Safety Share

June 2005

Dear Colleague:

A special thank you for completing our satisfaction survey - 97 percent of respondents rated Safety Share as good or excellent. Congratulations to James Hoffman from Memphis, TN, the winner of the Palm Tungsten E!

We appreciate all your comments and suggestions!

Gina Pugliese, editor
Vice President, Premier Safety Institute


Safety tools

Diverse causes of IV pump errors - integrated technology is key

"Smart" intravenous (IV) pump technology has been shown to reduce programming errors and is a necessary part of a comprehensive medication safety system. Since the causes of IV medication errors are diverse, improvements can be maximized by integration and interface of IV pump technology with all phases of the medication use process, from prescribing through administration and monitoring with attention to behavioral and human factors engineering.

IV medication errors can lead to considerable harm
IV medication errors are a common type of error identified in hospitals and can lead to considerable harm. A number of studies have recently evaluated the risks associated with IV administration and the experiences with IV "smart" pumps that have built-in safety systems. A study by Rothchild conducted in 2002 at the Brigham and Women's Hospital, Boston, demonstrated that medication errors (ME) and adverse drug events (ADE) were common among critically ill cardiac surgical patients. These researchers also identified a number of improvements related to the design of earlier technology of "smart" pumps, including human factors to increase compliance with its use that needed to be addressed for this technology to achieve its potential for improving medication safety.

"Smart" IV pumps can reduce programming errors
MEs and ADEs are common among patients who receive medication errors through IV pumps. Some data have shown that IV medication pumps with built-in safety systems ("smart pumps") can reduce IV programming errors.

The experiences of a successful implementation of a computerized "smart" IV medication safety system at St. Joseph Candler, a 675 bed tertiary care system, was described in a study by Field and Peterman published in Nursing Administration Quarterly. Preliminary data indicated an estimated 849 annual programming changes ("near misses"), i.e., potential infusion errors were averted by the new system. The authors provide an example of the four-fold reduction in the risk priority score of the FMEA (failure mode and effects analysis) related to setting IV heparin infusion (from 210 to 56) after implementation of the IV safety system. The system also provided continuous quality improvement data for best practice improvement. For example, identification of the peak times for error warnings occurred between 3 p.m. and 9 p.m., prompting a review of workload and staffing patterns.

IV smart pumps have also been shown to reduce serious medication errors related to programming in a study by Malashock and conducted at the Nebraska Medical Center, Omaha (see July 2004 Safety Share study by Malashock). Seventeen of the 157 programming errors averted by the "smart" pump technology were identified as potentially life-threatening.

IV medication error-reduction technology must be integrated
Because IV administration errors can originate in any phases of the medication process such as prescribing, dispensing, patient identification, pump programming, or documentation, there needs to be a seamless interface of "smart" IV pumps with other technology designed to reduce MEs.

Researchers (Husche, et al) at Northwestern Memorial Hospital, Chicago, found that MEs associated with IV pumps were common, with 66 percent of the 426 medications infusing through an IV pump in a point prevalence study having one or more errors associated with administration. They also assessed the preventability of IV medication errors with IV "smart" pump technology and found that few errors were related specifically to programming, but to other types of errors, including no rates or incorrect rates on labels, wrong medication, or patient identification errors. In order to achieve maximum protection against all IV administration-related errors, the authors proposed seamless, multi-directional communication among "smart" pumps and, a) an electronic medical record (EMR); b) a computerized physician order entry (CPOE) with rules and alerts and human factors engineering; c) a bar-coded medication administration (BCMA) system; and d) a pharmacy administration system.

Bar-code technology being integrated with smart IV pump systems
An article by Carbasho in the April 25, 2005, print edition of the Pittsburgh Business Times reported that Ohio Valley General Hospitals in McKees Rocks, PA, has become the first hospital in the country to implement an automated IV system that integrates bar-coding medication administration and smart pumps.

The system provides real-time access to patient information that is transmitted electronically across a radio frequency network, using a handheld bar-code scanning device for the patient, IV bag, IV pump and caregiver, and mechanisms to signal a discrepancy and prevent administration until issue corrected.

Downloads and links

Rothchild study, Brigham and Women's hospital (.doc) (26 KB)

Field and Peterman, Nursing Administration Quarterly (.doc) (26 KB)

Husch et al, Quality and Safety in Health Care (.pdf) (104 KB)

Malashock CM, et al, "Effect of Smart Infusion Pumps on Medication Errors Related to Infusion Device Programming." Hosp Pharm - 2004:39:460-469

Carbasho study

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Nursing input critical for construction planning

Nursing input and careful planning have been identified as critical success factors in healthcare construction and remodeling. Tools, resources, guiding principals and tips for construction design and planning have been provided in a number of recent publications. "Tips for planning a new surgical facility" are provided in the OR Design & Construction section of OR Manager (May 2005). One recommendation is to plan all procedure rooms with a minimum size of 600 square feet. This dimension is larger than the current recommendations in the "2001 AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities," but ensures that any surgical case may be done in any room without having to wait for a specialty room. Other suggestions include:

  • Making OR rooms identical, so any staff member will know where anything is.
  • Incorporate sufficient information technology (IT).
  • Upgrade ventilation and heat exchanges.
  • Plan for high-tech communication devices such as radio frequency identification (RFID), electronic "white boards," and hands-free communication tools.

Other issues to consider are material flow, as well as having enough storage space so that hallways remain clear. Planning pre- and post-operative areas are also important. Multiple free tools for planning, as well as links to more tools, are available from OR Manager on a Web site that focuses specifically on design and construction.

The importance of nursing input as a critical success factor also is highlighted in the March 2005 issue of Nursing Management. The article notes that nursing input from beginning to end can prove crucial to the success of new healthcare construction or remodeling projects. Rosalie Hill, critical care services director at Longmont United Hospital in Colorado, emphasizes nurse input at all stages of design and construction. The article, "Hospital construction 101: Blueprints for success," suggests having experienced nurses join department managers on the design team because they have the most knowledge of the needed improvements. Front-line nurse should also be involved in weekly walkthroughs, increasing to daily as the work nears completion, because they will be the most likely to see potential problems, such as whether electrical outlets are positioned for easy nurse access.

Downloads and links

Tips for planning a new surgical facility, OR Manager (.pdf) (475 KB)

Additional resources for OR design and construction can be found at:

Download slides from the 2005 OR Business Management Conference: "Using Guiding Principles in OR Design and Construction," go to

Premier's Construction - Infection control risk assessment web module

"Hospital construction 101: blueprints for success;" Hill, Rosalie RN, CAN, MSM; Nursing Management. 2005 March; 36(3): 46-51. Available for a fee at:

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Alcohol-based hand rubs linked to reduction in infection

Three recent studies support the use of alcohol-based hand rubs (ABHR) by demonstrating that ABHR use is associated with a reduction of reported infections. The first of three studies by Lee, at al, published in the April issue of Pediatrics showed that use of an alcohol-based hand rub was associated with a reduction in the transmission of respiratory illness in families with children in day care. The researchers demonstrated a strong association between the frequent use of alcohol-based hand sanitizers and a decreased rate of secondary transmission of respiratory illness. The second study by Zerr, et al also appeared in the April issue of Pediatrics and showed a significant association between the regular use of alcohol-based hand sanitizers and decreased risk of gastrointestinal illness in hospitalized children undergoing elective surgery. Finally, a third study by Larson, et al, from the Archives of Pediatric and Adolescent Medicine supports the Centers for Disease Control and Prevention's (CDC) guideline that alcohol-based hand sanitizers should be used in healthcare settings to prevent the spread of infection. The researchers found that use of an alcohol-based hand sanitizer was equivalent to hand washing with a traditional antiseptic detergent with respect to decreasing infection rates in neonatal intensive care units, but the hand sanitizer was better tolerated by staff.

Downloads and links

Pediatrics, Lee and Zerr abstracts (.doc) (31 KB)

Archives of Pediatric and Adolescent Medicine, Larson abstract (.doc) (27 KB)

For more information on alcohol based hand rubs:
Premier's Hand hygiene web module

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Patient-safety incidents, including infections, rising at U.S. hospitals: Report

HealthGrades' second annual report on patient safety covers over 39 million hospitalizations for the years 2001 through 2003. The HealthGrades "Patient Safety in American Hospitals" study is based on 13 of the Agency for Healthcare Research and Quality's (AHRQ) patient safety indicators. The data were risk adjusted, with teaching and non-teaching hospitals evaluated separately so that hospitals were compared with their peers. The report indicated that while the total number of patient safety incidents increased slightly in 2004, the gap among hospitals widened as the best-performing hospitals reduced their numbers of patient-safety incidents and the worst performers saw their incidents rise.

Patients in the top 10 percent of high performing hospitals were 50 percent less likely to experience a patient safety incident than a patient in one of the bottom 10 percent. The report also suggested that the hospital-associated infection (HAI) rate increased by 20 percent and was the indicator that most closely correlated with a hospital's overall performance. The two mortality indicators that were tracked, i.e., failure to rescue and death in low-mortality diagnostic related groups (DRGs), declined. The three most common incidents, accounting for 62 percent of all patient safety incidents, included failure to rescue, pressure sores and post-operative sepsis.

In a recent news release, infection prevention experts warned that administrative codes and billing data have been shown to be unreliable in identifying infections. Rather, accurate collection and reporting of HAI data can only be accomplished through a standardized methodology for defining infections and data collection that incorporates expert review of clinical data from the chart, as recommended by CDC definitions and surveillance of infections. (See "CDC's Guidance on Public Reporting of Healthcare-Associated Infections 2005.")

Downloads and links

HealthGrades' "Patient Safety in American Hospitals" (.pdf) (276 KB)

APIC news release (.doc) (66 KB)

CDC Guidance on Public Reporting of Healthcare-Associated Infections 2005

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Premier - CMS Pay-for-Performance demo reports quality and safety improvements

More than 270 hospitals participating in a Premier/CMS Hospital Quality Incentive Demonstration Project, a pay for performance initiative, have improved quality and safety significantly during the project's first year. These hospitals provided data on 34 process and outcome measures during the initial year of the project, which was launched in October 2003. The Centers for Medicare & Medicaid Services (CMS) reported initial results are showing that financial incentives to reward hospitals for quality care have worked as intended - resulting in better care and fewer complications.

The median quality performance scores for all hospitals - just one measure of improvement - went up 7.5 percent in the project's first year. The overall composite score is calculated by combining the process of care and outcome measures, including mortality and complications, from five clinical conditions tracked: acute myocardial infarction, coronary artery bypass, heart failure, hip and knee replacement, and pneumonia. The preliminary analysis indicates median quality scores for hospitals improved to 93 percent from 90 percent for patients with acute myocardial infarction, to 90 percent from 83 percent for patients with coronary artery bypass graft, to 76 percent from 64 percent for patients with heart failure, and to 91 percent from 85 percent for patients with hip and knee replacement.

After evaluation and auditing of the data, the hospitals in the top 10 percent for a specified condition will be given a 2 percent bonus on their Medicare payments for that condition. Hospitals in the second 10 percent will be given a 1 percent bonus. Hospitals in the remainder of the top 50 percent will get recognition for their quality but no bonus. CMS Administrator Mark McClellan said hospitals could expect to receive their Medicare incentive payments in September. For the three years the project is in effect, Medicare will reward high performers with bonuses totaling $7 million per year. Poorly performing hospitals may face financial penalties in the third year.

Downloads and links

Premier news release

CMS press release (.pdf) (77 KB)

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Managing patient flow increases nurse staffing efficiency, reduces errors

Inadequate nurse staffing has been linked to medical errors. Hospitals can reduce certain types of medical errors by improving their elective surgery scheduling, leading to improvements in patient flow in related areas and increased nurse staffing. A report in the June issue of Joint Commission Journal on Quality and Patient Safety, "Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety," was led by Eugene Litvak, PhD, of Boston University, and coauthored by Peter Buerhaus, RN, PhD, the leading researcher on the nursing workforce, and Donald Berwick, MD, leader of the Institute for Healthcare Improvement. One way hospitals can ease the demand for nurses is to more efficiently schedule elective surgeries, the authors suggest. The authors also noted that when surgeons' block time is underused, there are dips or valleys in the surgical case volume; when surgeons extend OR use beyond their block times, census peaks. This can lead to competition for scarce hospital resources, and possible ER crowding, ambulance diversions, and overwork for nurses. The report indicates that Boston Medical Center was able to cut nursing expenses $130,000 annually in its surgical step-down unit by better coordinating vascular and cardiac surgery. The authors recommend more research and pilot programs to test changes that could reduce system stress and improve flow and efficiency.

Downloads and links

Abstract, "Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety" (.doc) (25 KB)

The article can be purchased at:

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ADEs in long-term care - heparin and psychotropics biggest culprits

A new study on adverse drug events (ADE) in long-term care demonstrated over 800 ADEs, of which more than 40 percent were judged preventable. The study was conducted in two large long-term care facilities during a nine-month period in 2000-2001 and was funded by the Agency for Healthcare Research and Quality (AHRQ). Over 60 percent of the 225 ADEs considered serious, life threatening, or fatal, was deemed preventable. The study, led by Jerry H. Gurwitz, M.D., of the University of Massachusetts Medical School, found that preventable ADEs occurred most often during the ordering and monitoring stages of care, and that the two drugs most commonly involved in preventable ADEs were warfarin and atypical antipsychotic agents (olanzapine, risperidone, quetiapine, and clozapine). The study, "The Incidence of Adverse Drug Events in Two Large Academic Long-Term Care Facilities," was published in the March 2005 issue of the American Journal of Medicine.

Downloads and links

Abstract, "Incidence of Adverse Drug Events in Two Large Academic Long-Term Care Facilities" (.doc) ( KB)

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IV free flow pumps, concentrated electrolytes, dropped from 2006 JCAHO Patient Safety Goals

Major compliance with free-flow protection on all general-use and patient-controlled analgesia intravenous infusion (IV) pumps prompted the JCAHO to remove this requirement from the 2006 National Patient Safety Goals (NPSG). The removal of concentrated electrolytes from patient care units was also retired as a requirement. Medication labeling, communication during "handoffs" and pressure ulcer prevention are among the new goals.

New goals and requirements
On May 31, 2005, JCAHO released the 2006 NPSG and related "requirements" for each of its accreditation programs and its Disease-Specific Care certification program. As a patient safety strategy, new goals address the prevention of pressure ulcers and encourage the active involvement of patients and their families in the patient's care. New requirements include standardizing the patient "hand offs" between caregivers, making special note of providing the opportunity to ask and answer questions. These requirements are part of the goal: "Improve the effectiveness of communication among caregivers." and apply to all types of accredited organizations that provide surgical or other invasive services. Another requirement specifies that all medications, medication containers and other solutions used in perioperative settings are to be labeled and is part of the goal to "Improve the safety of using medications." A crosswalk and interpretive guidelines on the 2006 Goals also provides information on where each goal specifically resides for each setting.

Retired or eliminated requirements
The following requirements will be retired for all applicable accreditation programs in 2006:

  • To remove concentrated electrolytes (including but not limited to potassium chloride, potassium phosphate, sodium chloride greater than 0.9 percent) from patient care units. This requirement will continue to exist in relevant accreditation manuals.
  • To ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in an organization. Compliance has been greater than 99 percent, and equipment manufacturing and availability issues for all healthcare setting have been satisfactorily resolved.

Downloads and links

JCAHO 2006 crosswalk and interpretive guidelines
(.doc) (164 KB)

JCAHO press release:

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Safety tools

JCAHO/H2E guide - Environment-of-care compliance and improvement

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has provided a guide to assist with compliance with the JCAHO Environmental of Care Standards. Hospitals for a Healthy Environment (H2E) is working on a clipboard version for JCAHO surveyors. This guide relates each JCAHO Element of Performance (EP) to specific federal regulations, to help facilities be in compliance with both. The guide also suggests steps that facilities can take to encourage environmental performance improvements. A comprehensive environmental program, including waste minimization and pollution prevention initiatives, can help ensure compliance and reduce costs. To view this guide, go to:

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EPA Notebook - Healthcare waste management profiles, resources

The Environmental Protection Agency (EPA) Office of Compliance has released a "Profile of the Healthcare Industry" that includes hospitals, physician offices, dental offices, nursing homes, and more as part of its Sector Notebook Project. The project helps various industry sectors in pollution prevention, waste minimization, and regulatory compliance efforts. The EPA document contains information on waste and emissions profiles, pollution prevention opportunities, a summary of federal statutes and regulations, compliance and enforcement history, and compliance activities and initiatives. The Notebook can be accessed at:

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AHRQ-DOD compendium - Four-volume set of patient safety research studies

The federal Agency for Healthcare Research and Quality (AHRQ) and Department of Defense (DOD) have jointly released a compendium of 140 peer-reviewed articles on patient safety studies by government-sponsored researchers. These studies include findings on medication safety, technology, and investigative approaches to better treatment, process analyses, human factors and practical tools for preventing medical errors. The 140 articles in the four-volume set cover a wide range of research paradigms, clinical settings, and patient populations. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present useful tools and products that can be used to improve patient safety. Go to:

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AHA and Commonwealth chart books - 2005 healthcare quality trends

The American Hospital Association's (AHA) annual "TrendWatch Chartbook 2005" is now available. The 5th annual collection of charts and graphs depicts key trends affecting hospitals and health systems. Sections include trends in the overall health care market, organizational trends, utilization and volume, trends in hospital financing, workforce, and the economic contribution of hospitals. Go to:

The Commonwealth Fund's chart book "Quality of Care for Medicare Beneficiaries" assesses the quality of care provided to elderly and disabled Medicare beneficiaries. This is just one of several chart books available from the Commonwealth Fund on health policy matters. The chart books are available in either Adobe or PowerPoint Other topics available include insurance, access, and quality of care among Hispanic populations, the state of child health care in the United States, adults' primary care experiences in five industrialized countries, the health of women in New York City, and the value of state pharmacy assistance programs. All chart books are available at:

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HHS pocket guide offers resources to assist patients with smoking cessation

A new pocket guide recently released by Health and Human Services (HHS), "Helping Smokers Quit: A Guide for Nurses," was developed by AHRQ in collaboration with "Tobacco Free Nurses," a national initiative funded by The Robert Wood Johnson Foundation. This new tool is designed to give nurses evidence-based information that they can use to help their patients quit smoking. The free guide gives nurses' easy access to information based on the "5 A's" approach to cessation intervention: Ask, Advise, Assess, Assist, and Arrange. It also includes a current listing of smoking cessation medications approved by Food and Drug Administration (FDA) and a referral to HHS' National Quitline, 1-800-QUIT NOW.

Download the guide (.pdf) (109 KB), or go to:

A print copy of the guide is available by sending an e-mail to:

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New patient safety video - Patient's role in avoiding errors

A campaign designed to help distribute valuable information about improving patient safety to healthcare providers and patients across the country has been initiated by the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA) and the American Hospital Association (AHA). The campaign, called "5 Steps to Safer Health Care," includes posters and fact sheets that offer evidence-based, practical tips on the role patients can play to help avoid errors related to prescription medicines, laboratory tests, procedures, and surgery. A public service announcement featuring actress Laura Innes, who plays Dr. Kerry Weaver on the hit NBC show ER, is airing nationwide. Copies of "5 Steps to Safer Health Care" and the public service announcement are available on the AHRQ's Web site:

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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.