Safety Share

October 2004

Dear colleague:

We hope you like the new look of our 30th issue of Premier Safety Share. You can delete this email after you read it because every issue is archived on our Web site.

Also, single-bed patient rooms might be safer - see story below.

Gina Pugliese, editor
Vice President, Premier Safety Institute


Safety tools

Emergency response teams reduce cardiac arrest and mortality

The April 2004 issue of Critical Care Medicine describes the effect of an intensive care unit-based medical emergency team (MET) in reducing postoperative morbidity and mortality rates at Austin Hospital in Heidelberg, Victoria, Australia.

Specifically, in a study of more than 1,000 post surgery patients, MET was associated with a 37 percent relative reduction in mortality, a 65 percent drop in cardiac arrests, and an 88 percent reduction in overall hospital post-cardiac arrest bed days. In addition, the team reduced relative risks by 79 percent for respiratory failure, 78 percent for stroke, 74 percent for severe sepsis, and 88 percent for acute renal failure. The MET includes the intensive care unit doctor on duty and an intensive care nurse who assesses the patient and makes appropriate interventions. The team also empowers nurses, who can activate a support system without needing to track down doctors who may be in the operating room or otherwise not immediately available. Specific indicators for clinical instability were established in the study, including staff members being worried about the patient; other indicators such as acute changes in heart rate, blood pressure or conscious state also were included.

The Institute for Healthcare Improvement also reported on the successful use of a rapid response team (RRT) in reducing mortality at Baptist Memorial Hospital in Memphis, TN. The Baptist Memorial uses a process that empowers nurses and other staff members to proactively call upon the RRT before a patient’s condition seriously worsens. Baptist Memphis’ team is headed by an experienced critical care nurse who works along with a lead respiratory therapist. The team reported a reduction in the number of cardiac arrests by 26 percent while doubling survival rates from 13 to 24 percent.

The implementation of these response teams is a departure from the traditional view that a single physician is in charge of the patient. That paradigm may no longer work in hospitals filled with patients suffering from multiple serious conditions, Baptist Memorial officials said.

Downloads and links

Abstract, “Prospective controlled trial of effect of medical emergency team” from Critical Care Medicine (.doc) (26 KB)

For more information on Baptist Memorial’s success, visit the Institute for Healthcare Improvement (IHI) Web site at:

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Hospital-wide teams, performance metrics and ongoing evaluation improve ED patient flow

A new report from the Urgent Matters Learning Network, “Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments,” discusses best practices and critical success factors from 10 hospitals that were selected to help identify ways to eliminate emergency department crowding, assisting communities in understanding the challenges facing the healthcare safety net. The report is part of a national initiative of the Robert Wood Johnson Foundation.

Emergency department (ED) overcrowding is a hospital wide problem, not just an ED problem. Improving patient flow is a critical factor for success and includes changes in policies to improve access to care and patient safety. The report also reviews strategies developed and implemented by each participating hospital to improve patient flow through different parts of the ED and reduce ED overcrowding overall. Eight common factors were identified as critical for success.

These factors include:

  • Securing leadership buy-in and commitment from the hospital to make these improvements;
  • Identifying a "champion" from the staff affected by the proposed changes to help secure buy-in from employees and physicians;
  • Having the right multidisciplinary, hospital wide teams in place; and
  • Identifying the right performance measures; and ongoing evaluation of progress.

One final factor critical for success is sharing results of the key performance measures between departments and with other institutions in order to motivate internal staff and administrators to perform at high levels and be recognized as leaders.

Downloads and links

“Bursting at the Seams” (.pdf) (367 KB)

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CMS and JCAHO reconcile reporting measures

Beginning in January 2005, hospitals will be able to report identical quality measures to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the national quality initiative for discharges required by the Centers for Medicare & Medicaid Services (CMS). Implementing processes for data collection and reporting should become easier and less costly for hospitals with consistent measures. The organizations will be issued a specifications manual that provides common definitions for each of the quality measures reported to JCAHO and “The "Hospital Quality Alliance...Improving Care Through Information," formerly known as the Quality Initiative.” Currently, participating hospitals report data for the same medical conditions to both organizations, but the organizations specify the measures differently. This increases the data collection and reporting burden for hospitals. JCAHO and CMS say they will work to align their Hospital Quality Measures in their condition-specific performance measure sets and have common schedules for modifications.

The current Hospital Quality Measures are included in JCAHO's ORYX Core Measures and CMS' Seventh Scope of Work Quality of Care Measures for heart attack, heart failure, pneumonia and surgical infection prevention. CMS and JCAHO released and made available on their Web sites a common measures specification manual, which includes a data dictionary, measure information forms, algorithms and other technical support. The intent is to achieve alignment by the time that data for January patient discharges begins to be collected.

Downloads and links

JCAHO web site:

CMS web site:

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Pharmacist-patient interviews can reduce medication errors

According to a study reported in the August 15, 2004 issue of the American Journal of Health-System Pharmacy titled, “Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients,” hospitals can reduce medication errors by having pharmacists interview patients to obtain a complete medication history. From August 2002 to July 2003, researchers interviewed 204 patients within 24 to 48 hours of admission. Pharmacists and pharmacy students tried to identify and resolve any discrepancies between the patients' medical records, admission profiles and actual medication regimens, including vitamins and herbal supplements and medications taken prior to admission.

The study found that over half of the patients had discrepancies in their medication histories; 22 percent of those could have resulted in patient harm during hospitalization and 59 percent could have caused harm if the error continued after discharge. The authors estimate the study cost $5,000 in pharmacists' salaries but saved nearly $39,000 in hospital costs through error prevention.

Downloads and links

Abstract, “Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients.” (.doc) (30 KB)

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Standardized discharge checklist for medications lowers mortality and readmission rates

Researchers from Intermountain Health Care (IHC), Salt Lake City, UT, published a recent study that demonstrated that a relatively simple reminder to physicians using a standard form is an inexpensive and potentially effective way to ensure that patients with heart disease are discharged on the appropriate drugs. IHC hospitals showed that such use of systematic medication programs reduced readmissions and lowered mortality rates. The study published in the September 21, 2004 issue of Annals of Internal Medicine examined records from 57,465 patients discharged from 10 of IHC's largest hospitals. The study found that a strategy implemented in 1997 using checklists, reminder cards, follow-up phone calls, and educational brochures was effective in tracking whether the patients got prescriptions and in improving doctors' adherence to recommended standards of care. The program follows patient care guidelines of the American College of Cardiology and the American Heart Association.

Before the discharge effort began in 1997, only half of the hospitals' patients admitted for several heart conditions, including heart failure and coronary-artery disease, received the proper medicines at discharge. By 1999, the rate of discharged patients’ prescriptions for heart-beneficial medicines such as aspirin, cholesterol-lowering statins, beta-blockers, angiotensin-converting enzyme inhibitors (ACEI) and the anti-stroke drug warfarin increased to more than 90 percent. The study followed the patients through 2002 and found that the program had a lasting effect. The greatest benefits were seen in congestive heart-failure patients; after one year, researchers saw a 23 percent reduction in mortality and a 9 percent drop in readmissions for those patients. Nurses and other health professionals now use the form as a guideline to ensure similar patients receive the same medications. Two of the checklists are provided with permission of the journal.

The need for implementing standardized discharge protocols for medication was recently highlighted in a study by Butler and colleagues. The study appeared in the June 2004 issue of the Journal of the American College of Cardiology. The results indicated that heart failure patients discharged while taking ACEIs showed a significant decline in use after discharge and that patients not discharged with ACEIs were unlikely to be started on medications as outpatients. This study confirms the need for quality improvement efforts focused on both discharge planning and outpatient care.

Downloads and links

Abstract Annals of Internal Medicine 21 9 04 (.doc) (26 KB)

Checklist, “Heart Services Discharge Orders and Instructions” (.pdf) (111 KB), provided with permission.

Checklist, “Discharge Medications for CV Patients” (.pdf) (105 KB), provided with permission.

Abstract, “Utilization of angiotensin-converting enzyme inhibitors.” (.doc) (56 KB)

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Cell phone use within 15 cm distance of ventilators causes malfunction

A recent Critical Care Medicine study, “Cellular phone interference with the operation of mechanical ventilators,” addresses the use of cell phones near ventilators in an intensive care unit. The study found that six of 14 tested ventilators malfunctioned when cell phones were placed less than 15 cm away. None of the ventilator responses were considered life threatening, except a Puritan Bennett 840 model, which reportedly stopped functioning when a fully powered cell phone was placed less than 30 cm away. The study researchers concluded that it is reasonably safe to permit the use of cellular phones in an intensive care unit, as long as they are kept more than three feet from all medical devices.

Wireless technology use is increasing rapidly both in hospitals and in our daily lives. Attempts to ban or limit the use of wireless technologies in patient care areas are often unsuccessful. The study concludes that current medical device manufacturing standards need to be reevaluated to encompass the growth in wireless technologies. Researchers also called upon mechanical ventilator manufacturers to protect their devices from electromagnetic impulses – even those that are emitted nearby. Study authors also asserted that current electromagnetic compatibility (EMC) standards should be modified to include a final test for cellular telephones and similar wireless personal devices.

Downloads and links

Abstract, “Cellular phone interference with the operation of mechanical ventilators.” (.doc) (25 KB)

For more information, go to the Premier Safety Institute Web topic, Cell phones and EMC

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Positioning and stress ulcer prophylaxis among measures to prevent ventilator-associated pneumonia

Ventilator-assisted pneumonia (VAP) is a common and frequently life-threatening condition that affects between 10 percent and 25 percent of critically ill patients. A review of studies on how to prevent ventilator-associated pneumonia, published by Henry Collard, M.D., Sanjay Saint, M.D., M.P.H., and Michael Matthay, M.D., reveals the benefits and risks of several specific interventions to reduce the incidence of VAP. Based on their review, the authors recommend several practices. Preventive practices with the strongest supportive evidence are:

  • Semi-recumbent positioning;
  • Sucralfate in lieu of H2-antagonists for stress ulcer prophylaxis; and
  • Selective digestive tract decontamination.

The authors noted that aspiration of subglottic secretions and oscillating beds may be useful in select populations. There was no evidence to support specific methods of enteral feeding or increased frequency of ventilator circuitry changes. The article, "Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review," was published in the March 18, 2003 issue of the Annals of Internal Medicine and is in the process of being integrated into medical schools’ curricula.

Downloads and links

Abstract, Prevention of Ventilator-Associated Pneumonia (.doc) (24 KB)

“Guidelines for Preventing Healthcare-Associated Pneumonia, 2003” and others may be downloaded from the Premier Safety Institute Web topic, Guidelines.

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Patient fall rates drop 20 percent using innovative prevention strategies

Significant reduction in falls were associated with a fall prevention program that included a risk assessment of all patients on admission and every 24 hours, coupled with standard interventions for all patients and targeted interventions for high-risk patients. This program, dubbed “Take a Second Glance” at Northwestern Memorial Hospital, Chicago, was described in the June 2004 issue of the Joint Commission Journal on Quality and Safety.

The program goal was to standardize and simplify the approach to fall prevention based on the premise that all patients are at risk for falls and that all hospital staff members have a role in fall prevention. Caregivers incorporated a fall prevention assessment tool into the routine patient assessment documentation. The assessment tool is completed upon admission and updated every 24 hours and whenever a patient is transferred to another unit. The interventions include a set of prescribed measures, signage, training materials, and updated patient education materials. Overall, there were statistically significant reductions in total falls (20 percent) and the average hospital fall rate (15 percent). When caregivers compared 11 months of data to the previous year, the average number of days between falls with injuries more than doubled.

Other resources for fall prevention
Premier’s Safety Institute provides a wide spectrum of fall prevention resources. Other sites provide state-specific information (for example, California, Florida, Connecticut, Minnesota, and Washington).

Downloads and links

Full article, “Take a Second Glance,” provided with permission from the Joint Commission Journal on Quality and Safety. (.pdf) (332 KB)

For more resources on fall prevention, visit the Premier Safety Institute Fall prevention site.

For individual state resources on fall prevention for the elderly, go to:

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Safety implications of single-bed rooms being addressed in revision of AIA construction guidelines

Single room versus semi-private room as a minimum requirement for new construction is among the issues in the revision of the 2001 edition of the AIA Guidelines for Design and Construction of Hospital and Health Care Facilities. In addition to being used widely as a guide for healthcare professionals, architects and engineers, more than 40 states and the JCAHO reference the Guidelines for licensure or accreditation. The Guideline will be available for public comment on November 1, 2004 on the AIA web site with comments due January 31, 2005. The new edition is anticipated to be published in January of 2006.

The issue of single room versus semi-private rooms as a minimum requirement has been an ongoing controversy. A study was commissioned to provide additional research to address this issue that focused on costs, disease control, fall prevention, and impact on healing. A number of key safety-related findings supporting single rooms were cited by the Coalition of Healthcare Environment Research (CHER) that coordinated the study (see executive summary). Single patient rooms were found to be associated with shorter length of stay and reduction in both medication errors and nosocomial infections.

Further research is needed to address the influence of single rooms on pain medication intake, patient confidentiality and patient consultation, and fall prevention. Because most falls among elderly occur in patient rooms when patients are alone or while attempting to go to the bathroom, it is believed that increased surveillance in a multi-occupancy room may be more appropriate. However, experts suggest that falls may be reduced from assistance from family members who are easier to accommodate in private rooms.

Other areas that will be given particular consideration in the 2006 Guideline revision include:

  • Therapeutic environments (environment of care, green design and sustainability).
  • IT and health care technology and communications (includes patient documentation, imaging).
  • Infection control (includes biohazard control, handwashing, infection control risk assessments, and construction materials).
  • Disaster planning.
  • Safety and security.
  • Dimensional consideration (includes space planning, costs).
  • Energy and cost-effectiveness.

Downloads and links

AIA Guidelines:

Executive Summary (.pdf) (271 KB)

Complete information and all files are located at Premier’s Construction Web site

Fall information is available from Premier’s Fall prevention Web site

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Safety tools

CDC email registry – Real-time emergency updates for clinicians

To facilitate the rapid dissemination of information to clinicians, the Centers for Disease Control and Prevention (CDC) operates the “Clinician Registry for Terrorism and Emergency Response Updates and Training Opportunities.” The registry provides real-time information to help healthcare providers prepare for (and possibly respond to) emerging diseases and terrorism events. Via weekly e-mail updates, the CDC informs clinicians of recent changes to information on smallpox, SARS, and other related health issues. CDC also uses the registry to announce new clinician training opportunities related to terrorism and emergency response topics. To register: Go to: and follow the links to “Clinician Resources” and “Registry.” The direct registration link is:

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JCAHO e-tools - Interpretive guidelines detail insight into 2005 NPSG

The Joint Commission on Accreditation of Healthcare Organizations has a document titled "Rationale and Interpretive Guidelines" for the 2005 National Patient Safety Goals (.pdf) (300 KB). This document provides insight into how surveyors will be interpreting the goals next year. The JCAHO has also recently updated its frequently asked questions (FAQs) on the 2005 NPSGs and included a new look-alike/sound alike drug list:

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Free video – AHRQ-funded tape on disclosure of medical errors

An instructional video, available from the Georgia Hospital Association and funded by the Agency for Healthcare Research and Quality (AHRQ), teaches health professionals the art of disclosing medical errors. The video discusses how best to inform patients and their families in the event of a medical error that causes harm. Titled “Discussing Unanticipated Outcomes and Disclosing Medical Errors,” the video includes clinical scenarios and comments from a medical ethicist, a hospital risk manager, and two healthcare attorneys. The comments offer suggestions on how to effectively disclose adverse events to patients and their families. The free video is the outgrowth of an AHRQ-funded study by the Georgia Hospital Association Research and Education Foundation. The suggestions in the tape are meant as recommendations only – not legal standards or guidelines. The videotape is copyrighted by the Georgia Hospital Association. For information on how to obtain the videotape, go to:

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Web-based guide - Using AHRQ quality and safety indicators

Using the Agency for Healthcare Research and Quality’s (AHRQ) Inpatient Quality Indicators or Patient Safety Indicators to report on hospital quality or make payment decisions are discussed in a new guide. AHRQ's Quality Indicators are measurement tools that were developed by AHRQ and researchers to help individual hospitals use their own discharge data to better understand and improve the care they provide. To download the “Guidance for Using the AHRQ Quality Indicators for Hospital-Level Public Reporting or Payment,” go to:

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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
  • John Deem, managing editor
  • 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.