Premier Safety Share

In this issue

Premier Safety Web site

September 2004

Dear Colleague,

We have some special resources this month, including:

  • Executive scorecard for environmental assessment
  • Literature review on sharps safety device research
  • Web resources on safety cleaning chemicals and pesticides

Please share this newsletter with your colleagues and encourage them to subscribe to Safety Share so they don't miss any issues.

Gina Pugliese, editor
Vice President, Premier Safety Institute


Safety tools


Premier provides 'Executive Scorecard' for environmental responsibility programs

Premier, Inc. and its Premier Safety Institute launched an "Executive Scorecard for the Environment" a web-based tool designed exclusively for medical facility administrators to assess environmentally preferred purchasing, waste reduction, mercury elimination, recycling, and resource conservation.

The assessment and scorecard results are designed to help executives prioritize goals and action plans while providing valuable information to hospital and medical groups' governing boards, sponsors and communities.

The scorecard, produced by Premier with assistance and support from Health Care Without Harm and Hospitals for a Healthy Environment (H2E), is unique because it is designed specifically for executives looking for a high-level assessment. It complements H2E's more-comprehensive "Self Assessment Guide," which leads facilities in the subsequent steps of setting goals, collecting baseline data, developing action plans and tracking progress.

The scorecard reinforces Premier's strong commitment to assisting its members with socially responsible purchasing while achieving the national goals of waste and toxicity reduction and mercury elimination established by H2E. Earlier this year, H2E awarded its Champions for Change award to Premier. Premier, which adopted its EPP program in 2000, was the first group purchasing organization to win the H2E Champions for Change award in 2003.

The scorecard rates the implementation status of specific elements within environmentally preferred purchasing (EPP), solid waste reduction, regulated medical waste reduction, mercury elimination, hazardous waste reduction, computers and electronics, facilities and environment. The web tool also measures administrators' efforts in communicating environmental progress to the community.

Premier plans to publish a summary of the results of environmental assessments from participating organizations on its Safety Web site. Data will be in aggregate format only by type and size of facility, and by state, so that an organization can compare their results with similar organizations. All individual organizational results will be kept confidential. Survey results can be sent via facsimile to the Safety Institute. Additional information available with the survey tool.

According to Gina Pugliese, vice president of Premier's Safety Institute, "Our Premier members that have implemented comprehensive environmental programs report cost savings, better staff and community relations, and measurable environmental improvements. The Executive Scorecard for the Environment gives them a meaningful measure of where they are, and what remains to be done."

Downloads and links

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Multiple studies, Leapfrog confirm need for CPOE balance of physician autonomy and override capabilities

A number of recently published studies have identified approaches to overcoming the barriers to implementing computerized physician order entry (CPOE) systems in order to maximize its effectiveness. These include strong leadership, physician autonomy, high-quality technology, and analysis of reasons for overrides to maximize effectiveness. A summary of these studies follows.

Health Affairs: The July/August 2004 article, "Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals," is the result of a survey of senior management at 26 hospitals that identifies ways to overcome barriers to adopting and implementing computerized physician order entry (CPOE). To date, few U.S. hospitals have implemented CPOE, in spite of its proven effectiveness at preventing serious medication errors. Results of the surveys indicate that within the hospital, strong leadership and high-quality technology were critical. Hospitals that placed a high priority on patient safety could more easily justify the cost of CPOE. Outside the hospital, financial incentives and public pressures encourage CPOE adoption.

Leapfrog Group: CPOE is the first of four patient safety improvement practices supported by the Leapfrog Group, a coalition of more than 150 public and private organizations that provide healthcare benefits. According to the research, when CPOE systems with intercept capability based on protocols specified by the Institute for Safe Medication Practices are used in hospitals, serious prescribing errors can be reduced by more than 50 percent. Yet, fewer than 7 percent of hospitals surveyed reported using them. CPOE systems can eliminate errors caused by misreading or misinterpreting handwritten instructions. They also can intercept orders that might result in adverse drug reactions or that deviate from standard protocols. Additional information on the Leapfrog Group's CPOE Patient Safety Standard can be found at the Leapfrog group Web site.

Journal of the American Medical Informatics Association: A study done at Brigham and Women's Hospital, "Characteristics and Consequences of Drug-Allergy Alert Overrides in a Computerized Physician Order Entry System" pre-published in the August 18, 2004 Journal of the American Medical Informatics Association, describes the experience with drug allergy alert overrides and how often they led to a preventable adverse drug event (ADEs) in a CPOE system. The study found that 80 percent of the alerts generated by computerized physician order entry systems are overridden, but few of these overrides (about 6 percent) result in ADEs. Those overrides that did lead to ADEs were clinically justifiable. The study results led to recommendations for increasing the specificity of drug allergy alerting.

Downloads and links

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Veterans hospitals share experiences with planning, troubleshooting to maximize effectiveness of bedside bar coding

The Veterans Health Administration (VHA) initiated a bar-coded medication administration (BCMA) system in 2000 that is now being used in all of its facilities. As with any new technology, the effectiveness is dependent upon many design, implementation, and maintenance choices. In an article, "Fifteen best practice recommendations for bar-code medication administration in the Veterans Health Administration," published in the Joint Commission Journal on Quality and Safety, VHA officials detail some of the unintended side effects and recommend 15 practices that will maximize the effectiveness of BCMA and reduce the risk of injury to patients. These practices include pharmacist cross-training, physician and nurse recruitment and training as "superusers," replacement of all malfunctioning equipment during servicing, prominent display of updated contact information to resolve recurring types of problems, and routine replacement of wristbands.

Downloads and links

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Control of antibiotics, oxygen, glucose, temperature and razor use reduce risk of surgical-site infection

Using evidence-based processes of care and redesigning their systems to reduce risk factors, the operating room staff at OSF St. Joseph's Medical Center in Bloomington, IL, has dramatically reduced its incidence of surgical-site infections. This process also led to reduced post-surgical nausea and reduced use of post-surgery pain medications. Working with the Institute for Healthcare Improvement's (IHI) Collaborative on Reducing Surgical Site Infections (SSI), staff at OSF made a series of changes. Through this collaborative, staff at OSF learned an important fundamental lesson about improving surgical safety: One cannot make one small change, or two small changes, but must be willing to embrace a series of changes to make noticeable improvement that is sustainable. These changes included:

  • Using prophylactic antibiotics appropriately;
  • Administering prophylactic antibiotics within 60 minutes of the incision;
  • Eliminating use of razors;
  • Maintaining glucose control;
  • Optimizing oxygen tension; and
  • Maintaining normothermia preoperatively.

Downloads and links

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More studies needed before mandating minimum nurse-patient ratios

A recent analysis of the peer-reviewed literature published in the July/August 2004 Journal of Nursing Administration attempts to determine whether literature supports minimum nurse-patient ratios for acute care hospitals and if nurse staffing is associated with patient, nurse/employee, or hospital outcomes.

The researchers concluded that the literature does not support the establishment of mandatory, minimum nurse-to-patient ratios at hospitals. Only one recent study was found that addressed minimum nurse staffing ratios. Evidence did suggest, however, that richer nurse staffing (e.g., skill mix and competence) is associated with lower failure-to-rescue rates, lower inpatient mortality rates, and shorter hospital stays.

Downloads and links

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Epinephrine label changes needed to prevent medication errors, ISMP warns

The Institute for Safe Medication Practices (ISMP) recommends instituting labeling changes to prevent medication errors involving the drug epinephrine, following the death of a 16-year-old boy in an emergency department due to an epinephrine overdose. According to ISMP, current labeling makes it easy for caregivers to confuse dose concentrations, which can lead to overdose. The organization is advocating changes to the way dose concentration is expressed on epinephrine labels, as well as a warning on epinephrine ampoules to remind clinicians to dilute the more concentrated form of the drug before use. ISMP says changes are also needed to prevent confusion of epinephrine with the similar-looking and sounding "ephedrine." They have petitioned the United States Pharmacopeia (USP), which sets medication safety standards, for these changes in an ISMP alert. Meanwhile, the organization is recommending that providers take steps to avert potential errors, such as posting a dose conversion chart on emergency carts and other areas where the medication is prepared, reviewing the dose chart with clinical staff each year, and applying auxiliary warning labels to ampoules.

Downloads and links

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ISMP Medication Safety Self-Assessment deadline extended

The deadline for hospitals to submit 2004 assessment data for the 2004 ISMP Medication Safety Self-Assessment has been extended to October 29. Survey responses are confidential, and only aggregate data will be released. Self-assessment results are the main data source for developing medication safety improvement tools, and a high response rate will benefit all hospitals. Participation in the 2004 survey allows hospitals to:

  • Measure progress made since completing the 2000 self-assessment;
  • Compare their own efforts with those of demographically similar institutions; and
  • Inform future development of improvement tools and educational models that are appropriately tailored to the needs of the field.

Downloads and links

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Safety tools


Detailed literature review - Safer needle devices: selection, testing and evaluation

The Premier Safety Institute has developed a list of journal articles published between 1988 and 2004 that pertains to the review, selection, testing, or evaluation of safer needle devices. The document, titled "Articles and abstracts," (link below) includes a list of selected references, followed by the citation and full abstract. A detailed analysis of the same journal list is provided in a tabular summary format (link below), permitting ease in sorting the journals by: study focus, author, journal, title, population-setting, study design, key findings-summary, conclusions and key words for searching. The journal list is not meant to be definitive or exhaustive; as new devices are released, new articles can be expected to be added. Go to, or:

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Web-based resources - Safer chemical cleaners and pesticides

Hospitals and other healthcare institutions use a surprising number of highly toxic chemicals on their premises, including pesticides and environmental cleaners. These chemicals may contain volatile organic compounds (VOCs) and other toxic chemicals that contribute to poor overall indoor air quality (IAQ) and have been reported to be associated with a host of health problems. Patients are particularly vulnerable to indoor air quality threats, as many have compromised respiratory, neurological, or immunological systems and/or have increased chemical sensitivities.

Healthcare facilities can manage pests and provide a clean and sanitary environment without the use of toxic pesticides or cleaning products. There are safer, effective methods of controlling pests and cleaning the environment that can improve indoor air quality and will not harm the health of workers, patients and the public.

Premier's Safety Institute has added one more important section to the Environmental Preferable Purchasing (EPP) module addressing chemical cleaners and pesticides. The EPP "Topic summary" describes a number of important and useful resources. "Key documents" includes a case study of a safer, successful integrated pest management program.

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New Web site - Disinfection and sterilization resource

A new Web-based resource about disinfection and sterilization has been developed and made available to the public by William A. Rutala, Ph.D., University of North Carolina (UNC) at Chapel Hill and UNC Health Care. The Web site, though still under construction, currently includes slide sets that can be downloaded, an extensive chapter on disinfection and sterilization, and links to useful web sites.

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Electronic information sheets - Influenza vaccine delay

The National Influenza Vaccine Summit, a group of more than 100 organizations, has created a fact sheet and document with answers to frequently asked questions about the delay in delivery of flu vaccine. The National Influenza Vaccine Summit does not expect the delay to have a significant impact on the administration of flu vaccine during the current 2004-05 influenza season. The vaccine should be shipped in October, permitting most people to receive the vaccine between October and February. This year's projected supply of vaccine is substantially greater than last year's.

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Workshop - Reducing occupational exposure to hazardous drugs in healthcare

NIOSH will sponsor a workshop October 3-5 in San Antonio, TX, to familiarize healthcare professionals with the recently published NIOSH Alert on "Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings" and to discuss implementation of the recommendations contained in the alert. More information is available at

The Alert is also available on Premier's web site under the "Resources" section of the pharmaceutical waste management module.

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Editorial team

Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, CIC, associate editor
John Deem, managing editor
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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