophylaxis for deep-vein thrombosis in hospitalized patients is underused and they wanted to encourage greater use of preventive treatment in high-risk hospitalized patients. The authors describe the study in the March 10 issue of the New England Journal of Medicine.

Patients were randomly assigned to one of two groups - an intervention group and a control group. A computer alert was issued to the responsible physician for each patient in the intervention group. The physician had to respond to the computer generated alert by either ordering prophylaxis or withholding the treatment. Treatments included graduated compression stockings, pneumatic compression boots or anticoagulant medication. Conclusions reached at the end of 90 days indicated an increased use of prophylaxis and a greatly decreased rate of deep-vein thrombosis and pulmonary embolism in at risk hospitalized patients. Approximately 34 percent of patients in the intervention group received deep-vein thrombosis prophylaxis, compared with about 14.5 percent in the control group. The computer alert program reduced risk by 41 percent in 90 days of deep-vein thrombosis or pulmonary embolism.

Downloads and links

New Journal of Medicine March 10 abstract (.doc) (25 KB)

See ISMP tool (below)

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Business case for ergonomics program for clinicians

Back injuries in the healthcare industry are frequently caused by overexertion and occur at a very high rate. Healthcare industry workers sustain 4.5 times more overexertion injuries than any other type of worker. In the United States, back disorders are costly and account for over 24 percent of all occupational injuries and illnesses involving days away from work, according to the National Institute of Occupational Safety and Health. (NIOSH Chart book)

The January-March 2005 issue of Nursing Administration Quarterly (NAQ) describes a business case for patient ergonomics programs. A successful patient project in a Florida Veterans Health Administration (VHA) is described in "A Business Case for Patient Care Ergonomic Interventions." A financial evaluation, conducted two years after the implementation of a project aimed at reducing the number of injuries to nurses and nursing associates with direct patient handling, showed an annualized savings of greater than $200,000 per year. This included medical care and associated employee costs. An 18 percent decrease in missed workdays due to work-related injuries was also demonstrated.

The article provides a valuable framework for developing a business case and summarizes useful rates and estimated costs. According to national statistics, six of the top 10 professions at greatest risk for back injury are: nurse's aides, licensed practical nurses, registered nurses, health aides, radiology technicians, and physical therapists. Greater than one third of back injuries among nurses are attributed to handling patients and the frequency with which they are required to manually move patients. The observed average costs per healthcare staff-related musculoskeletal injuries per 100,000 work hours are greater than $160,000. Nationally, the estimated average cost per claim is $24,000. If surgery is involved, the cost for claims increases significantly to $40,000 per injury or higher. One recent back injury involving surgery totaled $240,000.

Premier's Safety Institute provides a wealth of resources on prevention of back injury and the related concerns for patient falls, including patient lifting and transfer equipment.

Downloads and links

Worker Health Chartbook, 2004.
National Institute for Occupational Health and Safety (NIOSH) NIOSH Publication Number 2004-146.

Business case abstract (.pdf) (28 KB)

For further information and a list of resources go to:

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Public reporting of quality data - good news and bad news

Public reporting of quality data has been hailed as a crucial step to improve the quality of health care through informed selection of high-quality physicians and motivation for physicians to compete and improve quality. Although public reporting does promote a spirit of openness that enhances the trust of the health profession, evidence supporting its success in improving quality is mixed.

The authors acknowledge concerns that such data reporting may have unintended consequences, including avoidance of "sicker" patients.

The pros and cons of public reporting of quality data and recommendations for improving the design, format, and use of the data was discussed in a special communication in the March 9 Journal of the American Medical Association on "The Unintended Consequences of Publicly Reporting Quality Information."

The authors suggest that reporting quality information publicly is presumed to motivate quality improvement by allowing patients, referring physicians, and healthcare purchasers to preferentially select high-quality physicians and to motivate physicians to compete on quality and thereby improve it. However they point out that value of publicly reporting quality information is largely undemonstrated and may have unintended and negative consequences, such as physicians avoiding sick patients in an attempt to improve their quality ranking.

Recommendations to improve the goals of public reporting include broad public promotion of data to consumers, mandatory provider participation with universally adopted measurement and reporting, and adjustment of report card rankings to include case-mix, severity adjustment, socio-economic status, and race.

Downloads and links

Unintended Consequences – Reporting JAMA abstract (.doc) (25 KB)

See Hospital leaders favor disclosure (below)

See CMS Web site for consumers (below)

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Hospital leaders favor patient disclosure of errors but fear negative impact of public reporting

Most hospital leaders are concerned that mandatory, non-confidential public reporting would discourage internal reporting of patient incidents and encourage lawsuits while failing to provide substantial benefits to patient safety, according to a recent survey of hospital executives in the March 16 issue of the Journal of the American Medical Association.

The Institute of Medicine has recommended establishing both mandatory and voluntary reporting systems for healthcare institutions such as hospitals and nursing homes. The purpose of these reporting systems is to collect data on a broad range of events so that system problems can be detected and changed to decrease errors. As of October 2003, 21 states had mandatory event reporting systems for hospitals, but the requirements vary. Some states mandate reports just for serious injuries. Some require only aggregate data and others don't release the reports to the public.

This study found that 69 percent of hospital executives said mandatory systems discourage internal reporting of patient safety incidents; 73 percent said reporting would encourage lawsuits without having any effect or a negative effect on patient safety. Respondents in states with confidential reporting systems said they were more likely to report certain patient safety incidents than those in states with public reporting systems. Many hospital leaders favor disclosure of safety incidents to involved patients, yet fewer would disclose those incidents involving moderate or minor injury to state reporting systems. Study authors suggest that states that require error reporting: use the data to analyze trends and identify best practices instead of looking at individual cases; clarify definitions of reportable events; grant hospitals protected access to anonymous abstracts of reported incidents; and promote cooperative relationships with state hospital and medical groups to minimize duplication of reporting.

Downloads and links

Error Reporting and Disclosure Systems (.doc) (27 KB)

See Public reporting (above)

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Congenital rubella eradication and continued TB decline lauded as U.S. public health successes

A significant health related milestone has been achieved in the United States by eradication of the rubella virus. The elimination of rubella, also known as congenital rubella syndrome (CRS), a major source of childhood illness and birth defects such as deafness and blindness, is due to effective immunization, according to Dr. Julie Gerberding, director, Centers for Disease Control and Prevention (CDC). Gerberding made the announcement at the March 21, 2005 National Immunization Conference in Washington, DC.

Since the development of a vaccine in 1969, reported cases of rubella have steadily declined. More than 95 percent of children in the U.S. are vaccinated against the virus before they start school. Even with this success, the CDC continues to recommend that the rubella vaccine be given to children as part of the measles-mumps-rubella vaccine, the first dose of which is to be given to children between 12 and 15 months; a second dose is usually given to children before they enter kindergarten or first grade, because the disease is still active in other countries and can be brought in by travelers. It also remains important for women to verify their immunity to rubella before they get pregnant.

Another apparent success in the United States is the steady decline in annual tuberculosis (TB) rates, which have declined an average of 6.6 percent from 1993 to 2002. However, TB continues to exact a staggering toll worldwide, with nearly nine million people developing TB disease and more than two million dying from it each year. Even in the United States, annual declines in rates for 2003 and 2004 were the smallest since 1993, raising concerns that the progress toward eliminating TB might be slowing. To continue to control TB in the United States, it remains important to provide sufficient local resources, target interventions to populations with the highest TB rates, and continue collaborating with other nations to reduce TB globally.

Downloads and links

CDC transcripts (.doc) (47 KB)

TB Fact sheet (.doc) (35 KB)

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CMS Web site for consumers compares hospital quality performance

A new federally sponsored Web site designed to compare U.S. hospital quality of care is now available for the healthcare consumer. Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services (CMS), has said the agency is receptive to suggestions about how the quality data can be better aggregated and verified. The new Web site, "Hospital Compare," allows consumers to compare hospitals' performance on 17 key measures of care for myocardial infarction, heart failure and pneumonia, with the rationale for those measures provided in simple language. The listed statistics represent treatments at 99 percent of the nation's hospitals (more than 4,200 and nearly every general acute care hospital), which were given additional Medicare reimbursement as an incentive to submit data. The Hospital Quality Alliance, a public-private partnership that designed the Web site, plans to continue collecting and disseminating quality data, including adding new quality measures related to patient satisfaction and hospital-acquired infections to the site by next year.

The site may eventually include the results of patient-satisfaction surveys. CMS is preparing to launch the first national survey of patients' perception of hospital care. As early as this summer, hospitals could start asking discharged patients to complete the 27-question Hospital Consumer Assessment of Health Plans Survey (HCAHPS). An ongoing review process continues to refine the survey, which has been pared down from 66 questions to the current 27. The National Quality Forum (NQF), a government advisory group on standards, is expected to vote on the final draft next month. The questionnaire will cover issues ranging from how well doctors and nurses explained treatments and controlled pain, to whether patient rooms were clean and patients got help with bedpans and going to the bathroom. The Hospital Compare site will begin public reporting of HCAHPS as early as 2006. The new survey will be in addition to whatever the hospitals are already doing, but HCAHPS will include only about 300 surveys per hospital per year - fewer for small hospitals or those in rural areas that do not have high patient traffic.

Downloads and links

The Web site can be visited at:

See Public reporting (above)

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Safety tools

AHRQ new fact sheet - 30 safe practices in healthcare

The Agency for Healthcare Research and Quality (AHRQ) has published a new fact sheet entitled "30 Safe Practices for Better Health Care" (.doc) (42 KB). These are AHRQ-supported, evidence-based practices from the National Quality Forum (NQF) that demonstrate they can work to reduce or prevent adverse events and medical errors. The safe practices were endorsed by the NQF member organizations, which strongly urge that these 30 safe practices be universally adopted in all applicable healthcare settings to reduce the risk of harm to patients. An executive summary (.pdf) (495 KB) of the report is available from AHRQ and contains information on how to obtain copies of the complete report.

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Downloadable charts - Rapid HIV antibody screening tests from the AHA

The Health Research & Educational Trust, an affiliate of the American Hospital Association (HRET/AHA), has developed two charts to help hospitals select the best rapid HIV test for their needs. The charts, developed with input from the Centers for Disease Control and Prevention (CDC), are designed to help hospitals as they implement the CDC's recommendation that the test be offered to all women presenting to labor and delivery with undocumented HIV status. One chart compares information on test price, external controls, numbers of tests per case, catalog number, storage temperature, operating temperature, shelf lives of tests and controls, time required to conduct test, and validity window periods; the other chart compares information on FDA-approval date, specimen type, CLIA-status, specificity, sensitivity, manufacturer, HIV-2 detection capabilities, list price, and external controls.

To view the charts, go to:

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AAMI guidance documents - Cleaning and sterilization

Two new guidance documents from the Association for the Advancement of Medical Instrumentation (AAMI) are designed to assist manufacturers in assessing the device reprocessing information they provide. These documents help address concerns that manufacturer's instructions are often inadequate or don't consider the common reprocessing methods facilities use. The first document, entitled "Designing, testing, and labeling reusable medical devices for reprocessing in healthcare facilities: A guide for device manufacturers" (TIR12: 2004), is intended to help manufacturers validate the reprocessing procedures they recommend and guide them in choosing facility protocols. The second, "Sterilization of medical devices - Information to be provided by the manufacturer for the processing of re-sterilizable medical devices" (ANSI/AAMI/ISO ST81: 2004), sets forth requirements for labeling and reprocessing instructions.

To order, call 800.332.2264, Ext. 217, or visit

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H2E resources - Chemo conference; waste disposal management tools

Hospitals for a Healthy Environment (H2E) hosted a March 11 teleconference on disposal of chemotherapeutic wastes. Presenters from a waste consultancy and H2E offered an overview of proper chemotherapeutic waste segregation, treatment, and minimization techniques to reduce the safety, health, and environmental impacts of managing this hazardous waste stream. The conference included education on safest practices, with the understanding that many chemotherapeutic agents in use today are not regulated under Environmental Protection Agency's (EPA) Resource Conservation and Recovery Act, but should be included from a safety and health perspective. Teleconference materials are available at:

On a related note, H2E as provided six free Microsoft® Excel spreadsheets to help hospitals collect and manage waste data (solid waste, solid waste recyclables, hazardous waste, hazardous waste recyclables, infectious waste and general facility information). The bottom half of the spreadsheet contains basic data and the top half of the spreadsheet does the calculations. Users register and then receive a notice if the database is updated. Register at to access the H2E Waste Management System and receive updates about the tool.

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IHI forms - Simplifying advanced directives

Advance directives, the legal documents that allow individuals to make their personal healthcare wishes known before a serious illness or injury, can be confusing and difficult to understand. The Institute for Healthcare Advancement has an advance directive form designed for American adults who read below a fifth-grade level. The forms are available in both English (.pdf) (906 KB) and Spanish (.pdf) (911 KB). The form is designed in a simple fill-in-the-blank format with illustrations and easy-to-read bullet points. Low-literacy Americans will be able to choose an agent to make medical decisions for them, make their healthcare wishes known so that their loved ones don't have to guess for them, and provide the necessary signatures to make the document legally binding.

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ASHES guide - Environmentally friendly pest control practices

The American Society for Healthcare Environmental Services has partnered with Orkin, Inc. to promote more effective and environmentally friendly pest-control practices in healthcare settings, including the release of a guide on integrated pest management. The partners also plan to publish educational articles and host two educational sessions on the recommended practice at ASHES' annual conference in September. The partnership was launched in response to a growing movement in healthcare toward hazardous-chemical reduction. See Premier Safety Institute's Environmental and Safety Product list at:

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ISMP tool - New self-assessment survey for antithrombotic therapy

The Institute for Safe Medication Practices (ISMP) announced it has developed a new tool (.doc) (33 KB) designed to assist hospitals in evaluating antithrombotic therapy. The survey has been mailed to hospitals with a submission deadline of September 1, 2005. The self-assessment will help organizations examine medication safety practices associated with the use of antithrombotic drugs in their facilities. Hospitals may submit data through a secure Web-based form, which will allow them to compare their weighted scores with aggregate data from similar hospitals. Further information is available at

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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

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.