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July 2004

Dear Colleague:

Fall prevention - is this on your radar screen with JCAHO's proposed 2005 patient safety goals? If so, our new Web site on fall prevention has many resources to assist you.

Also, August 16 is the deadline for scholarship applications for the first-ever online Sharps Injury Prevention program from Touro University.

Gina Pugliese, editor
Vice President, Premier Safety Institute


Safety tools

JCAHO approves fall prevention 2005 safety goal; Premier provides resources

Recognizing the importance of falls as a major safety issue, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has approved fall prevention as one of the new 2005 National Patient Safety Goals (NPSG), and the Premier Safety Institute has launched comprehensive Web resources on fall prevention.

JCAHO approves fall prevention as one of the 2005 patient safety goals. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will now require that hospitals assess, and periodically reassess each patientís risk for falling, including potential risks associated with the patientís medication regimen, and take steps to address those risks as one of its 2005 National Patient Safety Goals (NPSG). Another new 2005 medication-related NPSG requires healthcare organizations to identify, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of the these drugs. A related new goal requires accurate and complete reconciliation of medications across the continuum of care. That is, the organization must develop a process for identifying a complete list of a patientís current medications upon admission and communicating that information to the patientís next provider The remaining new goal requires organizations measure, assess and if appropriate, take action to improve the timeliness of both reporting and receiving of critical test results and values. The 2005 proposed goals are no longer available on the JCAHO Web site. but are expected to be re-posted later this month, pending final revision.

Premier launches fall prevention resource. Recognizing the critical importance of fall prevention from all causes, including medication usage, Premierís Safety Institute has recently launched a comprehensive Web site on Fall prevention that provides a complete set of materials, resources, sample procedures, case histories and other tools to assist facilities in planning fall prevention programs.

Downloads and links

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Smart infusion pumps reduce risk of potentially life-threatening drug errors

Potentially life-threatening drug errors related to IV pump programming can be eliminated with preprogrammed computerized systems in new "smart infusion pumps." A recent study in Hospital Pharmacy reported that one hospital averted 17 life threatening events out of 157 IV pump programming errors due to IV pump alerts that prompted discontinuation and reprogramming of IV infusion rates.

The "smart infusion pumps" with preprogrammed, customizable, computerized software have been developed to address the problem of IV infusion errors. The ALARIS Guardrails software, for example, has been designed to apply user-defined maximum/minimum infusion rate limits for selected medications (e.g., those that are frequently used or have a narrow therapeutic index).

Colleen Malashock, Pharm.D, and her colleagues at Nebraska Medical Center, Omaha, recently conducted an observational prospective study to gain better understanding of efficacy of this new technology in preventing medication programming errors, including the frequency with which the smart infusion alerted users to potential errors, the specific alert types, the medications involved in alerts, and trends associated the devices. Data representing all device alerts that occurred on three special care units over an eight-month period [May 20, 2002, to January 13, 2003] was downloaded from the infusion devices. Seven categories were used to describe each alert. One hundred fifty-seven alerts resulted in the discontinuation of the initial entry and subsequent reprogramming of the device to a different rate of infusion. Five medications comprised 63 percent of programming errors (vecuronium [27], epinephrine [22], dopamine [21], heparin [17], and midazolam [12)]).

A potentially life-threatening dose was initially programmed in the 17 different analyzed events. Researches described one example of a potentially life-threatening event -- an infusion of dopamine. The infusion device was originally programmed to administer the medication at a rate of 666 mcg/kg/min (100 mL/hr). The user received an alert that this dose exceeded the maximum dosage limit. The user then changed the programming to administer 100 mcg/kg/min of dopamine. An alert was again displayed. Finally, the device was programmed to initiate dopamine at 2 cg/kg/min. This paper suggests that smart pump infusion technology is able to assist with prevention of IV-related medication errors and serious adverse outcomes.

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Longer nursing shifts linked to patient errors

A study published in the July /August issue of Health Affairs suggests that hospital nurses working shifts of 12.5 hours or more are three times more likely to make an error than nurses working shorter shifts. The work habits of 393 hospital staff nurses were studied. The nurses worked at least 12.5 consecutive hours in 2,057 shifts, or about 40 percent of those studied. They were involved in at least one error during 103 of the long shifts and at least one near error during 94 of those shifts. Participants reported 199 errors and 213 near errors during the data-gathering period. More than half of the errors (58 percent) involved medication administration; other errors included procedural errors (18 percent), charting errors (12 percent), and transcription errors (7 percent).

Researchers found that most hospital nurses no longer work eight-hour shifts on the evening or night-time slots. Instead, they may be scheduled for 12-hour, 16-hour or even 20-hour shifts. Even when working extended shifts (less than or equal to 12.5 hours), they were rarely able to leave the hospital at the end of their scheduled shift. All participants reported working overtime at least once during the data-gathering period and one-third of the nurses reported working overtime every day they worked.

Only 12 of the 771 shifts of 8.5 hours or less involved errors, and 20 of those shifts involved near errors, according to the study. Among the 2,484 shifts that lasted 8.5 hours to 12.5 hours, 77 and 95 involved errors and near errors, respectively. The research team found that nurses working more than 12.5 consecutive hours were three times more likely to make an error than nurses working shorter hours. Working overtime at the end of a shift also increased the risk of making an error. Study authors also found that working shifts greater than 12 hours, as well as overtime, pose significant threats to patient safety and that routine use of 12-hour shifts and overtime associated with 12 hour shifts should be eliminated.

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Very young and poor at higher risk of medical errors

Thousands of children die unnecessarily in hospitals because of medical errors stemming from patient-safety lapses, and the extra cost of care for pediatric patients exposed to 20 types of safety problems exceeds $1 billion annually, according to a study in the June issue of Pediatrics. The study, funded by the Agency for Healthcare Research and Quality (AHRQ), confirmed that medical errors are a significant problem for children as well as adults, and it identified the very young and the very poor as more vulnerable than children in general.

The AHRQ's recently developed Patient Safety Indicators (PSIs) were used in the study. It is one of the first studies to quantify the impact of patient safety events on children in terms of excess hospital stays and charges, as well as the increased risk of death among children due to medical errors. Researchers from the department of pediatrics at Johns Hopkins University, Baltimore, said the figures on patient deaths were conservative. The methods used to identify 4,483 unnecessary deaths from an analysis of 5.7 million records in 2000 "can detect only a small portion of the types of patient safety events that actually happen in hospitals," according to the study authors.

More than 51,000 cases of medical error were discovered, and four of the 20 types of treatment failure occurred at a rate exceeding 100 per 10,000 discharges. Those four were: failure to rescue a patient suffering from a threatening event; postoperative sepsis; and obstetric trauma with and without the use of instrumentation. The researchers also concluded that children under the age of one year and those on Medicaid are more susceptible to certain types of adverse events, including infection and postoperative sepsis, than are older and privately insured children.

Patient safety events resulting in injuries among children also have an impact on the length of stay, charges and the rate of in-hospital deaths, according to the study. The financial cost of each of the 20 types of treatment failure was recorded. For example, infections resulting from medical care caused a 30-day increase in the average length of stay and resulted in increased charges of over $121,000 per discharge, on average. Moreover, if all deaths among pediatric patients who experience a medical injury are attributed to those injuries, the used records in the analysis alone account for 4,483 deaths among hospitalized children in the year 2000. AHRQ has published materials for consumers that address pediatric healthcare quality.

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Comments for CDC draft isolation guideline due in August

The Centers for Disease Control and Prevention (CDC) is seeking comments on a draft infection control guideline for hospitals, long-term care facilities and other healthcare settings. "The Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004" updates and expands the "1996 Guideline for Isolation Precautions in Hospitals." All CDC guidelines, including drafts editions, are available on the Premier Web site, though it is important to note that new or modified organizational policies should not be based on draft guidelines since they will change considerably following public comment. Comments on the draft guideline are due by August 13.

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Equipment disinfection lapses place patients at risk of infection

A New York hospital voluntarily alerted 177 patients who underwent endoscopic procedures that a breakdown had occurred in infection-control measures related to the disinfection of the equipment used during that time period. Those lapses included improper documentation on the cleaning and disinfection of the endoscopes. One employee was fired and another suspended without pay. Eighty-six of the patients have returned to the hospital for precautionary blood tests, and none so far have tested positive for hepatitis or human immunodeficiency virus (HIV).

Infectious disease experts consulted on the case said viral hepatitis and HIV had never been transmitted in such a manner. Health department officials are investigating and monitoring the situation to make sure patients receive appropriate follow-up care. About 15 million endoscopies are performed each year. As more endoscopies are performed, hospitals across the country are putting more pressure on employees to clean the instruments so they can be used again.

There are no New York state standards for cleaning endoscopes. Existing guidelines for the reprocessing of endoscopes are available. The 2003 multi-society guideline for reprocessing flexible gastrointestinal endoscopes is the result of a Gastrointestinal Endoscopy Consensus Conference sponsored by the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Healthcare Epidemiology of America (SHEA). The Association for Professionals in Infection Control & Epidemiology (APIC) also has a 2000 guideline for infection prevention and control in flexible endoscopy.

In a related issue, a June 23, 2004, Medical Device Alert was released by the Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom. The alert describes the risks of transmission of infection in flexible and rigid endoscopes due to inadequate decontamination. Several examples of inadequate decontamination are listed as well as the actions to be taken to assess the endoscope decontamination process. Endoscopy guidelines are available from the British Society of Gastroenterology (2003).

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RAND Corporation: follow-up report on quality

The RAND Corporation has produced a national report card that describes the quality of healthcare in the United States. The report was developed by a team of experts who conducted a comprehensive examination called the Community Quality Index Study. This research assessed the extent to which recommended care was provided to a representative sample of the U.S. population for a broad range of conditions in 12 metropolitan areas.

Some of the key findings include:

  • Overall, adults received about half of recommended care.
  • The level of performance was similar for chronic, acute, and preventive care.
  • Quality of care varied substantially by condition.
  • Performance was similar in each of the metropolitan areas studied.
  • No community had consistently the best or worst quality.

This report highlights RAND's study published in the June 26, 2003, issue of the New England Journal of Medicine. The quality indicators used in the study were derived from RAND's Quality Assessment Tools system and represent the leading causes of illness, death, and utilization of healthcare, as well as preventive services related to these causes.

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JCAHO releases quality performance reports to the public

On July 15, 2004, the Joint Commission on Accreditation of Healthcare Organizations released organization-specific performance information to the public on its Web site. It is critical that all JCAHO-accredited organizations check their data and information on the JCAHO site for accuracy.

Much of the content in the Quality Reports is in addition to information already portrayed in the organization-specific performance reports. The Quality Report includes organization accreditation status, compliance with the National Patient Safety Goals (for organizations surveyed in 2003 and 2004), and, for hospitals, data referencing the National Quality Improvement Goals, as well as specific recognition of certain specific achievements.

The new Quality Report offers a format using checks, pluses and minuses to compare an organization's performance to the aggregate performance of similar accredited organizations at the statewide and national levels. Hospitals should be aware that the comparative portrayals of the National Quality Improvement Goal data are based on the use of a very conservative 99 percent confidence level. The data and information in the Quality Report will be updated quarterly. A special section in the Quality Report permits organizations to provide their own comments. The JCAHO site also provides frequently asked questions, a fact sheet and a user's guide.

Downloads and links

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FCC announces bandwidth freeze extension through 2005

On July 8, 2004, the Federal Communications Commission (FCC) extended through 2005 its freeze on the licensing of high-powered private land mobile radio service users in the 460-470 MHz band. The Wireless Telecommunications Bureau (WTB) is extending the freeze to provide hospitals that operate medical telemetry equipment in the 460-470 MHz band adequate time to migrate to the Wireless Medical Telemetry Service (WMTS) bands, and to protect patients from harmful interference from higher-powered users.

The announcement came after a series of temporary extensions at the request of American Hospital Association (AHA) and American Society for Healthcare Engineering (ASHE), permitting development of a consensus agreement with the Land Mobile Communication Council (LMCC) to support an orderly migration to WTMS bands. Over the last several months, the Wireless Telecommunications Bureau has permitted freeze extensions to allow time for AHA, ASHE, and LMCC to work cooperatively with the bureau.

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Safety tools

Poster - CMS clinical guideline reminder

The Arkansas Foundation for Medical Care in Little Rock has developed a poster to concisely demonstrate the clinical guideline focus for the Centers for Medicare & Medicaid Services national inpatient priority topics. The poster is also available on the Institute for Healthcare Improvement Web site at This tool was designed as a reminder to those individuals who are documenting the care for patients in certain areas.

The poster provides clinical guideline reminders for surgical infection prevention, acute myocardial infarction, congestive heart failure, and community-acquired pneumonia. The tool is intended to be displayed in areas where staff document the care provided, such as in nurses' stations, doctors' dictation areas, and medical record areas, among others.

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Updated guidelines - Outpatient antimicrobial therapy

New practice guidelines are available to assist with the administration of outpatient antimicrobial therapy (OPAT). Due to the lack of evidence-based studies, these guidelines were formulated from the collective experience of the Infectious Diseases Society of America Guidelines Committee and advisors from related organizations. The Practical Guidelines for Outpatient Parenteral Antimicrobial Therapy updates the 1997 guidelines and are intended to aid in the successful implementation of parenteral antimicrobial services for patients in a variety of outpatient settings including the home, physician offices, and skilled nursing facilities. OPAT is a huge growing therapy, estimated to be provided to 1 in 1,000 Americans each year. Its growth is the result of the push for cost containment, the development of antimicrobial agents that can be given once a day, advances in vascular access devices, increased acceptance by patients and healthcare personnel, and the availability of skilled and reliable services in the community. The guidelines are general and need to be adapted for each specific setting.

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CD-ROM - AAMI sterilization documents available

The Association for the Advancement of Medical Instrumentation (AAMI) is making its complete collection of 50 sterilization documents available on CD-ROM. The collection has every AAMI document covering sterilization in healthcare facilities, sterilization equipment, and industrial sterilization process control. It includes FDA and CDC guidance documents and the Code of Federal Regulations sections pertaining to sterilization. The CD-ROM is $475 for AAMI members and $655 for non-members. Contact AAMI at 800.332.2264, Ext. 217, or visit and click on "marketplace."

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Leadership tools - Patient safety rounds database and measuring hospital flow

An access database, available from Brigham and Women's Hospital in Boston, MA, is designed to allow institutions performing Patient Safety Leadership WalkRounds to collect data and then keep track of how the information is used, what actions are taken, and generate feedback and reports.

Measurement guide for hospital flow patterns. In addition, the Institute for Healthcare Improvement has measurement guide for hospital flow patterns. Hospital flow can be measured at five levels: patient and community; hospital throughput; hospital activity; hospital performance; and unit performance. Each level provides a portion of the total measurement picture. Use this guide to learn how to measure data in these key areas to help you improve patient flow.

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CDC resources - West Nile Virus cases in 2004; plague training module online

West Nile Virus. The Centers for Disease Control and Prevention (CDC) provides updated information on West Nile virus activity in the United States. As of July 13 of this year, 57 human cases have been reported to CDC. Of the 108 cases, 40 were reported as West Nile fever, 61 were reported as West Nile meningitis or encephalitis (neuroinvasive disease), and seven were clinically unspecified. Three deaths were also reported during this time period. The information is available at The CDC also provides PowerPoint presentations that describe West Nile Virus and methods of treatment and prevention.

Plague training module online. The Centers for Disease Control and Prevention has a Web-based module designed to teach the natural epidemiology of plague and how to manage it as both a natural disease and an intentional attack. This will be the first in a series of six bioterrorism agent Web-based modules offered by the CDC. Available for continuing education credit, the plague training module content is presented in a series of eight lessons to be completed in the order that they appear. The objectives include:

  • Identify where plague occurs naturally in order to recognize possible bio-terrorism.
  • Identify patient symptoms that will lead to a diagnosis of bubonic, pneumonic, or septicemic plague.
  • Rule out other diseases when diagnosing plague.
  • Identify the appropriate specimens to obtain in order to diagnose plague.
  • Describe the medical management of confirmed plague cases.
  • Describe the public health response needed for naturally occurring versus bioterrorist plague.
  • Describe the diagnosis of plague in animals.

The module can be completed at

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Web database - Quality incentive programs for physicians, hospitals, health plans

The Leapfrog Group, with support from the Commonwealth Fund and the Robert Wood Johnson Foundation, has launched a national database of pay-for-performance programs. "Paying for performance" or providing financial and other incentives to encourage health professionals to practice better medicine is one approach that has been studied as a way to improve the quality of care. The database is intended to raise awareness among healthcare purchasers, providers and plans to improve care quality. The Leapfrog Compendium documents and categorizes financial and non-financial programs, such as those that reward providers with quality bonuses, and those that reward providers with public recognition. Incorporated are the Leapfrog standards of computerized physician order entry, evidence-based hospital referrals and hospital intensivist programs. The site can be searched by state for programs targeting hospitals, physicians, consumers and health plans, or it can be searched from a nationwide list. The Leapfrog Compendium can be freely accessed at

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Editorial team

Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, CIC, associate editor
Donna Bernstein, MPH, marketing consultant
John Hall, BSJ, contributor
Derek Kleckner, BA, Web master
Judith Luca, RN, BSN, contributor

About Premier

Premier, Inc. is a healthcare alliance entirely owned by 200 of the 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 Premierís Perspective Online database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.

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