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Report: Medication Errors Led to Patient Death at Boston Children’s Hospital

Boston Children’s Hospital was threatened with termination from Medicare last year after three patients suffered from serious medication errors. An inspection report revealed that one of the patients waited 14 hours for an antibiotic and later died, while two others suffered overdoses of a powerful anesthetic, according to the Boston Globe.

The errors took place between January and November 2017, involving two medications and leading CMS surveyors to threaten Boston Children’s with potential termination from the Medicare program. The patient who died had been prescribed Zosyn, an antibiotic, at noon, but the drug was not administered until 14 hours later, the Globe reported. Two days later, the patient died after developing a sepsis infection.

The other two medication errors involved patients receiving overdoses of Propofol, an anesthetic. The first overdose occurred in January 2017 and was followed by a recommendation from leadership for an improved procedure for measuring Propofol doses. But the recommendations were never developed and 10 months later, another patient was given an overdose of the drug by a doctor using the same procedure. The inspection report said both patients eventually recovered, although the second patient had to be resuscitated.

Boston Children’s was able to avoid disciplinary measures this spring by adding improvement plans to treat sepsis patients immediately and for proper Propofol administration. The inspection report said the hospital failed to properly analyze the errors and correct the conditions that led to them.

The Globe reported that in 2016, Massachusetts hospitals reported 47 medication errors that killed or injured patients.

First published in PSQH. 

AORN Expects to Revise its Guideline for OR Headwear

After participating with other healthcare heavy-hitters in February in a task force that met to discuss recommendations for OR attire, specifically ear and hair covering, The Association of periOperative Registered Nurses (AORN) expects to make changes to its Guideline for Surgical Attire.

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN’s director of evidence-based perioperative practice, tells OSHA Healthcare Advisor that AORN will still recommend complete hair coverage in that revised guideline, but “there’s not going to be a recommendation on which head covering.”

As for the coverage of ears, AORN is “probably going to come out in our new guideline and say the ears don’t need to be covered” because the task force feels the research focusing on its necessity has been inconclusive. “However,” she says, “our guideline stands as is until it’s revised.”

It is significant that AORN will be changing its official guideline. While the organization is the world’s largest professional association for perioperative nurses, it has been a tone-setter for issues that affect all healthcare workers who enter the OR. CMS and subsequently The Joint Commission followed AORN’s lead on headwear and has cited healthcare organizations accordingly.

AORN decided to reconsider its stance on headwear after a study led by Troy Markel, MD, assistant professor of surgery at Indiana University, examined the effectiveness of disposable bouffant hats and skull caps as well as newly-laundered cloth skull caps in preventing airborne contamination.

Not only did Markel and his peers observe no significant differences between the disposable bouffant hats and disposable skull caps “with regard to particle or actively sampled microbial contamination,” they also determined that the disposable bouffant hats had greater permeability, penetration, and greater microbial shed compared to both disposable and cloth skull caps.

Therefore, the researchers wrote in conclusion that disposable bouffant hats “should not be considered superior to skull caps in preventing airborne contamination in the operating room.”

The Markel study made the strongest case to date in the contentious debateover OR headwear, which started several years ago when AORN began, depending on who you ask, either promoting the use of bouffant hats among surgical staff or advocating for skull caps to be banned. AORN encouraged full coverage of the ears in the OR, one of the reasons why it favored bouffant hats.

Spruce says the study “just sparked everybody’s interest and opened up this discussion.” AORN and others felt the evidence was enough to revisit the controversy and, according to Spruce, the American College of Surgeons assembled the task force. That group met in February and recently released a joint statement that “covering the ears is not practical for surgeons and anesthesiologists” and also that “available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and [surgical site infection] rates.”

Spruce says AORN had already decided “that it was time to revise that guideline” but “it was valuable” to hear the thoughts among that multi-disciplinary group. She adds, “The perioperative setting has always been a team environment and we’ve always promoted that, so we want the teams to come together and agree on issues that are important to patient safety.”

AORN’s Guideline for Surgical Attire will be reviewed by AORN’s advisory board, which includes representatives from organizations that formed the task force and others. That revised guideline will be available for public comment early next year and will be ready for publication in April.

First published in OSHA Healthcare Advisor

National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

Study Questions Effectiveness of Performance Measures

study published in the New England Journal of Medicine asserts that the U.S. healthcare system does a poor job of measuring quality. The study’s researchers led by lead author Catherine McLean, MD, PHD, chief value medical officer, Hospital for Special Surgery, recommend that organizations should stop using performance measures until they can be assessed and revised.

The study notes that a recent survey found that 63% of physicians said that current performance measures do not capture the quality of the care physicians provide. The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) had developed criteria to assess the validity of performance measures. McLean and researchers applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/ Quality Payment Program (QPP), hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians would have more confidence in using them to improve patient outcomes.

In this study, the researchers identified and rated the validity of 86 measures on the 2017 QPP list that were considered relevant to ambulatory general internal medicine. Of those, 32 (37%) were rated as valid by this method, 30 (35%) were found to be not valid, and 24 (28%) were of uncertain validity. For each measure, the committee rated validity using five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability.

“We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise,” the researchers wrote. “Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.”

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

Study: Improvement in Errors, Accidents, Infections

The Leapfrog Group this week released its spring 2018 Hospital Safety Grades, which found that hospitals have stepped up their game when it comes to reducing avoidable deaths from errors and infections. Leapfrog issues the report cards twice a year, grading hospitals on an “A through F” scale based on their patient safety efforts.

“The national numbers on death and harm in hospitals have alarmed us for decades. What we see in the new round of Safety Grades are signs of many hospitals making significant improvements in their patient safety record,” said Leah Binder, Leapfrog’s president and CEO, in a release. “Leapfrog Hospital Safety Grades have definitely spurred these improvement efforts. But the hospitals achieving new milestones are doing the hard work, and we salute them as the leaders, researchers and organizations fighting every year for patient safety.”

Leapfrog listed improvements including:

  • Five hospitals achieving “A” grades for the first time once had received “F”s
  • Since the report cards started six years ago, 46 hospitals have received an A for the first time
  • 89 hospitals receiving an A had at one point received a D or F
  • Strong performance from hospitals in states that once were ranked poorly, including Rhode Island, Hawaii, Wisconsin, and Idaho

Of the approximately 2,500 hospitals graded by Leapfrog, 30% earned an A, 28% received a B, 35% were given a C, 6% got a D, and 1% received an F. The states with the highest percentage of A-graded hospitals are Hawaii, Idaho, Rhode Island, Massachusetts, and Virginia. Hospitals with F grades are located in California, Washington, DC., Florida, Iowa, Illinois, Maryland, Michigan, Mississippi, New Jersey, and New York.

The Leapfrog Hospital Safety Grades are calculated by top patient safety experts, peer-reviewed, transparent, and free to the public. The report card is released each spring and fall.

Story first published in PSQH

Patient Safety Strategies: Building a Fall Prevention Toolkit

When: May 30, 1-4 p.m. EST

Speakers: Virginia Hall, DNP, MSN/Ed. RN, CNE

Carole Eldridge, DNP, RN, CNE, NEA-BC

Registration: http://hcmarketplace.com/patient-fall-prevention

Patient falls are a fixture in The Joint Commission’s list of top 10 sentinel events; in fact, they were the third highest sentinel event reported to the accreditor in 2016. Causes of falls can include inadequate assessments, side effects from medications or diseases, and environmental hazards, as well as a lack of leadership or staff orientation.

During this three-hour virtual workshop, Carole Eldridge, DNP, RN, CNE, NEA-BC, and Virginia Hall, DNP, MSN/Ed. RN, CNE, will provide a step-by-step guide to setting up a successful and sustainable evidence-based multidisciplinary fall prevention program in your facility.

Learn more about the workshop here.

Joint Commission Urges Hospitals to Protect Workers from Abuse

This story originally ran on HCPro’s OSHA Healthcare Advisor.

The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.

About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.

The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, The Joint Commission wrote in this latest Sentinel Event Alert publication.

Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.

Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).

The Joint Commission cites both of those facts in this Sentinel Event Alert publication and adds that Joint Commission data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.

The Joint Commission is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and it also wants an incident report to be created. Under its Sentinel Event policy, The Joint Commission says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.

Additionally, The accreditor says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.

This Sentinel Event Alert, which you can download here along with other resources, comes on the heels of an emergency preparedness rule from CMS that recently went into effect and efforts from the National Fire Protection Association to fast-track its new standard for active shooter events and other violent incidents. OSHA is also considering a standard to help protect healthcare and social workers from violence.

HFAP to keep name going forward

HFAP will be keeping its name. The accreditor had originally planned to take the name of the Accreditation Association for Hospitals/Health Systems (AAHHS), which acquired them in 2015 from the American Osteopathic Association (AOA.)

AAHHS is a non-profit organization focused on quality and safety in healthcare and has been acting in a management capacity for existing HFAP accreditation programs since the merger.  According to HFAP media representative Mary Velan, to avoid the alphabet soup of switching from AOA/HFAP to AAHHS/HFAP, they plan to simplify by going forward as “HFAP”.

“We had considered a name change but HFAP has over 70 years of history behind its accreditation programs and we want our current and future customers to know that the practical, educational approach that is what HFAP delivers remains unchanged,” she said.

Even though the name change is off, HFAP members shouldn’t worry said Velan. The change in plan won’t affect any of the services provided by HFAP or its survey process.

“HFAP continues with its mission of advancing high-quality patient care and safety through objective application of recognized standards,” Velan said in an email.

She also added the accreditor is expanding their specialty care certification programs, including stroke, lithotripsy, wound care, joint arthroplasty, and compounding pharmaceuticals. HFAP is also working on renewing its CMS deeming authority prior to 2019 expiration dates.

Study: Link between infection control and antibiotic stewardship

Healthcare facilities must ensure that infection prevention and control (IPC) and antibiotic stewardship (AS) programs work together, according to a joint position paper released last week by the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), and the Society of Infectious Disease Pharmacists (SIDP).

An update to a 2012 paper that examined the roles of infection preventionists and healthcare epidemiologists in the use of antimicrobials, the new paper was published in the American Journal of Infection Control and Infection Control and Hospital Epidemiology. The new paper focuses on the synergy between IPC and AS programs, with emphasis on the importance of an effective IPC program as part of a strong AS strategy.

?The issues surrounding the prevention and control of infections are intrinsically linked with the issues associated with the use of antimicrobial agents and the proliferation and spread of multidrug-resistant organisms,? said lead author of the new paper Mary Lou Manning, PhD, CRNP, CIC, FSHEA, FAPIC, in an APIC press release. ?The vital work of IPC and AS programs cannot be performed independently. They require interdependent and coordinated action across multiple and overlapping disciplines and clinical settings to achieve the larger purpose of keeping patients safe from infection and ensuring that effective antibiotic therapy is available for future generations.?

AS programs strive to emphasize the appropriate use of antimicrobials to minimize overuse, improve patient outcomes, reduce microbial resistance, decrease infection spread, and preserve antibiotic efficacy, according to the release. AS programs are more effective when rolled out alongside IPC programs than they are on their own, the paper states.

A study recently released in the Joint Commission Journal on Quality and Patient Safety found that antimicrobial-resistant organisms lead to more than 2 million infections and 23,000 deaths each year in the U.S. The use of AS programs can reduce inappropriate antimicrobial use, length of stay, rates of antimicrobial-resistant infections, and cost, the researchers found.

This story originally ran in PSQH.