March 2007     ICSI Safe Site Protocol

The Institute for Clinical Systems Improvement ( ICSI ) has released its new Safe Site Protocol for All Invasive High-
Risk or Surgical Procedures (Protocol).

The New York State Department of Health (NYSDOH) released its revised New York State Surgical and Invasive
Procedure Protocol (NYSSIPP) in late 2006.

Both emphasize the importance of repeating the timeout verification process whenever there is a change in
personnel involved or a change in location of the patient.

Both closely mirror Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery.

Some great learning tools are available through the Utah C³ (Correct Patient, Correct Procedure, Correct Site)
Correct Site Surgery Initiative. Not only do they have a brochure for patients but they also used a tool from IHI to do a
Failure Mode and Effects Analysis for use of an OR Verification List.

April 2007   New Sidney Dekker Book

Many of you involved in patient safety are familiar with Sidney Dekker’s book “The Field Guide to Human Error Investigations” (2002). He has now followed that up with a new book “The Field Guide to Understanding Human Error” (Ashgate Publishing 2006) and this is a must-read for all involved in investigations of adverse events. Though much of his work has been in the aviation industry, Dekker’s work in human factors and cognitive systems engineering is directly applicable to medicine and patient safety. He masterfully walks the reader through the ways to avoid hindsight bias, remain objective and focus on how the participants perceived the unfolding events at the time. After all, the focus of an investigation is to determine why the events happened in order to prevent similar events and adverse outcomes in the future.

May 2007        WHO/Joint Commission

                   "Nine Patient Safety Solutions"

The World Health Organization and Joint Commission and Joint Commission International have introduced "Nine Patient Safety Solutions" through the WHO Collaborating Centre for Patient Safety Solutions. 

 The nine solutions include:

• Look-Alike, Sound-Alike Medication Names
• Patient Identification
• Communication During Patient Hand-Overs
• Performance of Correct Procedure at Correct Body Site
• Control of Concentrated Electrolyte Solutions
• Assuring Medication Accuracy at Transitions in Care
• Avoiding Catheter and Tubing Misconnections
• Single Use of Injection Devices
• Improved Hand Hygiene to Prevent Health Care-Associated Infection

These solutions are downloadable in 3-4 page summaries that include suggested actions, potential barriers, potential unintended consequences, and references and other resources. They are an excellent resource for any organization in implementing their patient safety programs.

June 2007            Mistake-Proofing

Many of you have already been familiar for several years with John Grout’s website on mistake-proofing. Well, he has now put together a monograph Mistake-Proofing the Design of Health Care Processes that is available on the AHRQ website. There is also an AHRQ podcast with Dr. Grout discussing mistake-proofing in healthcare.

The most effective interventions we recommend in our root cause analyses (RCA’s) are usually forcing functions or redesign of processes and equipment to direct one toward the most appropriate action. There are several examples in our Tip of the Week Archive.  Grout’s monograph provides numerous examples of  using the principles of mistake-proofing to either avoid errors or to have errors result in more benign outcomes.

He begins with an overview of general mistake-proofing, human error, use of FMEA and CRM, and current state of patient safety activities. He points out that mistake-proofing is generally inexpensive and has a good ROI (return on investment). He also talks about the limitations and potential unintended consequences of such redesign efforts. He then presents numerous real-life examples of mistake-proofing implemented at various healthcare facilities around the country.

Overall, this is an excellent monograph that has many practical examples you may wish to implement in your patient safety activities. It will also help you in developing your own solutions to potential problems in your facilities. This is a nice complement to Donald Norman’s classic text on using design to prevent the wrong actions (Norman DA, The Design of Everyday Things. New York: Doubleday; 1989 -  also in paperback from Basic Books 2002).

March 2008   AHRQ’s Healthcare411

AHRQ has just launched a new consumer-oriented website, www.healthcare411.org with up-to-date news and tips on quality and patient safety. Its presentations are available in print, audio and video formats and can even be downloaded to iPod’s or other multimedia devices. This is a great new site to help your patients navigate safely through the healthcare system. Congratulations to Carolyn Clancy, M.D. and all the staff at AHRQ for another great contribution to safe and effective healthcare!

This site builds upon AHRQ’s wealth of patient safety resources that may be used by patients or families. From AHRQ’s Medical Errors & Patient Safety web page you can access not only a whole host of documents on patient safety aimed at professionals but also many useful patient safety resources for patients and consumers.

Most of you are probably already familiar with AHRQ’s “20 Tips to Help Prevent Medical Errors”, a fact sheet you can give your patients and their families and friends. There is also the companion fact sheet “20 Tips to Help Prevent Medical Errors in Children”.

“Ways You Can Help Your Family Prevent Medical Errors!” provides some of the same questions with cartoon illustrations. And “How to Create a Pill Card” illustrates how one can make a personalized card that helps patients remember how and when to take their medications, with illustrations and pictures of the medications.

One of our favorites is “Be prepared for medical appointments”. This is a great tool that helps your patients develop their own list of questions to ask on medical visits. It includes sample questions to ask about prescriptions, diagnostic tests, surgery.

These tools are also nice complements to Joint Commission’s “Speak Up” program tools.

Print “AHRQ’s Healthcare411”

April 2008 

More Neonatal Nursery Incubator Fires

More on Nosocomial UTI’s

More on 1000-Fold Heparin Overdoses

More Neonatal Incubator Fires

Our January 29, 2008  Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” discussed a fire in a neonatal nursery incubator in Minnesota and the ongoing investigation into the causes. We mentioned that we have always been somewhat surprised that fires in patient care areas other than surgical suites seem to be seldom reported. Well, last month within the space of two hours – in two separate hospitals in India – two infants died from incubator fires. So such occurrences may not be so rare. A short circuit was suspected in one of the cases but a full root cause analysis is not yet available. We still anxiously await the results of the investigation in the Minnesota case and these two cases to identify contributing factors and causes. In the interim, many of the components mentioned in our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires should be emphasized, as well as all the excellent work done by ECRI on surgical fires.

And, again, given the risk of fires in incubators hospitals need to take a careful look at the clinical indications for use of concentrated oxygen and have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.

Update: See also our What’s New in the Patient Safety World column for March 2009 “Followup on the Minnesota Bassinet Fire”.

More on Nosocomial UTI’s

We discussed nosocomial urinary tract infections in our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?” and our January 8, 2008 Patient Safety Tip of the Week “Urinary Catheter-Associated Infections”. In the latter, we focused on a paper by Sanjay Saint, M.D. and colleagues at the University of Michigan Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study in the January issue of Clinical Infectious Diseases.

A related paper by Saint et al. discusses themes arising from their study. They found that even though preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early removal of a urinary catheter for patients. Second, those hospitals that made UTI prevention a high priority also focused on noninfectious complications and had committed advocates, or “champions,” who facilitated prevention activities. Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial-impregnated catheters. Finally, external forces, such as public reporting, influenced UTI surveillance and infection prevention activities.

Another article in that same journal (Raffaele 2008) found 30% of urinary catheters were clinically inappropriate. This article has a good discussion of the appropriate indications for urinary catheters and identifies some of the factors that were associated with inappropriate use.

Saint S, Kowalski CP, Forman J, Damschroder L, Hofer TP, Kaufman SR, Creswell JR, Krein SL. A Multicenter Qualitative Study on Preventing Hospital-Acquired Urinary Tract Infection in US Hospitals. Infect Control Hosp Epidemiol 2008;29:333–341 http://www.journals.uchicago.edu/doi/abs/10.1086/529589

Raffaele G, Bianco A, Aiello M, Pavia M. Appropriateness of Use of Indwelling Urinary Tract Catheters in Hospitalized Patients in Italy. Infect Control Hosp Epidemiol 2008;29:279–281 http://www.journals.uchicago.edu/doi/abs/10.1086/528814?prevSearch=(raffaele)+AND+[journal:+iche]

More on 1000-Fold Heparin Overdoses

Our December 2007 “What’s New in the Patient Safety World” column discussed the continued occurrence of 1000-fold heparin overdoses. This included discussion about the Cedars-Sinai incident involving, among others, the children of actor Dennis Quaid and the previous Indianapolis incident that resulted in death of 3 infants. We discussed many of the ISMP recommendations and listed multiple lessons learned.

Dennis Quaid did an interview on CBS’s “60 Minutes” recently to highlight this problematic issue. The 60 Minutes piece did a good job of keeping the issue of medical errors in front of the public and focused a great deal on the fact that the two different heparin solutions had come in vials that looked very much alike. The piece did not delve into many of the systems issues previously raised by ISMP or some of the system lessons learned we had in our December column. However, the Quaid family is apparently leading an effort to promote bar-coding initiatives more widely.

ISMP’s March 27, 2008 Newsletter has an excellent followup “There’s more to the 60 Minutes story on heparin errors”. It discusses the role that confirmation bias may have played in both the Cedars and Indianapolis incidents as well as in many other medical errors. And it really highlights the fact that human error will continue to occur so we need better systems in place to intercept those errors before harm comes to patients. They make a major case for implementation of systems such as bar-coding. Lastly, they discuss the importance of dissemination of lessons learned from incidents elsewhere and the issue of when to do recalls of products implicated in safety threats.

Print “More Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin Overdoses”

May 2008

UK NPSA Alert on Heparin Flushes

We’ve had several recent columns on 1000-fold heparin overdoses related to heparin flushes. Our December 2007 “What’s New in the Patient Safety World” column discussed the continued occurrence of 1000-fold heparin overdoses. This included discussion about the Cedars-Sinai incident involving, among others, the children of actor Dennis Quaid and the previous Indianapolis incident that resulted in death of 3 infants. We discussed many of the ISMP recommendations and listed multiple lessons learned. There was also followup in the April 2008 “What’s New in the Patient Safety World” column.

Now the National Patient Safety Agency of the UK NHS has just issued an alert “Risks with Intravenous Heparin Flush Solutions”. Timely because of all the recent cases of heparin overdose in the US due to inadvertent administration of high dose heparin, the alert was actually issued after an extensive root cause analysis in the UK of inadvertent high dose heparin administered by an anesthetist during procedures of 4 successive pediatric patients. Though the investigator had difficulty identifying other cases from the UK incident reporting system (because of problems with data structure and taxonomy of the database), he did find at least one other comparable case. The cases are very similar to the ones in Indiana and California that have received substantial media attention in the US.

The alert and its additional information point out that heparin flushes have no advantage over normal saline for maintaining peripheral intravenous catheters (evidence is less clear for arterial catheters or central venous catheters). Though there is minimal drug cost savings in moving to use of normal saline for such flushes, keep in mind that unnecessary use of heparin also exposes patients to the risks of allergic reactions, bleeding complications, medication error, and heparin-induced thrombocytopenia. And some other medications may be incompatible with heparin when injected into the same catheter. The alert also stresses that heparin flushes should not be “routine” and should only be used when specifically prescribed. It also reaffirms previous NPSA recommendations on injectable medications such as only stocking low-dose heparin products in areas other than pharmacy, correctly labeling all syringes, and using double checking systems when preparing medication for injection and when administering such injections.

But the real value in this alert is the independent review/RCA, which is extremely thorough and highlights a whole host of circumstances, human factors, and errors that combined to produce the incident(s). This is a long (and often repetitious) investigation report but we highly recommend you read it in its entirety. It’s filled with many of the things we’ve talked about in numerous columns: time pressures, look-alike/sound-alike (LASA) drugs or packaging, information overload, workarounds, drugs showing up in unexpected places, confirmation bias, failure to communicate important patient safety policy changes, failure to convey important clinical information to those who needed to know, slips, latent errors, culture of safety issues and a host of others. Though it’s not presented in a structured RCA format, most of the key elements of the RCA are readily perceived. And the lessons learned and multiple recommendations made would be good ones for almost any healthcare facility.

In a nutshell, 4 pediatric oncology patients were to have procedures (bone marrow aspirates, lumbar punctures, etc.) performed under anesthesia in a treatment room in an outpatient area. Each patient was to receive a heparin “flush” of their access line. The anesthetist, unaware that vials of high-dose heparin (25,000 units in 5 ml) had inadvertently been placed in the controlled drug cupboard (CDC), administered the high-dose heparin to each child thinking he was using a low-dose heparin “flush” (50 units in 5 ml). He, nor other staff involved in the care of these patients, recognized the errors. By chance, because parents of the children had noted some excess bleeding from puncture sites and nurses performing routine inventory of the medication cabinets noticed missing high-dose heparin vials, the incident was discovered the following morning. Fortunately, no long-term harm came to any of the affected children.

Some enabling conditions were identified. The anesthetist had arrived to the facility somewhat late and, to avoid inconvenience to the patients and their families, proceeded without taking a rest break or lunch break (time pressure).

He examined the four patients who were to have procedures done that day, then went to the treatment room to begin preparation for the procedures. He laid out the anesthetics tray for each of the four cases and syringes for each of the three medications each patient was to receive (they were all to receive the same medications). He did not label any of the syringes. Rather he was using his own method of recognizing what was in the syringe by the size of the syringe. This is an example of a workaround. Not only are there dangers in the failure to label the syringes but the preparation of medications for multiple patients at the same time is also extremely dangerous.

The high-dose heparin was not supposed to be in the CDC. It had been placed there because another adult patient had needed it on several occasions. The box containers for the two heparin preparations were distinctive. However, the four vials of high-dose heparin were not in the box container. The actual vials were difficult to distinguish from the vials of low-dose heparin. The anesthetist filled a syringe from each tray with the high-dose heparin, not realizing it was the wrong heparin preparation (look-alike/sound-alike or LASA issue). In such cases, confirmation bias likely plays a significant role: the vials looked like the ones he expected to use and even the word heparin appeared on the vials. Failure to read the exact label obviously was an error. However, it is clear from multiple similar occurrences of these incidents, that such confirmation bias is common and may affect even experienced well-intentioned healthcare workers. In fact, experienced staff are probably more prone to confirmation bias than inexperienced staff.

At no point during either the preparation of  the injectable medications or their administration was a double check performed (i.e. a second observer did not independently verify the correct medication, dosage, route, and patient). Though this was required by policy, this anesthetist and most others were unaware of the requirement (see below in section on policy issues). Also keep in mind that good medication safety also requires verification of the medication at the time of disposal. In this case, the anesthetist simply discarded the used heparin vials in a sharps container.

The investigation does note the controversial issues related to double checks (i.e. that the second checker is more prone to error and, in fact, both checkers may be more prone to error because they assume the other checker correctly verified all the information). However, he cites two research studies that showed a roughly 30% reduction in drug errors with a double checking system.

Another problem identified was that the controlled drug cupboard had over time become an area where many things other than controlled drugs were kept (including personal valuables) and had become vulnerable to access by extraneous staff. In fact, the keys to that CDC were used by so many people that it was often difficult to locate the keys. Hence, one wonders if this had made it more likely unexpected drugs would show up in the CDC. This is an issue of the nature of the local culture of safety. The CDC’s in similar rooms also differed. This was due to an old CDC being moved from the old facility. It exemplifies the importance of standardization.

The anesthetist involved and most of the other anesthetists were unaware of the policy that double checks were required for preparation and administration of intravenous drugs. This was largely a result of policies being too long (some as long as 60 pages), important points not being highlighted, and changes not being highlighted. As a result the policies often went unread by those who needed to see them. And the organization had no formal means of assessing who had read the policies or policy changes. This is an example of both failure of communication and information overload. Sound familiar in your facility?

The investigation also revealed some after-the-incident issues. Parents of two of the children called that evening noting excessive bleeding at puncture sites. That information was never conveyed to the day staff. The following morning the parents of one child brought their child in because of the bleeding. The bleeding had stopped and the child was discharged home. A short time later the vials of high-dose heparin were noted to be missing and it became apparent what had happened. That lack of communication between the evening on-call staff and the daytime staff almost allowed a serious incident to go undetected.

The staff at the outpatient area also had no guidance as to how to proceed with an investigation once the incident was recognized. Having a policy and checklist for what to do in such cases would have been usual (see our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist”).

The investigation report provides 51 recommendations regarding changes needed at multiple levels of the pertinent health care systems. The reader is referred to the full investigation report for all those details.

References:

NHS NPSA Rapid Response Report.

Risks with Intravenous Heparin Flush Solutions. April 24, 2008

http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=11433

NHS NPSA

Additional information

Rapid Response Report: Risks with Intravenous Heparin Flush Solutions

(Reference: NPSA/2008/RRR02) issued on 24 April 2008

http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=11434

Evidence on heparin flushes recently reviewed by UK Medicines Information (UKMi) indicates no advantage over normal saline for maintaining peripheral intravenous catheters. http://www.druginfozone.nhs.uk/Record Viewing/viewRecord.aspx?id=591809

Toft B. Independent review of the circumstances surrounding four serious adverse incidents that occurred in the Oncology Day Beds Unity, Bristol Royal Hospital for Children on Wednesday, 3 January 2007. (UHBT Final Report Heparin). August 2007 www.ubht.nhs.uk/documents/oct_UBHT_final_report_heparin.doc

Other heparin-flush discussions on our website:

December 2007 “What’s New in the Patient Safety World” column

April 2008 “What’s New in the Patient Safety World”

Print “UK NPSA Alert on Heparin Flushes”

June 2008

Potentially Inappropriate Medication Use in Elderly Hospitalized Patients

Our January 15, 2008 Patient Safety Tip of the Week “Managing Dangerous Medications in the Elderly “ focused on prescribing of medications on Beer’s List that may be potentially inappropriate for elderly patients. That column discussed the origin and updating of Beer’s List and ways to improve medication management in the elderly. Most of the published literature on Beer’s List has focused on outpatient or nursing home settings. Relatively little attention has focused on patterns of prescribing for hospitalized elderly inpatients.

An article by Rothberg et al (2008) recently published in the Journal of Hospital Medicine sheds some light on use of such medications on the inpatient side. They found that almost half of all inpatients over the age of 65 in a widely representative hospital sample received at least one medication meeting criteria as a “potentially inappropriate medication” (PIM) from the Beer’s classification. 49% received at least one PIM, 38% received at least one PIM with a high severity rating, and 6% received 3 or more PIM’s.

Prescribing of high severity PIM’s varied substantially across attending physician specialities, being highest for cardiologists (48%) and lowest for geriatricians (24%). Internists, family practitioners, and hospitalists all had median rates of 33%.

There was also great variation across hospitals in PIM usage, especially by geographic location. PIM usage ranged from 34% in the Northeast to 55% in the South. Teaching status of the hospital had little impact. Smaller hospitals had better rates than larger hospitals. Having geriatricians on staff also improved overall hospital prescribing of PIM’s. Patients older than 85 were much less likely to receive a PIM than those aged 65-84 and there was some variation depending on the specific reason for hospitalization.

Note that the study, which was based on review of administrative data, was not able to determine which PIM’s might have been continuation of medications prescribed prior to admission vs. medications newly started in the hospital. The process of medication reconciliation, which is now done on admission and discharge and should be done at all transfers of care, offers a good opportunity to minimize use of PIM’s. In our previous column, we mentioned that when a system in the outpatient setting notifies physicians that one of their patients is on a drug that is on the Beers List, the physician seldom discontinues the flagged drug in that individual patient. However, the number of new prescriptions for that drug diminishes in the patient population cared for by that physician. Perhaps the event of hospitalization may present the opportunity to reassess the potential benefits and risks of those drugs and might lead to their discontinuation.

As we implement CPOE (computerized physician order entry) with clinical decision support, alerts can be programmed to trigger when a PIM is ordered on a patient over a specified age. To minimize the number of alerts a physician may encounter (to avoid “alert fatigue”), we usually try to use standardized order sets wherever possible. However, the Rothberg article raises the possibility that sometimes the standardized order set, which often fails to take into consideration the age of the patient, might actually promote use of certain PIM’s. Therefore, organizations would be wise to review their standardized order sets to see whether any modification for Beer’s list medications is desirable.

While, to our knowledge, no one has ever “validated” the significance of Beer’s List for inpatients, common sense tells us that many of the medications on the list are potentially dangerous for elderly inpatients. Certainly, the sedating agents and several of the medications that produce orthostatic hypotension will increase the risk of falls. And the sedating agents, analgesics, muscle relaxants and anticholinergic agents all have the potential of precipitating or aggravating delirium. Falls and delirium are of importance not only from a human standpoint, but both are on the list of complications for which CMS will no longer be paying come October 2008 (though see our April 22, 2008 Patient Safety Tip of the Week “CMS Expanding List of No-Pay Hospital-Acquired Conditions” where we speculate that delirium may not make the final cut). And several of the drugs may depress respiration or predispose to aspiration or inspissation of secretions, all potentially complicating several conditions that might have led to hospitalization. So while the “evidence base” for use of Beer’s List in elderly inpatients may be scant, we have no problem recommending its use in inpatients.

So don’t hesitate to use some of our most important patient safety interventions, like medication reconciliation and CPOE, to reduce the risk of adverse events from Beer’s List drugs in the elderly hospitalized patient as well as the elderly outpatient.

References:

Rothberg MB, Pekow PS, Liu F, Korc-Grodzicki B, Brennan MJ, Bellantonio S, Heelon M, Lindenauer PK. Potentially Inappropriate Medication Use in Hospitalized Elders. Journal of Hospital Medicine  2008; 3: 91-102 http://www3.interscience.wiley.com/journal/118860229/abstract

Print “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”

July 2008

Joint Commission 2009 National Patient Safety Goals

Joint Commission has published the new 2009 National Patient Safety Goals. There are several new additions and several modifications of previous NPSG’s. Most are in keeping with the quality and patient safety focus being fostered by the new Medicare reimbursement policies regarding potentially preventable adverse outcomes or involve activities your organization may already be performing under such quality improvement collaboratives with IHI or SCIP (the surgical care improvement project). Hot topics are healthcare-associated infections, medication reconciliation, and safe site surgery.

Joint Commission has also redone the numbering scheme to make the format similar to that used for all the other Joint Commission standards. Our recommendation to Joint Commission: Add “NPSG.02.02.01” to your list of “Do Not Use Abbreviations”! For an organization that stresses the important techniques we use in patient safety, such as simplification and improved communication, Joint Commission certainly doesn’t practice what it preaches. It clearly needs to simplify its nomenclature and use descriptors that readily convey to all the nature of the standard under discussion.

Our railing about the less-than-useful nomenclature aside, these new and/or revised NPSG’s make a lot of sense from both a patient safety and business perspective and your hospital should already be doing most of the required activities.

Some changes have been made to the Universal Protocol. Several elements present in the New York State Surgical and Invasive Procedure Protocol (NYSSIPP) are now in the Joint Commission Universal Protocol. That includes a separate timeout when more than one procedure is being performed on the patient. It also requires use of a checklist during the pre-procedure verification process. The checklist can be paper or electronic or even on a wall-mounted white board and needs to include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed.

We’ve long been advocates of using the surgical timeouts for far more than originally intended. In our April 9, 2007 Patient Safety Tip of the Week “Make Your Surgical Timeouts More Useful” we advocated using either the pre-surgical timeout and/or the final verification timeout to also focus on some of the more common complications you wish to avoid. For example, use the timeout to ask questions such as following:

• Is this patient getting prophylactic antibiotics? Who is giving them? When?
• Is this patient a candidate for perioperative beta blockers? Did he get them?
• Is this patient a candidate for DVT prophylaxis? Will it begin intraoperatively?
• Will this patient need repositioning to avoid nerve compression or decubitus? If so, when?

Consider adding these questions to your checklist. And see our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”.

And the Universal Protocol now clarifies issues regarding marking the procedure site. This applies to all procedures involving incision or percutaneous puncture or insertion. The updated goal/standard addresses who does the marking, method of marking, and additional requirements for verifying the site for spinal procedures.

The new NPSG’s have a phase-in period where leadership has assigned responsibility for oversight and coordination by April 1, 2009, an implementation plan is in place by July 1, 2009, pilot testing is being done on at least one clinical unit by October 1, 2009, and full implementation across the hospital is done by January 1, 2010. They also have requirements for educating appropriate healthcare workers, patients and their families, conducts assessments and measurements, and reports the results and outcome measures to key stakeholders.

Three new NPSG’s focus on prevention of nosocomial infections: healthcare-associated infections resulting from multiple drug-resistant organisms (“MDRO’s”) such as MRSA or VRE or C. diff infections, central line-associated bloodstream infections, and surgical site infections. Hospitals are expected to use evidence-based practices or best practices in their programs to prevent these potentially preventable infections. These include things like use of CDC guidelines for reducing transmission of MDRO’s, surveillance programs for MDRO’s based on risk assessment, laboratory-based alert system that identifies new patients with MDRO’s and systems to alert patients readmitted or transferred with MDRO’s. The central line-associated bloodstream infection (“CLAB”) standard applies to both central venous catheters and PICC lines. The evidence-based/best practices include use of checklists and protocols for line insertion, proper hand hygiene prior to insertion or manipulation, avoidance of femoral catheters where possible, standardized all-inclusive supply kits, standardized sterile barrier precautions, chlorhexidine-based antiseptic for skin preparation (for patients over 2 months of age) unless contraindicated, standardized protocols for disinfecting catheter hubs and injection ports before accessing the ports, and routine evaluation for continued necessity of catheters. And the surgical site infection standards focus on some of the SCIP recommendations such as use and timing of antimicrobial prophylaxis and their discontinuation, and use of clippers or depilatories (rather than shaving) in those cases where hair removal is appropriate.

We expect that the evidence-based interventions for preventing infections in all three categories are likely to be expanded by the time full implementation of these new NPSG’s are required.

We spend a great deal of time in our infection control activities attending to the local patient environment, meaning their room and the personnel and equipment entering their room. But we also need to pay attention to some of the other areas in which transmission of infection is a potential threat. One such area is the radiology suite. Many of the patients at highest risk for transmission of nosocomial pathogens are also the likeliest to get high tech imaging studies in the radiology suite, such as CT or MRI scanning. Dr. Peter A. Rothschild has been running an excellent series on “Preventing infection in MRI: Best practices for infection control in and around MRI suites” on the radiology website AuntMinnie.com.

A new goal/standard was added to eliminate transfusion errors related to patient misidentification.

On the medication reconciliation side, Joint Commission has clarified some issues about medication reconciliation in those areas where medications are used minimally or prescribed for a short duration (such as ER’s, urgent care, convenient care, office-based surgery, outpatient radiology, ambulatory care, and behavioral health care). Facilities are still required to obtain a list of all the medications a patient has been taking at home but are not required to know the dose, route, or frequency of use. Another new requirement is that facilities provide at discharge from the hospital a complete and current list of reconciled medications directly to the patient (and document this interaction). Lists of  reconciled medications should also be sent to the primary care provider, next provider of care, and referring provider.

Requirements for patient education and active involvement in their care have been emphasized in standards on patient identification, anticoagulation, and prevention of infection. The anticoagulation standard has been clarified and does not apply to short-term prophylactic anticoagulation (eg. DVT prophylaxis) where laboratory coagulation parameters are not expected to be significantly outside the normal range.

Overall, the new NPSG’ are very reasonable standards and hopefully most of you are already in significant compliance with these because they make sense from multiple perspectives.

Update: See our March 2009 What’s New in the Patient Safety World column “Joint Commission Puts a Hold on Medication Reconciliation Scoring”.

References:

Joint Commission. 2009 National Patient Safety Goals.

http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf

Joint Commission. Renumbering Scheme for National Patient Safety Goals.

http://www.jointcommission.org/NR/rdonlyres/9FB72FBB-431A-4E88-BA5E-09A187EC9862/0/09_NPSG_Renumbering_HAP.pdf

Rothschild PA. Preventing infection in MRI: Best practices for infection control in and around MRI suites. Auntminnie.com 2008

Part I

http://www.auntminnie.com/index.asp?sec=sup&sub=mri&pag=dis&itemid=81530

Part II

http://www.auntminnie.com/index.asp?Sec=sup&Sub=imc&Pag=dis&ItemId=81616

WHO surgical safety checklist

http://www.who.int/patientsafety/safesurgery/tools_resources/technical/en/index.html

Print “Joint Commission 2009 National Patient Safety Goals”

August 2008

AHRQ's New Patient Safety Primers

AHRQ PSNet has introduced a series of patient safety primers. The following topics are covered:

• Computerized Provider Order Entry
• Handoffs and Signouts
• Medication Reconciliation
• Health Care-Associated Infections
• Never Events
• Patient Disclosure
• Rapid Response Systems
• Root Cause Analysis

They are, in fact, primers – meaning they are very introductory works on several important areas related to patient safety. However, each has extensive links to both classic and contemporary bibliographic references and tools.

The primer on Computerized Physician Order Entry (CPOE) discusses the basic concepts of  both CPOE and clinical decision support systems (CDSS) and provides data about the efficacy of CPOE and CDSS and the unintended consequences. Then it provides references (with links) to over 180 resources on CPOE/CDSS including journal articles, newspaper/magazine articles, books, and audiovisual tools.

The primer on Handoffs & Signouts provides background on the problematic issues with communication in healthcare and discusses structured signout techniques like SBAR and ANTICipate. Medication reconciliation is included as one of the critical areas prone to communication difficulties. The reference list of over 400 resources includes links to some of the classic literature on handoffs in other high-risk industries and includes topics like medication reconciliation, correct patient identification, followup of diagnostic testing results, and many more.

Medication Reconciliation also gets its own primer. Though the text of this primer is extremely brief, there are excellent links to toolkits and papers on technological solutions to this issue which continues to perplex us all.

Health Care-Associated Infections (HAI’s) focuses on the four most common nosocomial infections: Central venous catheter–related bloodstream infections (CRBSI), Surgical site infection (SSI), Ventilator-associated pneumonia (VAP), and Catheter-associated urinary tract infection (CAUTI). A simple table outlines the more common evidence-based interventions to help prevent these infections. There are good links to CDC guidelines on infection control and the great work by Peter Pronovost and Atul Gawande on use of checklists as a simple but powerful technique in infection prevention (not to mention the many other uses of checklists in patient safety).

Never Events is primarily a compilation of serious untoward patient consequences appearing in Joint Commission’s Sentinel Events, or the Minnesota Department of Health’s list of serious reportable events, and NQF’s list of “never events”. But again – good  references.

Patient Disclosure is a good discussion about the relatively recent trend in healthcare to both disclose and apologize to patients and/or their families and loved ones when an adverse event occurs as the result of the healthcare process itself. It discusses the studies supporting disclosure/apology, including continued controversies, and has good references about how such is best done. It notes the position statements of patient safety organizations and specialty societies plus the legislation in many states on this issue.

Rapid Response Systems remain controversial since evidence of their efficacy remains unclear at this time. However, the concept of earlier identification of clinical deterioration in patients is a logical patient safety concept. This primer talks about IHI’s role in bringing this issue to the table and Joint Commission’s endorsement of the need for earlier response, criteria for activating rapid response teams, and the various models for rapid response teams. The primer is nonjudgemental and notes the pros and cons of rapid response teams. Most importantly, the references point you to the evidence you need to help you decide what your organization will do to foster earlier (preventive) interventions.

Root Cause Analysis is only a few paragraphs long but its value is in its very extensive list of references, guidelines and tools for performing RCA’s.

If you are looking for one comprehensive “chapter” on any of these eight topics, you won’t find them here. However, if you want to easily get to a comprehensive bibliography and list of tools and other resources related to these topics, you can’t go wrong by visiting this site. AHRQ does a great job of putting the tools you need at your fingertips.

Update: See our February 2009 What’s New in the Patient Safety World column “Some More New AHRQ Patient Safety Primers”.

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September 2008 

CMS’s Final Rule on Non-Payment for “Never Events”

CMS has finalized its list of “never events” for which there will be no additional payments beginning in October 2008. The final rule was published in the August 19, 2008 edition of the Federal Register.

We previously discussed the upcoming changes in our August 21, 2007 Patient Safety Tip of the Week “Costly Complications About To Become Costlier” and January 22, 2008 Patient Safety Tip of the Week “More on the Cost of Complications” and April 22, 2008 Patient Safety Tip of the Week “CMS Expanding List of No-Pay Hospital-Acquired Conditions”. In the latter column we had speculated that not all of the proposed “never events” would make the final list. The final list contains even fewer than we had anticipated.

The first eight hospital-acquired conditions (HAC’s) were:

• Objects inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection- Mediastinitis after coronary artery bypass graft surgery
• Certaintypes of falls and trauma

Of the nine newly proposed changes, only the following made the final list:

• Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
• Certain manifestations of poor control of blood sugar levels
• Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

CMS’s action thus brings to 11 the number of never events for which it will not make additional payments beginning next month. The final rule also contains a list of other “never events” which will be considered for addition to the list in future years.

CMS has also contacted state Medicaid directors and provided information about how states can adopt the same never events practices. The letter specifically encourages states to adopt the same nonpayment policies outlined in the final rule. Many states already have developed their own plans to eliminate payment for some never events. Some, such as New York, have developed even more extensive lists of events that will no longer be paid for. Private insurers are often following suit as well.

It thus behooves all organizations to ensure they have appropriate patient safety/quality improvement programs in place to minimize the risk of these complications. CFO’s have traditionally focused much more on the revenue side of the balance sheet than the cost avoidance side. Justifying patient safety initiatives to CFO’s should no longer be difficult when you put together a spreadsheet with the number of occurrences of the above events at your facility. And the list will grow in future years.

Update: See also our December 2008 What’s New in the Patient Safety World column “CMS Plans to Stop Payment for Wrong-Site Surgery”.

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October 2008

More Medical Helicopter Crashes

Hospital at Night Project

Preventing Infection in MRI

More on Color-Coded Wristbands

Joint Commission Sentinel Event Alert on Hazards of Anticoagulation

This month we look at a number of items in the news that are follow-ups to columns we have previously published.

More Medical Helicopter Crashes

In our July 8, 2008 Patient Safety Tip of the Week “Medical Helicopter Crashes” we discussed the “epidemic” of crashes of helicopters and other medical rescue aircraft in the recent past. Since that column there have been two more medical helicopter crashes. In August a small plane on a medical mercy mission crashed in Easton, Massachusetts, killing a cancer patient and his wife plus the pilot. The plane was flying the cancer patient from Long Island to the Dana Farber Cancer Institute in Boston. Then last weekend a medical helicopter crashed in Maryland, resulting in four more deaths. Details about the former crash are not available at this time but the Maryland crash apparently occurred in foggy weather. In our previous column we noted medical helicopter flights are often riskier because of conditions such as night flying and inclement weather, both of which were present for the Maryland crash. We also talked about Dr. Bryan Bledsoe’s work that had questioned how many medical helicopter flights were truly indicated. Details about the Maryland crash are sketchy but apparently the planned trip was to a hospital only 25 miles away. A recent state audit of Maryland’s MedEvac helicopters, which are run by the Maryland State Police, had also uncovered a number of issues and questions.

It is very difficult to second guess the people on the ground (or at the helicopter control site or the regional emergency response center) who have to make on-the-spot decisions about appropriate triage of accident victims. However, each such incident should have a post-event analysis that includes an assessment as to whether the type of transportation used was the most appropriate one. We would expect that ultimately a checklist of a short series of questions (eg. What is the distance to the trauma center? What is the anticipated drive time? What are traffic conditions like at this time? What are the weather conditions like at this time? What is the condition of the accident victim(s)? etc.) would probably help the on-site and emergency response personnel quickly make a good decision about the type of transportation most appropriate for the situation.

Hospital at Night Project

Our February 26, 2008 Patient Safety Tip of the Week “Nightmares….The Hospital at Night” mentioned one of the presentations at IHI’s Annual National Forum on Quality Improvement this past December “The Hospital at Night Program: Reducing Risks at Our Most Vulnerable Time of the Day” by David Gozzard and Carol Haraden. This described a redesign of hospital structure and processes in anticipation of a significant limitation of work hours imposed by the European Union (the European Working Time Directive). As part of the redesign they collected data on the tasks performed off-hours and found that many tasks performed by doctors at night could be redistributed to nonmedical staff and that many tasks could be performed during daytime hours. For instance, leaving space in the OR schedule for emergencies reduced delays in regularly scheduled cases and reduced the likelihood of doing overflow cases at night. They also focused on communication and handoffs and made greater use of SBAR and written reports that were discussed verbally. And they made better use of the MEWS (Modified Early Warning System) to identify patients at risk of deterioration. Preliminary, largely anecdotal, experiences with the program have been positive.

We said it would be most interesting to see the effect of this program on hard outcome measures. Well, the first report of outcomes of this project are available at the Hospital at Night project website. Outcomes to date have been modest. It does appear that implementation has reduced the number of deaths within 2 days of admission and the number of deaths within 2 days of surgery/procedure. And it did result in the need for fewer transfers externally to other hospitals. And there were some modest improvements in productivity and efficiency measures such as number of hospital beds and average length of stay. While the improvements to date are not eye-popping, we like the concept behind this program and hope that future outcome measurements will demonstrate the effort is worthwhile.

Preventing Infection in MRI

In our July 2008 "What’s New in the Patient Safety World"” column we mentioned the issue of nosocomial infection spread via the radiology department. We noted Dr. Peter A. Rothschild had been running an excellent series on “Preventing infection in MRI: Best practices for infection control in and around MRI suites” on the radiology website AuntMinnie.com. That full paper is now available at a commercial website with eleven suggestions for infection control procedures for imaging centers and departments. Also available at that website is a short You Tube video clip. We’re somewhat bothered by the use of this paper in what appears to be a commercial venture marketing pads for MRI’s. Nevertheless, the paper is one we find quite useful in pointing out some of the hazards of the MRI/radiology suite.

More on Color-Coded Wristbands

The Alabama Hospital Association has announced its plan for member hospitals to use standardized color-coded wristbands starting January 1. Yellow will signify the patient is at risk for falls, red an allergy, and purple DNR. More than 20 states have now standardized on these three colors for wrist bands.

The American Hospital Association is now leading the charge to get all hospitals standardized on these colors. See the AHA Quality Advisory on Implementing Standardized Colors for Patient Alert Wristbands for advice on implementing, education and risk reduction strategies. Their materials include a state-by-state list of  state hospital association efforts to standardize wristband colors.

Joint Commission Sentinel Event Alert on Hazards of Anticoagulation

The Joint Commission has released a new Sentinel Event Alert “Preventing errors relating to commonly used anticoagulants” This alert summarizes the sentinel events in the Joint Commission Sentinel Event Database related to anticoagulation and provides excellent discussion on contributing factors and risk reduction strategies.

Those of you who have been reading our columns for the past year have seen multiple discussions on the hazards of anticoagulation including Patient Safety Tips of the Week:

August 19, 2008                 Arterial Line Issues

July 29, 2008 

Heparin-Induced Thrombocytopenia

July 22, 2008

Lots New in the Anticoagulation Literature

July 15, 2008

Heparin Flushes.....Again!

July 17, 2007

Falls in Patients on Coumadin or Other Anticoagulants

And also the following “What’s New in the Patient Safety World” columns:

December 2007

What’s Old is What’s New: 1000-fold heparin overdoses back in the news again

April 2008

More Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin Overdoses

May 2008

UK NPSA Alert on Heparin Flushes

Print “October 2008 What's New in the Patient Safety World (full column)”

Print “More Medical Helicopter Crashes”

Print “Hospital at Night Project”

Print “Preventing Infection in MRI”

Print “More on Color-Coded Wristbands”

Print “Joint Commission Sentinel Event Alert on Hazards of Anticoagulation”

November 2008

Preventing Surgical Site Infections: New Resources

Two great new resources on preventing surgical site infections (SSI’s) became available last month. NICE (the UK’s National Institute for Health and Clinical Excellence) released its guidance on surgical site infections. The guidance includes a summary guideline, a quick reference, and a much larger guideline, plus evidence tables and other resources.

The second resource is a supplement to the October issue of Infection Control & Hospital Epidemiology. The entire supplement consists of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” and is available free online. This resource includes articles on strategies to prevent central line-associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, preventing MRSA and C. difficile infections, plus the article on preventing surgical site infections. All the recommendations were sponsored and authored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), partnering with Association for Professionals in Infection Control and Epidemiology (APIC), the Joint Commission, and the American Hospital Association (AHA). You’ll find each of the individual articles to be comprehensive and useful or you can read the summary article, which includes the key recommended practices for all of the HAI’s.

The compendium article summarizes the statistics on SSI’s. SSI’s occur in 2-5% of surgical procedures and their occurrence greatly increases patient morbidity and mortality, length of stay, and resource consumption. The risk of death is 2-11 times higher in patients with SSI’s and in about three-quarters of those who die, death is attributable to the SSI. SSI’s add 7-10 days of hospital stay and $3000 to $29,000 additional cost.

The compendium article does a nice job of describing the methods for detection of SSI’s, including use of automated data systems to expand surveillance. It also discusses the need for post-discharge surveillance.

The compendium article includes a table with risk factors for SSI’s, both intrinsic and extrinsic, and their associated grades of evidence. Many of the interventions to prevent SSI’s are familiar to most of you through the SCIP (Surgical Care Improvement Project).

• Prophylactic Antibiotic Received One Hour Prior to Surgical Incision (2 hours for vancomycin or fluoroquinolones)
• Appropriate Prophylactic Antibiotic Selection for Surgical Patients
• Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time (48 hours for cardiac surgery)

• No hair removal or use of appropriate methods when hair removal is necessary. The latter include use of electric clippers or depilatory agents but use of razors is not appropriate.
• Control of serum glucose for cardiac surgery patient in the postoperative period
• Postoperative normothermia for patients undergoing colorectal surgery

Preoperative Care

Good surgical care begins well before the surgery. The patient (and family or caregivers where appropriate) should be informed about the risks of infection and what will be done to reduce those risks as part of the informed consent process. Good control of diabetes reduces the SSI risk. Smoking increases the SSI risk so smoking cessation should be encouraged well prior to surgery.

The NICE guideline notes the patient should bathe or shower with soap on the day of or day before the surgery. The usefulness of preoperative bathing with chlorhexidine-containing solutions remains an unresolved issue. Hair removal is no longer routinely recommended. For those operations where hair must be removed for surgical access, it should be removed with electric clippers on the day of the surgery, with clippers having a single-use removable head. Razors should not be used (they actually increase the risk of infection). The compendium guideline also allows use of depilatory preparations.

Antibiotic Prophylaxis

The full NICE guideline provides a summary of the procedures for which prophylactic antibiotics have been shown to be effective in reducing SSI’s and the associated evidence base. The timing of antibiotic prophylaxis in those cases where antibiotics are indicated is crucial. The SCIP project uses the target within one hour prior to surgical incision, though the period is extended to 2 hours for antibiotics such as vancomycin and fluoroquinolones to allow for maximum tissue availability during surgery. Note that vancomycin is not an antibiotic routinely used in prophylaxis but may be used under special circumstances. The compendium recommendation also notes that the dosing of the prophylactic antibiotic may need to be increased in morbidly obese patients. Limiting duration of prophylactic antibiotics is important to reduce the emergence of antibiotic resistance and to prevent C. difficile infections. Prophylactic antibiotics should be discontinued within 24 hours of surgery (48 hours for cardiac surgery). The NICE guideline differs in that it recommends considering a single dose of  prophylactic antibiotic be given on starting anesthesia, with subsequent doses determined by the operating time and the pharmacokinetics of the antibiotic. While the single dose approach may be more cost-effective, it should be noted that the evidence for single-dose vs. 24 hour dosing is still limited.

Prophylactic antibiotics should be an item on your surgical safety cheklist (see our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”).

Intraoperative Aspects

Both guidelines discuss many of the procedures related to the immediate operative period, including surgical scrub (staff hand cleansing/decontamination), use of gowns and gloves and masks, antiseptic skin preparation, etc. The NICE guideline also addresses many postoperative procedures such as dressing changes and also provides many “do not do” things for wound care. The NICE guideline has one major difference from the US guidelines: hospital staff should remove hand jewelry, artificial nails, and nail polish before operations. The NICE guideline also cautions that there be sufficient time for evaporation of skin antiseptics and avoiding pooling of alcohol-based preparations (see our Patient Safety Tip of the Week for December 4, 2007 “Surgical Fires” and April 29, 2008 “ASA Practice Advisory on Operating Room Fires”).

Neither the NICE nor the compendium guidelines have specific recommendations regarding duration of surgery. Work with the National Nosocomial Infections Surveillance system risk index had shown that the incidence of SSI’s increases when the procedure duration exceeds the 75^th percentile for the duration for that type of procedure. Though some of that may be simply explained by very complex procedures requiring more time, minimizing duration should be encouraged when possible. Yet we know of few hospitals that actually track procedure duration in real-time. And adding time pressure to a procedure might conceivably increase the likelihood of other intraoperative errors that might be detrimental to the patient. Nevertheless, since there are a limited number of operative risk factors that are amenable to change, tracking operative time might be useful in some circumstances (eg. in a teaching hospital where duration may be extended because of the educational aspects). A recent study of SSI’s (Campbell 2008) did show that hospitals that were high outliers for SSI’s had higher trainee-to-bed ratios and the operations took significantly longer.

The compendium article discusses the infrastructure needs and the importance of education (staff, patients, family) and especially a system for feedback about SSI rates to be used in quality improvement activities.

Both the NICE and the compendium guidelines also do a good job of discussing issues that are yet unresolved (eg. role of routine MRSA screening or decolonization, role of preoperative bathing with chlorhexidine-containing solutions, etc.) and those shown not to be helpful (eg. delaying surgery to give parenteral nutrition) and areas for further research (eg. role of tissue oxygenation).

Lastly, the compendium article discusses the performance measures that your facility should be using to monitor SSI’s and your preventive measures.

Long gone are the days when we thought that SSI’s were “part of doing business”. It is clear that 40-60% of SSI’s are preventable (IHI 5 Million Lives Campaign). Preventing them helps your patients, your staff morale, your standing in the community, and your bottom line.

Update: See our December 2008 What’s New in the Patient Safety World column “More on Preventing Surgical Site Infections (SSI’s)”

References:

NICE guidance on surgical site infections

http://www.nice.org.uk/Guidance/CG74

Hospital Acquired Infections Compendium. In supplement to October issue of Infection Control & Hospital Epidemiology 2008; 29: 901-994

http://www.journals.uchicago.edu/toc/iche/2008/29/s1

Campbell DA, Henderson WG, Englesbe MJ, Hall BL, O’Reilly M, Bratzler D, Dellinger EP, et al. Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons/National Surgical Quality Improvement Program Best Practices Initiative. Journal of the American College of Surgeons 2008;  published online 10 October 2008.

http://www.journalacs.org/article/S1072-7515(08)01318-5/abstract

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December 2008

More on Preventing SSI’s

CMS Plans to Stop Payment for Wrong-Site Surgery

IOM Report on Resident Work Hours

Another Good Paper on Handoffs

Rapid Response Teams Don’t Live Up to Expectations

Patient Photographs Improve Radiologists’ Performance

More on Preventing Surgical Site Infections (SSI’s)

Last month (November 2008 What’s New in the Patient Safety World “Preventing Surgical Site Infections: New Resources”) we noted some of the evidence-based recommendations for preventing surgical site infections (SSI’s). A couple of the recommendations that have been based on less rigorous evidence, smoking cessation and avoidance of hyperglycemia, have just received more backing in studies just published.

Lindstrom and colleagues (Lindstrom 2008) reported the results of a randomized controlled trial on the impact of smoking cessation begun within 4 weeks of elective surgery on surgical complication rates. The found almost a 50% reduction in total complication rate for patients in the intervention (smoking cessation) arm. The study, however, was limited by its small size (they had difficulty recruiting patients who might be randomized to the smoking cessation arm). Looking at just SSI’s, though fewer wound infections occurred in the intervention group, the numbers were far too small to meet statistical significance. Nevertheless, the study is important in lending weight to smoking cessation preoperatively. Whereas most prior studies that showed a benefit on postoperative complications began smoking cessation 6-8 weeks prior to surgery, this study demonstrates that there is a benefit even when smoking cessation is begun as late as 4 weeks prior to elective surgery.

Ramos and colleagues (Ramos 2008) published a study strengthening the correlation between perioperative hyperglycemia and postoperative infections (including SSI’s), independent of preoperative blood glucose level or diabetic status. Using data from a risk-adjusted outcomes database from the National Surgical Quality Improvement Project, they showed that for each 40 mg/dl increase in serum glucose the risk of postoperative infection rose 30%. Postoperative hyperglycemia also had a significant adverse effect on length of stay. Caution: this was not a randomized controlled trial to show that treatment to avoid perioperative hyperglycemia results in fewer SSI’s or better outcomes but it further strengthens the association between hyperglycemia and postoperative infections.

Together, these two studies strengthen the evidence for those two interventions in the guidelines for preventing SSI’s that we talked about last month.

References:

Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery. Ann Surg 2008; 248(4):585-591

http://www.annalsofsurgery.com/pt/re/annos/abstract.00000658-200810000-00011.htm;jsessionid=J4FJvqSvhcgWQqJQ2hKTH2Zyd3xXRdG42z6pHvlRyXnlcpblHjqM!273838506!181195628!8091!-1

Lindstrom D, Azodi OS, Wladis A, Tonnesen H, Linder S, Nasell H, Ponzer S, Adami J. Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial. Annals of Surgery. 2008; 248(5):739-745 http://www.annalsofsurgery.com/pt/re/annos/abstract.00000658-200811000-00008.htm;jsessionid=J2LL93fxpLQhQMXlrBMyG85SWpcX3xy1s3LPbxj5bF6S49HWfGhQ!976670012!181195629!8091!-1

CMS Plans to Stop Payment for Wrong-Site Surgery

CMS has posted on its website its proposed decision memos to withhold payment for wrong surgery performed on a patient, surgery on the wrong body part, and surgery on the wrong patient. Quite frankly, we were surprised to hear that CMS had no prior payment decision on such cases. Note that these were not part of the recent final decision on no-pay for “never events” (See our October 2008 What’s New in the Patient Safety World “CMS’s Final Rule on Non-Payment for “Never Events”) The proposals are open for comment, with 1/31/2009 as the proposed date for final decision.

http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=223

http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=222

http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=221

Update: these decisions have become finalized (See February 2009 What’s New in the Patient Safety World “CMS Plan to Stop Payment for Wrong-Site Surgery Final”).

IOM Report on Resident Work Hours

The Institute of Medicine (IOM) has released its new report “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety” this month. Though the report does not recommend further constriction of the current limit of 80 hours per week for residents, it does include recommendations about further reducing consecutive hours worked and inclusion of mandatory nap periods and mandatory days off. Moreover, it recommends that much of the work that residents currently peform (“scut” work) such as phlebotomy be done instead by other healthcare workers. It also calls for better supervision of residents and increased resident education in patient safety.

One important point has to do with handoffs (see our September 30, 2008 Patient Safety Tip of the Week “Hot Topic: Handoffs” and see the article just below this one). With more restricted workhours, the number of handoffs between residents has increased. The IOM report emphasizes the need to make adequate time available for handoffs to occur.

http://www.iom.edu/CMS/3809/48553/60449.aspx

Another Good Paper on Handoffs

In September we did our Tip of the Week on “Hot Topic: Handoffs”, citing great work done primarily by residents and other housestaff to improve on the handoff process. Now surgical residents at Johns Hopkins (Kemp 2008) have, based on their experiences with inadequate handoffs, put together their “Top 10 List for a Safe and Effective Sign-out”. They stressed providing adequate time and appropriate quiet environment for sign-outs, emphasizing the need for sign-out to be an active 2-way interaction. They want a standardized list/format, including items that are important to surgical patients. Prioritizing the patients (knowing which patients are the sickest and seeing them first) was important, as was knowing who the senior resident on-call was. The sign-out should include outstanding tasks, outstanding lab/radiology studies, outstanding consults, and details about any pending admissions. Morning sign-out is just as important as evening sign-out and adequate time should be provided for this as well.

They have included this list and process in their intern orientation. They even include a simulation sign-out as part of that orientation. They also discuss the utility of web-based patient sign-out lists but note that the sign-out lists, whether paper or electronic, should be destroyed after the on-call period to preserve patient confidentiality.

Reference:

Kemp CD, Bath JM, Berger J, Bergsman A, Ellison T, Emery K, Garonzik-Wang J, Hui-Chou HG, Mayo SC, Serrano OK, Shridharani S, Zuberi K, Lipsett PA, Freischlag JA. The Top 10 List for a Safe and Effective Sign-out. Arch Surg. 2008;143(10):1008-1010

http://archsurg.ama-assn.org/cgi/content/abstract/143/10/1008

Rapid Response Teams Don’t Live Up to Expectations

We first talked about Rapid Response Teams in our August 2007 What’s New in the Patient Safety World column “Responding to Patients with Clinical Deterioration”. Then, in our Novermber 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams” we discussed the weakness of the evidence supporting a positive effect of rapid response teams on patient outcomes and discussed many of the methodological problems in studies on RRT’s.

Chan and colleagues (Chan 2008) have just published a prospective cohort design study comparing code rates and mortality before and after implementation of rapid response teams for adult inpatients. Raw code rates per 1000 admissions were lower in the the post-RRT period. However, after adjustment for a number of variables, overall hospital codes rates were not significantly reduced, though those for non-ICU patients were reduced. Furthermore, mortality was not significantly better after implementation of the RRT program. A significant finding in their study is that a large percentage of patients who died after RRT intervention either had DNR status or were accorded DNR status during or after the RRT intervention.

The study did not include financial data. However, in addition to the costs of developing and staffing the RRT’s, it should be noted that a substantial number of patients were bumped up to a higher level of care (usually ICU or telemetry service) after RRT intervention, thus adding to overall costs without significantly affecting outcomes (at least in terms of mortality).

All this negative evidence does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. But it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept. The idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s.

References:

Chan PS, Khalid A, Longmore LS, Berg; RA, Kosiborod M, Spertus JA. Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team. JAMA. 2008; 300(21):2506-2513

http://jama.ama-assn.org/cgi/content/abstract/300/21/2506

Patient Photographs Improve Radiologists’ Performance

A paper presented at this month’s Radiological Society of North America’s annual meeting showed that inclusion of photographs of patients improved accuracy of radiologists’ reports, according to a press release from the RSNA. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study)  without taking more time to review the images.

This somewhat unexpected finding adds another reason to consider adding patient photographs to electronic medical records (EMR’s). We think that inclusion of a patient photograph could significantly improve patient safety (eg. helping prevent a physician from inadvertently ordering on the wrong patient during CPOE, or a nurse administering a medication to wrong patient). In the digital age, it is certainly easy enough to include photographs in the EMR. But the logisitics, legal and privacy issues, measurable outcomes, and unintended consequences remain to be determined.

Print “December 2008 What's New in the Patient Safety World (full column)”

Print “More on Preventing Surgical Site Infections (SSI’s)”

Print “CMS Plans to Stop Payment for Wrong-Site Surgery”

Print “IOM Report on Resident Work Hours”

Print “Another Good Paper on Handoffs”

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January 2009

Preventing Infections in the ICU

In our September 2, 2008 Patient Safety Tip of the Week “Updates on VAP Prevention” we discussed the recent NICE evidence-based guidance on technical patient safety solutions for prevention of ventilator-associated pneumonia. In that they noted that evidence suggests that selective decontamination of the digestive tract (SDD) using topical antibiotics may reduce the incidence of ventilator-associated pneumonia (VAP) and also reduce mortality. However, concerns about the risk of infection with Clostridium difficile and the induction and/or selection of resistant, including multiresistant, microorganisms as a result of SDD kept them from recommending this.

Now a new study from the Netherlands (de Smet et al 2009) published in the New England Journal of Medicine suggests that overall ICU mortality can be reduced by selective decontamination of the digestive tract (SDD) or by selective oropharyngeal decontamination (SOD) without emergence of antibiotic resistance or increase in C. diff infections. This study was not about preventing just VAP but rather preventing all ICU infectious complications and improving mortality. Eligibility for the trial required expected duration of intubation of more than 48 hours or expected ICU length of stay of more than 72 hours. Patients in the SDD group also received 4 days of systemic antibiotics (intravenous cefotaxime)in addition to topical application of tobramycin, colistin, and amphotericinB in the oropharynx and stomach. SOD consisted of oropharyngeal application of the same pasteused for SDD. Both groups were compared to a group receiving standard treatment. Also, in the SDD group only, systemic antibiotics with antianaerobic activity were discouraged.

The study utilized a cluster methodology in which all 3 study regimens were administered in each ICU over the course of 6 months, with the order being randomly assigned. The randomization procedure was scientifically sound but there were differences in baseline characteristics of the patients (with patients in the standard care group being younger, having lower APACHE II scores, less likely to be mechanically ventilated, and more likely to be admitted for surgical reasons).

The primary outcome measure was mortality at Day 28. In a random-effects logistic regression model adjusted for multiple covariates, the odds ratios for death at Day 28 compared to standard treatment were 0.83 for SDD and 0.86 for SOD, both statistically significant. The respective absolute risk reductions were 3.5% for SDD and 2.9% for SOD (respective numbers needed to treat = 29 and 34). Trends toward improvement in secondary outcomes such as ICU and total LOS, and time on ventilator in the SDD and SOD groups did not reach statistical significance. Median number of systemic antibiotic doses did not differ significantly among the three groups. Importantly, surveillance revealed no increase in antibiotic resistance nor increase in C. diff prevalence during the study period. Both SDD and SOD were low-cost (SOD costing about $1 per day and SDD about $12 per day).

But there are numerous issues with this study. Most importantly, benefit in the primary outcome measure was seen only after adjustment for covariates. The study analysis plan had to be changed from its original plan. The investigators had intended to use in-hospital mortality as the primary outcome measure. However, for a variety of theoretical statistical reasons that apply to cluster-randomization trials, the plan was changed and called for the Day 28 mortality as the primary outcome measure and use of the random effects model to account for effect of covariates. Also, as mentioned previously, the randomization procedure did not result in study groups with similar baseline characteristics. The study was also not blinded (the treating physicians and investigators were aware of the treatment group randomization).

So what are the take-home lessons here? Perhaps the best lesson is that the SOD group had essentially as good outcomes as the SDD group. The authors themselves note that this may also mean that oropharyngeal decontamination with agents such as chlorhexidine might be a potential alternative approach.

While the findings of this study are exciting, we remain conservative in endorsing their conclusions. We’d like to see another study confirm that one of these interventions (SOD would be the obvious one to choose) reduces mortality in ICU populations elsewhere. Hopefully that study will avoid some of the methodological problems and issues encountered in the current study.

This is particularly important since some other new studies are demonstrating that some rather simple interventions may be effective in preventing VAP. An article in Nursing Times cites a  research study to be published soon in the Journal of Intensive Care Medicine showing that teeth cleaning in ventilated patients cuts the rate of VAP in half. Twice daily brushing for one minute, followed by application of mouthwash, cut the VAP rate from 5.2% to 2.4%, an improvement that was sustained over time. However, we are awaiting publication of that study to see whether the more important clinical parameters improved. In our November 11, 2008 Patient Safety Tip of the Week “Probiotics and VAP Prevention” we had mentioned that oral decontamination with chlorhexidine (CHX) has been shown to prevent VAP (Chlebick 2007) but does not reduce the time on the ventilator, the length of stay (LOS) in the ICU or rates of mortality (Chan 2007). The incidence of VAP and other ICU infections is of interest but the more important clinical outcomes are outcomes like mortality, time on the ventilator, ICU and hospital LOS, and costs.

Update: The article referenced above has now been published in the Journal of Intensive Care Medicine (Sona 2009). Their protocol consisted of brushing thepatients' teeth with toothpaste, rinsing with tap water, and subsequent application ofa 0.12% chlorhexidine gluconate chemical solution done twicedaily at 12-hour intervals. Their VAP rate fell from 5.2 cases per 1000 ventilator days to 2.4 cases per 1000 ventilator days after institution of the protocol, a 46% reduction. The intervention was very low cost and nursing compliance with the protocol was over 80%. They did not actually measure savings but estimate that the 14 VAP cases prevented in one year would have saved $140,000 to $560,000 based on the literature estimates that VAP cases cost $10,000 to $40,000 per case.

References:

NICE. PSG002 Technical patient safety solutions for prevention of ventilator-associated pneumonia in adults: guidance. 27 August 2008 http://www.nice.org.uk/nicemedia/pdf/PSG002Guidance.pdf

de Smet AMGA, Kluytmans JAJW, Cooper BS, et al. Decontamination of the Digestive Tract and Oropharynx in ICU Patients. New England Journal of Medicine 2009; 360(1):20-31, January 1, 2009

http://content.nejm.org/cgi/content/short/360/1/20

Ford S. Pneumonia rates in ICU can be halved by cleaning teeth. Nursing Times. December16, 2008

http://www.nursingtimes.net/clinicalnews/2008/12/pneumonia_rates_in_icu_can_be_halved_by_cleaning_teeth.html?tmcsTrackingInfo=$ZtK4XIDT-Ac-ufWkKnGwruiHwz0U7cixusZSGP1L8KBKnEODKA--ASsoTbaUGEricPnHdtR7MD4$

Chlebick MP, Safdar N: Topical chlorhexidine for prevention of ventilator-associated

pneumonia: A meta-analysis. Crit Care Med 2007, 35:595–602 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200702000-00037.htm;jsessionid=JYzZFqbp77jdqFqLrhwhZ1cbDLbnBwLvyYMRxvhTwWK48kjGpw9B!-1031399950!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=2&nav=search

Chan EY, Ruest A, O Meade M and Cook DJ: Oral decontamination for prevention of

systematic review and meta-analysis pneumonia in mechanically ventilated adults.

BMJ 2007, 334:889 http://www.bmj.com/cgi/reprint/334/7599/889?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ruest&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, Coopersmith CM, Boyle WA, Buchman TG, Mazuski JE, Schuerer DJE.The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit. J Intensive Care Med 2009 24: 54-62

http://jic.sagepub.com/cgi/content/abstract/24/1/54

Print “Preventing Infections in the ICU”

Febuary 2009

Healthcare IT: The Good and The Bad

Unintended Consequences of eGRF Reporting

CMS Plan to Stop Payment for Wrong-Site Surgery Final

Some More New AHRQ Patient Safety Primers

Healthcare IT: The Good and The Bad

Seems we’ve heard a lot lately about the unintended consequences of healthcare IT. Just look at some of our recent Patient Safety Tip of the Week columns:

Unintended Consequences: Is Medication Reconciliation Next?

Joint Commission Sentinel Event Alert on Hazards of Healthcare IT

Pattern Recognition and CPOE

Technology Workarounds Defeat Safety Intent

CPOE Unintended Consequences – Are Wrong Patient Errors More Common?

Fortunately, there is also good news! A study in last week’s Archives of Internal Medicine (Amarasingham 2009) demonstrated a strong association between implementation of health information technologies and reductions in mortality rates, complications, and costs. Using a tool developed to measure hospitals’ level of implementation of various healthcare IT tools, the authors found that for every 10-point increase in the automation of notes and records there was an associated 15% decrease in mortality. Also, higher scores for implementation of clinical decision support were associated with a 16% decrease in complications. And progressively lower costs were seen for admissions if a hospital had implemented automated test results, order entry, and decision support.

Since this was not a randomized controlled trial, the study does not prove that the healthcare IT initiatives, per se, were the cause of the positive outcomes. Hospitals that have implemented HIT tend to be ones that have more of a culture of safety and it may be the latter that is more responsible for the good outcomes. Nevertheless, this study lends credence to our position that healthcare IT is a critical component for improving patient safety and may lead to substantial cost savings as well. Of note, HealthGrades also happened to release it “top hospital” report last week and it noted that the top 5% of hospitals had a 27% lower mortality than other hospitals. Many of these hospitals are heavily computerized.

On the down side, a series of software glitches in the VA system (see Yen 2009) nationally resulted in many patients receiving unnecessary and potentially dangerous doses of medications like heparin. This apparently began when the VA did its annual software upgrade in August. Numerous instances of medical data popping up under another patient’s name were noted, as were instances where discontinued medications continued to be administered. This example, of course, shows one of the potentially dangerous unintended consequences of healthcare IT is having a single error (such as a software coding error) result in harm to multiple patients.

References:

Amarasingham R, Plantinga L, Marie Diener-West M, Gaskin DJ, Neil R. Powe NR. Clinical Information Technologies and Inpatient Outcomes

A Multiple Hospital Study. Arch Intern Med 2009;169(2):108-114

http://archinte.ama-assn.org/cgi/reprint/169/2/108

HealthGrades press release

http://www.healthgrades.com/media/DMS/pdf/HealthGradesDHACERelease2009.pdf

Yen H. Veterans exposed to incorrect drug doses. Associated Press January 14, 2009

http://www.google.com/hostednews/ap/article/ALeqM5hzWcaC_f76P1tpPibAn0aRA83TLQD95N3VOO2

Unintended Consequences of eGRF Reporting?

Speaking of unintended consequences, a new study questions the cost-effectiveness of using a widely used formula to estimate patients’ glomerular filtration rate (eGFR). Use of the eGFR can identify patients with chronic kidney disease (CKD) who would not have been identified by simply looking at creatinine levels. Here in Western New York, we actually pioneered community-wide use of the eGFR to promote earlier identification of CKD (see Boissonault 2003). The new study (Sydney et al 2009) appears in the Clinical Journal of the American Society of Nephrology. It confirms the positive outcomes of using eGFR (identifying CKD earlier, preventing some deaths and progression to ESRD). However, it also notes the potential impact of false negative test results (identifying some incorrectly as having CKD). Those patients often undergo further testing that may not have been necessary. The final answer on the widespread use of estimated GFR’s will await further population-based studies. But this, again, is a great example of how you must always be vigilant for unintended consequences any time you introduce an intervention you expect to have positive outcomes.

References:

Boissonnault, BA. Chronic kidney disease project in Buffalo N.Y.: A community-wide approach identifying, education and treating CKD patients. Dialysis Times, 9:5:2–3, 7, 2003

http://www.renalresearch.com/pdf/dialysistimes/DT9-5.pdf

Sydney C.W. Tang, Bing L, Andrew S.H. Lai, Clara B.Y. Pang, Wai Kuen Tso, Pek Lan Khong, Mary Ip, Kar Neng Lai. The costs and benefits of automatic estimated glomerular filtration rate reporting. Clinical Journal of the American Society of Nephrology (CJASN) 2009 4(2): February 1, 2009

http://www.newswise.com/articles/view/548423/

CMS Plan to Stop Payment for Wrong-Site Surgery Final

In December 2008 we told you that “CMS Plans to Stop Payment for Wrong-Site Surgery”. As expected, those proposals have now become final and CMS has posted on its website its final decision memos to withhold payment for wrong surgery performed on a patient, surgery on the wrong body part, and surgery on the wrong patient.

Wrong Surgery Performed on a Patient (CAG-00401N)

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223

Surgery on the Wrong Body Part (CAG-00402N)

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222

Surgery on the Wrong Patient (CAG-00403N)

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221

Some More New AHRQ Patient Safety Primers

In our August 2008 What’s New in the Patient Safety World column we highlighted “AHRQ's New Patient Safety Primers”. AHRQ has added 3 more patient safety primers to the original eight.

As we noted previously they are, in fact, primers – meaning they are very introductory works on several important areas related to patient safety. However, each has extensive links to both classic and contemporary bibliographic references and tools. The new ones are no different and are equally useful resources.

The primer on Safety Culture begins with the key characteristics seen in other high-reliability organizations (acknowledgement of hi-risk activities, determination to achieve consistently safe operations, blame-free environment, encouragement of collaboration across ranks and disciplines, and organizational commitment to safety). They go on to discuss enablers and barriers to a culture of safety and many of the tools we often discuss to improve safety (teamwork and communication, patient safety walk rounds, culture measurement tools, etc.). They stress the concept of “just culture” and avoiding hierarchical structures that may impede patient safety progress. Once again, a real strength of the primer is its links to other patient safety tools and a very useful bibliography.

The primer on Adverse Events after Hospital Discharge stresses that 20% of patients discharged from the hospital will suffer an adverse event, most of which were preventable. They focus on various failed communication opportunities and discontinuities in care. They stress the importance of discharge planning, medication reconciliation, followup on pending tests, and attention to health literacy issues. Good discussion of our favorite tools, checklists and structured communication tools, as cornerstones. And the links and bibliography are what you’ve come to expect of these fine AHRQ primers.

The primer on Teamwork Training focuses on crew resource management and lessons from the realm of human factors. As you’d expect, there is a huge emphasis on TeamSTEPPS™ (see our Our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™”), SBAR, handoffs, debriefing, and other tools.

The entire collection of patient safety primers is an extremely useful resource not only for those new to the patient safety movement but even for experienced patient safety and quality improvement personnel.

References:

AHRQ Patient Safety Primers (home page)

http://psnet.ahrq.gov/primerHome.aspx

AHRQ Patient Safety Primer “Safety Culture”

http://psnet.ahrq.gov/primer.aspx?primerID=5

AHRQ Patient Safety Primer “Adverse Events after Hospital Discharge”

http://psnet.ahrq.gov/primer.aspx?primerID=11

AHRQ Patient Safety Primer “Teamwork Training”

http://psnet.ahrq.gov/primer.aspx?primerID=8

Print “February 2009 What's New in the Patient Safety World (full column)”

Print “Healthcare IT The Good and The Bad”

Print “Unintended Consequences of eGFR Reporting?”

Print “CMS Plan to Stop Payment for Wrong-Site Surgery Final”

Print “Some More New AHRQ Patient Safety Primers”

March 2009 

Joint Commission Puts a Hold on Medication Reconciliation Scoring

Followup on the Minnesota Bassinet Fire

Surgical Team Training

Risk of Burns during MRI Scans from Transdermal Drug Patches

Joint Commission Puts a Hold on Medication Reconciliation Scoring

Our December 30, 2008 Patient Safety Tip of the Week “Unintended Consequences: Is Medication Reconciliation Next?” discussed the difficulties healthcare organizations are encountering in implementation of medication reconciliation programs. Well, Joint Commission must have been listening because shortly thereafter they announced that, effective January 1, 2009, they will temporarily halt inclusion of NPSG #8 (medication reconciliation) in the accreditation decision. They will still survey your organization’s activities on medication reconciliation but there will be no requirements for improvement (RFI’s) issued.

Joint Commission remains committed to the concept of medication reconciliation and will gather evidence on best practices and conduct meetings with stakeholders over the next year with the intent of reinstituting NPSG#8 in 2010. As before, we’ve been very concerned about unintended consequences occurring as a result of hasty implementation of unproven medication reconciliation techniques. We commend Joint Commission for being both practical and considerate in this decision.

References:

Joint Commission. Medication reconciliation National Patient Safety Goal to be reviewed, refined. February 5, 2009

http://www.jointcommission.org/Library/WhatsNew/med_rec.htm

Followup on the Minnesota Bassinet Fire

ECRI Institute, which participated in the root cause analysis of the Minnesota bassinet fire, has issued an important equipment alert. This alert lists the manufacturers and model numbers of infant radiant warmers that have heater elements which ECRI feels have an increased risk of precipitating fires. Your facility needs to determine whether any such units are in use and remove them.

You’ll recall the unfortunate incident at Mercy Hospital in Coon Rapids, Minnesota of in which a neonate suffered burns in a flash fire while in an open-topped bassinette under a warmer while using an oxygen hood (see our January 29, 2008 Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” and our April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires”). Though nurses promptly extinguished the flames, the infant suffered burns over about 18% of his head and body.

Since that time there have been even more neonatal injuries and fatalities related to incubator fires in India.

Not only do you need to make sure you are no longer using one of the bassinet warming devices in the ECRI alert, but we’d suggest your organization consider performing a FMEA (failure mode and effects analysis) on potential neonatal unit fires. We had hoped by now we’d have several root cause analyses available to provide valuable lessons learned on these neonatal unit fires. However, details have not been published on any of the Indian cases. The executive summary of the Coons Rapids fire investigation is available and is a great place for you to start since it nicely outlines multiple theoretical concerns that you should be addressing. Focus, of course, is on all the components of the fire triad: an oxydizer, a heat source, and a fuel. That summary identifies the multiple potential heat sources you need to consider that could trigger a fire in an oxygen-rich environment. And, as we had expected in our previous columns, it does address potential fuels such as the alcohol-based disinfectants that we use so commonly now in our hospitals. The executive summary of the Minnesota incident does not go into much detail about oxygen but we have previously recommended that hospitals take a careful look to ensure that the clinical indications for use of oxygen are carefully adhered to. Just as in our discussions about the unnecessary use of urinary catheters, undoubtedly there are circumstances where neonates or other patients are “reflexly” begun on oxygen. (Worse yet, we know that reimbursement policies sometimes have the unintended consequence of unnecessarily prolonging oxygen therapy in neonates). Hospitals should have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.

Just as we need to ensure that everyone who enters an operating room has had appropriate training in surgical fire risk and procedures, we now need to consider similar training of everyone for any area in which oxygen is being used. This obviously would include not only staff, but everyone who might enter that area. That would include housestaff, agency personnel, and even parents and other visitors.

References:

ECRI Institute High Priority Medical Device Alert

Infant Radiant Warmer Fire Prompts ECRI Institute Recommendations for Replacement.

https://www.ecri.org/Documents/ECRI_Institute_HDA_H0045_Warmer_Hazard.pdf

Kanwar S. Concern focuses on patient safety. The Times of India. February 1, 2009

http://timesofindia.indiatimes.com/Chandigarh/Concern_focuses_on_patient_safety/articleshow/4058147.cms

Allina Hospitals & Clinics. January 15, 2009

www.allina.com/ahs/news.nsf/newspage/mercy_investigation

Surgical Team Training

Many of our columns have discussed teamwork, crew/cockpit resource management (CRM), communication, and handoffs. We are big advocates of the TeamSTEPPS™ program for teamwork training (see our our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™”). One of the problems we encounter in planning and implementing such team training programs, however, is measuring success of such programs. Many of the benefits of such teamwork training help the team function much better in emergency circumstances or in preventing unwanted events that are very rare to start with (eg. wrong site surgeries). So such events are likely to be absent in both pre- and post-intervention studies. Metrics of operating room efficiency can be used. But most assessments need to rely on process measures that are fairly labor-intensive to collect.

We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures.

A new study by Havlerson et al. from Northwestern Memorial Hospital (Halverson et al 2009) attempts to demonstrate the benefits of an intensive crew resource management training for all surgeons, anesthesiologists, OR nursing and ancillary personnel. The curriculum included a 4-hour training class plus some in-OR coaching. The intervention resulted in performance of a preoperative briefing in 86% of cases 2 weeks after the intervention but this fell to 66% at 6 months post-intervention. There was a modest improvement in formal announcement of intraoperative changes in staffing. There was no significant difference in timing of prophylactic antibiotic administration or case turnover times. A modest improvement in on-time first case starts may have been influenced by a concomitant intervention. A survey showed that 75% of participants had the perception that the briefings provided a better sense of teamwork. However, they noted a marked disparity in those perceptions by discipline, with nurses and anesthesiologists perceiving more benefit from the briefings than surgeons did.

This paper is definitely worth your reading. It details a whole host of lessons learned in implementing a program of this magnitude. They discuss not only the issue of metrics, but also the time and financial resources necessary, resistance to some of the concepts by some individuals, the need to get clinical leaders committed by actions rather than just words, and the issue of sustainability.

References:

Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17

http://archsurg.ama-assn.org/cgi/content/abstract/143/1/12?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=lingard&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Halverson AL, Andersson JL, Anderson K, et al. Surgical Team Training. The Northwestern Memorial Hospital Experience. Arch Surg 2009; 144(2):107-112

http://archsurg.ama-assn.org/cgi/content/abstract/144/2/107

Risk of Burns during MRI Scans from Transdermal Drug Patches

In our Patient Safety Tips of the Week for February 19, 2008 “MRI Safety” and May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications” we noted that drug patches may become patient safety issues in patients undergoing MRI. That is primarily because some of the patches contain metal or ferromagnetic elements that may overheat during MRI and cause burns. An article in Medscape had discussed which patches need to be removed prior to MRI and which are safe. That article stressed that communication should take place with the prescribing physician to see whether interruption in that drug therapy would be harmful to the patient. And a pharmacist may help determine whether a removed patch needs to be discarded or can be reused by the patient.

Now the FDA has issued a Public Health Advisory “Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings”. The FDA notes that not all transdermal patches that contain metal have this warning for patients in the labeling.

FDA is in the process of reviewing the labeling and composition of all medicated patches to ensure that those made with materials containing metal provide a warning about the risk of burns to patients who wear the patches during an MRI scan.  But until this review is complete, FDA recommends that healthcare professionals referring patients to have an MRI scan identify those patients who are wearing a patch before the patients have the MRI scan. The healthcare professional should advise these patients about the procedures for removing and disposing of the patch before the MRI scan, and replacing the patch after the MRI scan.

References:

Hulisz DT. Are Topical Patches Safe During MRI or CT Scans? Medscape. May 2, 2008. http://www.medscape.com/viewarticle/572561

FDA. FDA Public Health Advisory. Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings. March 5, 2009

http://www.fda.gov/cder/drug/advisory/transdermalpatch.htm

Print “March 2009 What's New in the Patient Safety World (full column)”

Print “Joint Commission Puts a Hold on Medication Reconciliation Scoring”

Print “Followup on the Minnesota Bassinet Fire”

Print “Surgical Team Training”

Print “Risk of Burns during MRI Scans from Transdermal Drug Patches”

April 2009

·Early Emergency Team Calls Reduce Serious Adverse Events

·Reducing Intravascular Catheter-Related Infections with Chlorhexidine-Soaked Dressings

·New Patient Safety Culture Assessments

·Nursing Companion to the BTS Oxygen Therapy Guidelines

Early Emergency Team Calls Reduce Serious Adverse Events

Though the concept behind deployment of Rapid Response Teams (RRT’s) makes good sense, the impact on patient outcomes after deployment of RRT’s has been disappointing to date. We first talked about Rapid Response Teams in our August 2007 What’s New in the Patient Safety World column “Responding to Patients with Clinical Deterioration”. Then, in our November 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams” and our December 2008 What’s New in the Patient Safety World column “Rapid Response Teams Don’t Live Up to Expectations” we discussed the weakness of the evidence supporting a positive effect of rapid response teams on patient outcomes and discussed many of the methodological problems in studies on RRT’s.

Now the researchers (Chen et al 2009) involved in one of the largest prospective randomized trials of RRT’s have reanalyzed the data from the MERIT study (Medical Emergency Response Intervention and Therapy) and found evidence to support the concept of the early emergency call. The MERIT study was a cluster randomized controlled trial in which hospitals in Australia were randomized into 2 groups: those that had rapid response systems and those that did not. That study failed to demonstrate any significant improvement in outcomes between the RRT hospitals and the control ones. However, when they analyzed the data, they noted that almost half the calls to the cardiac arrest teams in control hospitals were “early” calls (i.e. before a cardiac arrest) and that at the RRT hospitals many patients who met the criteria for a call to the RRT never had such a call. They speculated that this “contamination” may have been responsible for the insignificant results in MERIT.

So they reviewed the data, asking the new question “were early calls associated with improved outcomes?”. Indeed, they found that early calls were associated with reductions in the rate of cardiac arrests and unexpected deaths. For every 10% increase in early calls, there was a 2.2 per 100,000 reduction in cardiac arrests and a 0.94 per 100,000 reduction in unexpected deaths. There was no statistical reduction of overall deaths, unplanned ICU admissions, or an aggregate measure of all the outcomes combined.

So the data do support the concept of developing systems to recognize patients who are clinically deteriorating and respond earlier. What is unclear is what “early warning” systems work best and how to best respond.

As we have said before, all the negative evidence on use of RRT’s does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. Although it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept, the idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s. The Chen paper would suggest that refining the criteria and system for early recognition may be the best place to start.

In our August 2007 What’s New in the Patient Safety World column “Responding to Patients with Clinical Deterioration” we discussed 2 UK organizational guidelines on clinical deterioration in acutely hospitalized patients. The UK NHS National Patient Safety Agency had just published its report “Safer care for the acutely ill patient: learning from serious incidents” and NICE (National Institute for Health and Clinical Excellence) has just released its clinical guideline “Acutely ill patients in hospital. Recognition of and response to acute illness in adults in the hospital”. The NICE guideline discusses several scoring systems for identification of patients clinically deteriorating, including the MET (single parameter), MEWS (aggregate scoring system) and ASSIST (assessment score for sick patient identification and step-up in treatment – aggregate scoring system) systems.

While randomized controlled trials may be needed to determine the best method of responding to critical clinical deterioration of a patient, it remains intuitive that systems which enhance early identification of such clinical deterioration are desirable. Joint Commission’s National Patient Safety Goal requiring a plan to “Improve recognition and response to changes in a patient’s condition” makes sense even if a “traditional” rapid response team is not the best way to intervene.

References:

Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S; MERIT Study Investigators for the Simpson Centre; ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009 Jan;37(1):148-53.

http://www.ncbi.nlm.nih.gov/pubmed/19050625?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

UK NHS National Patient Safety Agency. Safer care for the acutely ill patient: learning from serious incidents. 2007

http://www.npsa.nhs.uk/nrls/alerts-and-directives/directives-guidance/acutely-ill-patient/

NICE (National Institute for Health and Clinical Excellence). Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. July 2007

http://www.nice.org.uk/guidance/CG50

Reducing Intravascular Catheter-Related Infections with Chlorhexidine-Soaked Dressings

In a prospective multicenter randomized controlled trial, Timsit et al. (Timsit et al 2009) demonstrated that use of chlorhexidine-impregnated sponges in dressings for intravascular catheters reduced rates of catheter-related bloodstream infections (CRI’s) by 60%, even in a population with a low baseline rate of CRI’s. The reduction was statistically significant, though the number needed to treat (NNT) to prevent one CRI for every catheter was 117. Significant contact dermatitis occurred in 10.4 per 1000 patients or 5.3 per 1000 catheters.

They also demonstrated that changing unsoiled adherent dressings could safely be done every 7 days rather than every 3 days.

The encouraging results were obtained even though most evidence-based practices were already in place to reduce the frequency of CRI’s.

References:

Timsit J-F, Schwebel C, Bouadma L, et al for the Dressing Study Group. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009;301(12):1231-1241

http://jama.ama-assn.org/cgi/content/abstract/301/12/1231

New Patient Safety Culture Assessments

AHRQ has put some new Patient Safety Culture Assessment Tools on its website. The following surveys on patient safety culture are available:

• Nursing Home Survey on Patient Safety Culture
• Medical Office Survey on Patient Safety Culture
• Hospital Survey on Patient Safety Culture

These tools are quite good. Not only do they assess the culture of safety, but they also get you thinking about some of the key patient safety areas you may need to spend more time on.

Speaking of patient safety culture surveys, Press Ganey has released their 2009 report on Safety Culture and it contains some very interesting observations and recommendations. Of the 13 dimensions of safety culture they address, the two areas most in need of improvement are non-punitive response to error and handoffs/transitions.

The perception of safety culture varies greatly by staff position, degree of patient contact, number of hours worked, amount of years in an organization, work area, organization size, and even governance. Management and staff with little patient contact tend to have much higher perceptions of patient safety culture than do front-line workers. Similarly, staff in very complex clinical areas have lower perceptions of safety culture. And new staff  have better perceptions than staff who have been employed for longer periods.

The report provides some examples of how specific organizations have been able to use the results of their surveys to improve patient safety culture. Concepts like safety “chats” and “safety coaches” are highlighted. And they stress the importance of continued training in patient safety for all staff, not just at the time of initial orientation. This report is worth reading. It’s clear that Press Ganey uses its survey tools to help organizations actually improve patient safety, not just to make the organizations feel good about it.

And while you are at it, take a look at ECRI Institute’s new programs for physician practice patient safety and risk management. They cover a broad range of topics that will improve the safety of your patients and improve your overall efficiency and probably your bottom line.

References:

AHRQ. Patient Safety Culture Surveys. 2009

http://www.ahrq.gov/qual/patientsafetyculture/

Press Ganey. P u l s e R e port 2009®. Safety Culture. Staff Perspectives on American Health Care. 2009

http://www.pressganey.com/galleries/default-file/Safety_Culture_Pulse_Report_2009.pdf

ECRI Institute. Patient Safety, Risk Assessment and Management 

https://www.ecri.org/PhysicianPractice

Nursing Companion to the BTS Oxygen Therapy Guidelines

Our January 27, 2009 Pattient Safety Tip of the Week “Oxygen Therapy: Everything You Wanted to Know and More!” summarized the new British Thoracic Society (BTS) guideline on oxygen therapy.

A 2-part series on implementation of these guidelines from a nursing perspective has appeared in Nursing Times in March 2009 (Smith et al 2009 Part 1,   Smith et al 2009 Part 2). While this largely reiterates many of the key points in the BTS guideline, it does have some very practical tips. For example, it describes barriers to appropriate management, such as need for removal of nail polish to prevent inaccurate pulse oximetry readings or use of an ear probe in patients severely vasoconstricted peripherally. It also points out that oxygen therapy is intended to treat hypoxemia, not breathlessness. But it does discuss approaches to the breathless patient. In a discussion about mucus plugging, it notes that there is little evidence that humidification with high-flow oxygen is effective and the oxygen guideline recommends that a bubble bottle should not be used but that single doses of nebulised normal saline have been shown to help in sputum clearance and reduce breathlessness in patients with COPD

References:

Smith, S.M.S. et al. Emergency oxygen delivery in adults 1: updating nursing practice. Nursing Times 2009; 105: 10, 16–18 March 13, 2009

http://www.nursingtimes.net/ntclinical/2009/03/emergency_oxygen_delivery_in_adults.html;jsessionid=ABC75C9CDCD5C1FA3FFBB13E4C13B438?tmcsTrackingInfo=$qPC7alAaJB8W80Gc9rYJxxLYq_FnNx_gmYECyFKVGNO02_u7EQW9QZVnlx8MiE73ypFACSQ449T$

Smith, S.M.S. et al. Emergency oxygen delivery 2: patients with asthma and COPD. Nursing Times 2009; 105: 11 March 24, 2009

http://www.nursingtimes.net/5000004.article

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Print “April 2009 Reducing Intravascular Catheter-Related Infections with Chlorhexidine-Soaked Dressings”

Print “April 2009 New Patient Safety Culture Assessments”

Print “April 2009 Nursing Companion to the BTS Oxygen Therapy Guidelines”

May 2009 

June 2009

AHRQ Hospital Survey on Patient Safety Culture: 2009

Are Single Hospital Rooms Controversial?

The Joint Commission solicits feedback on NPSG’s and Universal Protocol

AHRQ Hospital Survey on Patient Safety Culture: 2009

John Nance’s new book (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) drives home the compelling message that our failure to significantly impact patient safety outcomes since the 1999 IOM report “To Err is Human” is really due to our failure to develop a culture of safety. We have talked in the past on numerous occasions about tools used to assess the culture of safety in healthcare organizations. Our endorsement of these tools has been a cautious one because we have seen that the “culture” in one area of the organization may be significantly different from that in other areas. We also feel that you can get a much better understanding of the culture at the unit level when you routinely do patient safety walk rounds. Most published reports on survey results confirm marked variation in perception of patient safety culture by unit type and by type of respondent.

But that does not mean that these tools do not provide useful information. Just doing the survey raises awareness of patient safety issues and does allow identification of problem areas where extra attention needs to be focused.

Hospitals have been using the AHRQ Survey on Patient Safety Culture since 2004. That survey focuses on 12 areas of patient safety culture and contains 42 items in all. Since 2007 AHRQ has been releasing a comparative database report on the survey results, allowing hospitals to compare where they stand compared to other hospitals. AHRQ has just released its Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. The results are also made available sorted by hospital type, size (bed number), and the position/specialty of the reporters.

Not surprisingly, reporters not having direct patient care responsibilities (eg. hospital administrators) typically have a more positive perception of patient safety culture at their institutions than do those reporters with direct patient care responsibilities. We saw the same trend in Press Ganey's 2009 report on Safety Culture which we commented on in our April 2009 What’s New in the Patient Safety World column “April 2009 New Patient Safety Culture Assessments”. This certainly highlights the importance of understanding whose perception of patient safety you are seeing. If you are a Board member of a healthcare organization, you can expect that your C-suite evaluation of the patient safety culture will be rosier than what it is in reality. Therefore, you should be looking for the perception of those on the front lines, those with direct patient care responsibilities.

The AHRQ trended surveys show overall positive responses for the areas of “teamwork within units” and “overall patient safety grade”. But areas for improvement include “nonpunative response to error” and “handoffs and transitions”. The Press Ganey report also highlighted these as weaknesses. The AHRQ surveys also found “number of events reported” as an area needing improvement. That is no surprise to us. For years we saw striking disparities in incident reporting by hospitals in New York. And, of course, it is those hospitals reporting greater numbers of incidents that have begun to develop that culture of safety and are learning from their experiences. That is a big criticism of statewide “comparative” incident reporting systems in that their publication of “numbers of incidents” may unintentionally steer patients to hospitals that actually have more patient safety problems.

Smaller hospitals generally had more positive responses to all the patient safety culture survey areas. The difference when compared to large hospitals was most noticeable for “handoffs and transitions”. That is not surprising, since at smaller hospitals you tend to find more staff very familiar with each other. We still don’t know the “optimum” size for hospitals at which quality and patient safety outcomes are best. But we are always reminded of the “magic number” from Malcolm Gladwell’s book “The Tipping Point”. He cited research from multiple sources and multiple different organizations showing that when organizations or units exceed 150 members, organizational dysfunction increases. That is most likely due to the fact that in the smaller organization most people know each other by first name, are more likely to work together as a team, and better utilize both peer pressure and peer learning to reach their common goals.

References:

AHRQ. Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report

http://www.ahrq.gov/qual/hospsurvey09/

Press Ganey. P u l s e R e port 2009®. Safety Culture. Staff Perspectives on American Health Care. 2009

http://www.pressganey.com/galleries/default-file/Safety_Culture_Pulse_Report_2009.pdf

Print “June 2009 AHRQ Hospital Survey on Patient Safety Culture 2009”

Are Single Hospital Rooms Controversial?

Most of you know that the trend in hospital design has been toward providing more single patient rooms. That has largely been driven by the epidemic of hospital-acquired infections such as MRSA, VRE, and C. diff. but there are a variety of other evidence-based concepts suggesting single patient rooms should be the wave of the future.

In the past year we have seen two monographs on evidence-based hospital design, The Joint Commission’s “Guiding Principles for the Development of the Hospital of the Future” and a paper in this year IHI’s Innovation Series entitled “Using Evidence-Based Environmental Design to Enhance Safety and Quality”. And since we are big on John Nance this month, his description of the patient rooms and relationship to nursing presence in his new book (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) uses heavily the concepts in these works.

But is everyone on board? Of interest, two publications in the lay press last month just days apart but an ocean apart seemed to espouse different views. An article in the New York Times focused on the benefits of single-patient rooms. Benefits include increased privacy, improved sleep, and reduced infections and stress. But an article in The Herald highlighted a new Scottish study that more than half of hospital patients in Scotland would prefer to stay in a ward than a private room. They note that some of the prior studies showing that patients would prefer single private rooms had been done on younger, primarily surgical patients. They feel that their new study, done on older mixed med/surg patients, may be more reflective of the general hospital population. They point out that the Scottish Single Room Provision Steering Group Report, which mandated all new hospitals in Scotland should be built with only single beds, pointed out that the evidence base is, in fact, not terribly strong.

Much of the evidence in the literature comes from two studies (Ulrich et al 2004) and (Chaudhury et al 2005). Read them and decide for yourself the strength and relative merits of the evidence base.

Perhaps the “loneliness” factor cited in The Herald article can be overcome by design features that can still occur with single rooms. Many of the features described in John Nance’s book where patients are kept in proximity not only to other patients but also to their primary nurse are probably important design features.

At any rate, all the above articles are good reading since they get you to think about incorporating patient safety and communication principles into the design of new things.

References:

Guiding Principles for the Development of the Hospital of the Future.

The Joint Commission. 2008

http://www.jointcommission.org/NR/rdonlyres/1C9A7079-7A29-4658-B80D-A7DF8771309B/0/Hosptal_Future.pdf

Sadler BL, Joseph A, Keller A, Rostenberg B. Using Evidence-Based Environmental Design to Enhance Safety and Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009

http://www.ihi.org/IHI/Results/WhitePapers/UsingEvidenceBasedEnvironmentalDesignWhitePaper.htm

Health Outcomes Driving New Hospital Design

By CAROL ANN CAMPBELL

NY Times Published: May 18, 2009

http://www.nytimes.com/2009/05/19/health/19hosp.html?_r=1&scp=1&sq=+"health+care"&st=nyt

Carolyn Churchill. Hospital patients want wards rather than private rooms. The Herald. Web Edition. May 21 2009

http://www.theherald.co.uk/news/news/display.var.2509383.0.Hospital_patients_want_wards_rather_than_private_rooms.php

The Scottish Government. Single Room Provision Steering Group Report. December 2008.

http://www.scotland.gov.uk/Publications/2008/12/04160144/0

Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.

September 2004

http://www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf

Chaudhury H, Mahmood A, Valente M. Advantages and disadvantages of single- versus multiple-occupancy rooms in acute care environments: A review and analysis of the literature. Environment and Behavior 2005; 37(6): 760-786

http://eab.sagepub.com/cgi/content/abstract/37/6/760

Print “June 2009 Are Single Hospital Rooms Controversial?”

The Joint Commission solicits feedback on NPSG’s and Universal Protocol

As most of you know, The Joint Commission plans no new National Patient Safety Goals for 2010. Instead, it is reviewing and revising the current NPSG’s. On May 12 they posted the suggested revisions to the NPSG’s and Universal Protocol. These are available for downloading at this site. Most of the revisions are wordsmithing and consolidation of several elements of performance for each NPSG into one element of performance. Others involve moving a NPSG or element of performance to standards. You may submit for comments about the proposed revisions to The Joint Commission via that site for most of June.

Reference:

Joint Commission. Proposed Revisions to National Patient Safety Goals and Universal Protocol for Hospitals

http://www.jointcommission.org/Standards/FieldReviews/fr_npsg_hap.htm

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August 2010

August 2010 What's New in the Patient Safety World (full column)

August 2010 Sedation Costs for Pediatric MRI

August 2010 Surgical Case Listing Accuracy

August 2010 ISMP Advice on Catheter Misconnections

August 2010 Suicide Risk By Method Of First Attempt

August 2010 SCIP: Disappointing Outcomes on SSI’s. What’s Next?

July 2010

July 2010 What's New in the Patient Safety World (full column)

July 2010 More on Probiotics for VAP

July 2010 JCAHO Sentinel Event Alert on Violence in the Healthcare Setting

July 2010 Obstructive Sleep Apnea in the General Inpatient Population

July 2010 Methotrexate Overdose Due to Prescribing Error

July 2010 Cochrane Review: Oxygen in MI

June 2010

June 2010 What's New in the Patient Safety World (full column)

June 2010 The July Effect: Myth or Reality?

June 2010 Critical Care Medicine Supplement on Adverse Events in the ICU

June 2010 Seeing Clearly a Common Sense Intervention

June 2010 WHO Checklist for Radiological Interventions

June 2010 The Frailty Index and Surgical Outcomes