RSSAll Entries in the "Patient Safety" Category

Patient Handoffs: Stop Errors and Improve Compliance

Presented on: Thursday, June 27, 2019 | 1:00–2:30 p.m. Eastern

Register at:

Stop medical errors, patient harm, and angry surveyors by fixing your patient handoff process. Handoffs (AKA transitions) are when a patient is transferred from one caregiver to another—they’re also a weak point in the care process overall. Vital information can be forgotten or overlooked when making the handoff, and that means a high potential for harm, from wrong-patient scenarios to medication errors.

Join this 90-minute webinar and learn from international patient handoff expert Emily Patterson, PhD, as she teaches you how to adapt mnemonics, tools, and best practices to your facility.

At the conclusion of this program, participants will be able to:

  • Know what content to include for nurses and physicians during verbal handoffs
  • Know what key characteristics to include in printed forms that support nursing handoffs
  • Know what key features to request when implementing electronic support for tracking nurses’ activities during a shift


  • How to standardize verbal reports by nurses at shift change in the inpatient setting
  • How to determine what communication competencies are needed for an effective resident physician sign-out in the inpatient setting
  • How to electronically support physicians’ handoffs from the emergency department to the inpatient setting
  • How to design printed handoff forms in the EHR that support shift reports
  • How to electronically help nurses manage their activities during and after report
  • Live Q&A


  • I-NURSE content definitions and examples for nurse reports
  • IDHW content definitions and examples for physician sign-outs
  • Picture of a recommended layout for a printed handoff form

CDC clarifies opioid prescribing guidelines

In a letter released April 10, the CDC clarified its federal opioid prescribing guidelines were not meant to be unduly restrictive for chronic pain patients. The clarification came in response to repeated concerns that the rules were preventing patients from getting the pain care they needed.

“The Guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management,” wrote Deborah Dowell, MD, MPH, chief medical officer of the CDC. “Rather, the Guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options for patients.”

In the letter, Dowell explained that physicians are encouraged to use their best clinical judgement when it comes to opioid prescriptions. Nor was it their intention to deny chronic pain patients access to opioids, making special mention of sickle cell and cancer patients.  She also said that they’ll revisit the guidelines as new evidence and prescription recommendations become available.

“Chronic pain is common and multidimensional, and patients deserve safe and effective pain management…CDC will continue to emphasize what the Guidelines and associated materials say about communication, patient engagement in decision making and maintenance of the patient-provider relationship.”

The CDC published its Guideline for Prescribing Opioids for Chronic Pain in 2016. The guidelines consist of 12 recommendations [See sidebar] intended to reduce the use of opioids during an era of addiction and drug abuse. While the guidelines are voluntary,  many worried that they were too restrictive.

In March a group called the Health Professions for Patients in Pain (HP3) wrotethat the guidelines had made it too difficult to prescribe opioids to patients that need them.

“Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use,” HP3 wrote. “Others have experienced preventable hospitalizations or medical deterioration in part because insurers, regulators and other parties have deployed the 90 MME threshold as a both a professional standard and a threshold for professional suspicion. Under such pressure, care decisions are not always based on the best interests of the patient.”

PSMF Targets Problem of Postoperative Delirium in Older Adults

By Jay Kumar

As it works toward its goal of eliminating preventable in-hospital deaths, the Patient Safety Movement Foundation (PSMF) has identified a new challenge to target: postoperative delirium.

Speaking in January at the 7th annual meeting of the World Patient Safety Science & Technology Summit in Huntington Beach, California, a panel of experts discussed the issues around postoperative delirium and how to detect and prevent it. The PSMF has named postoperative delirium as its 18th patient safety challenge, collecting solutions for organizations to implement to reduce the number of preventable deaths from the condition.

Delirium is a condition of acute cerebral dysfunction that may be seen in patients in the early postoperative period or in patients in the intensive care unit (ICU). The condition is found frequently in elderly patients, but the diagnosis is often missed. In some patients, it manifests in hyperactivity and requires immediate intervention.

The audience heard the story of Audrey Curtis, an Australian retiree, who was in the hospital in March 2017 to undergo an operation to replace her aortic valve. After 48 hours in the ICU postoperatively, Curtis was moved back to a general ward. She began hallucinating and, believing she had been kidnapped and tied up with rope, pulled out all the tubes attached to her body. Curtis said the nursing staff never mentioned the incident after the initial nurse responded. Nearly two years later, she still remembers the visions vividly and is hesitant to undergo any further surgery.

“Delirium is a manifestation of brain organ dysfunction,” said Pratik Pandharipande, MD, MSCI, professor and chief of anesthesiology critical care medicine, Vanderbilt University Medical Center.

Delirium occurs in 62% to 80% of mechanically ventilated patients, and it has ramifications months to years later, he said.

Assessing delirium

One way to check for delirium in patients is to use the Confusion Assessment Method for the ICU (CAM-ICU), a tool that can help clinicians determine whether delirium is present. [more]

Joint Commission: How to improve patient depression screening and treatment

A new study published in The Joint Commission Journal on Quality and Patient Safety showcases four ways to improve screening and treatment of patients for depression. Depression is the leading cause of disability and 16.2 million Americans experienced a major depressive episode in 2016.  The condition often goes untreated in certain demographics such as minorities, refugees, and immigrants.

The study, “Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community,” was conducted by Ann M. Schaeffer, DNP, CNM, and Diana Jolles, PhD, CNM, at the Harrisonburg Community Health Center (HCHC) in Virginia. Their goal was to improve their Screening, Brief Intervention, and Referral to Treatment (SBIRT) method for identifying and treating depression.

Evidence-based guidelines recommend facilities screen for depression diagnosis, treatment and follow-up. However, they explain that only seven states report depression screening and follow-up data and the condition is the fourth least-reported measure on the Medicaid Adult Core Set.

“The project demonstrated the feasibility of using rapid-cycle improvement to improve depression screening and follow-up within a multicultural community health center,” the authors noted. “This project also brought attention to a chronic condition with long-standing implications for individual and community health that too often go unidentified and therefore unaddressed.”

The study looked at the impact of four core interventions:

  • Using written standardized screening tools in six languages
  • Using the Option Grid™, a standardized tool to help clients who screen positive for depression to share what matters most to them
  • Using a “right care” tracking log to help providers document follow-up phone calls and visits for at-risk patients
  • Conducting team meetings and in-services to support capacity building

By the end of the study:

  • The use of evidence-based care increased to 71.4 %
  • Compliance with follow-up policies increased from 33.3% to 60%
  • Screenings done in the patient’s preferred language increased to 85.2%
  • Identifying at-risk patients using a patient health questionnaire increased 45.5%

Improving depression care can also be useful in suicide prevention—a major goal of The Joint Commission this year.

Patient Safety Movement announces progress towards Zero Harm goal

By Jay Kumar

Patient Safety Movement (PSM) has made major progress toward its goal of zero preventable deaths worldwide by 2020, even though it likely won’t achieve that goal, PSM founder and CEO Joe Kiani told attendees Friday at the group’s 7th annual World Patient Safety, Science & Technology Summit in Huntington Beach, California.

That said, PSM plans to continue to aggressively pursue its efforts to reduce and eliminate medical errors through aligning with healthcare leaders, doctors and nurses, patients and families, politicians and medical technology companies.

“Our goal of zero preventable deaths by 2020 is daunting,” Kiani said. “If we’re not going to get to zero, we at least have to give it our all. I’m going to give it my all. We have to…Don’t let your miracle of healing get hijacked by some medical error.”

Kiani announced that he is stepping down as PSM’s leader, with David Mayer, MD, vice president of quality and safety for MedStar Health and executive director of the MedStar Institute for Quality and Safety, taking over as CEO effective immediately. In addition, Michael A.E. Ramsay, chairman of the Department of Anesthesiology and Pain Management at Baylor University, will be the incoming chairman of the PSM Foundation board. Kiani, who is found and CEO of medical technology firm Masimo Corporation, said he will remain active in the group by serving on the board.

“I’m not quitting, I’m not leaving,” he said. “This is about the mission. I’m going to help you like the two of you helped me.”

Ramsay lauded Kiani’s efforts and urged attendees to keep moving forward. “For every life that’s lost, there’s probably 1,000 patients that have avoided harm,” he said. While PSM has been successful in raising awareness and spreading education, “we have a lot more to do.”

Asked if there will be a new goal after 2020, Ramsay noted that PSM initially began as a U.S.-focused effort, and now it has gone global. Kiani said the goal could be revised to zero deaths by 2025 or 2030, but nothing official was announced.

Mayer noted that PSM has created urgency in the healthcare industry to improve processes. Another big step forward was bringing patients and families into the effort. “It’s about the transparency,” he said. “It’s about learning from the event.”

“We’ve got to make our hospitals safe,” Ramsay added. “Families want to get to the safe place, and that’s home, not the hospital.”

What’s also necessary is to improve education in medical and nursing schools, Mayer said.

One of PSM’s major efforts is to create a series of 18 Actionable Patient Safety Solutions (APSS) that it has encouraged healthcare organizations to implement as they work to reduce preventable patient harm.

“We need to treat every death as a plane crash that you learn from instead of a car crash, where you say that happens,” Kiani said.

Even as he discussed the progress made by PSM over the last several years, Kiani voiced frustration at the apathy he still finds in the healthcare industry when it comes to making radical changes to reach the group’s goal of zero preventable deaths.

“One life is one too many that we lose, and we’re losing millions a year,” he said. “How can anyone not be willing to do anything and everything to stop reckless care?”

Three Ways to Limit Overprescribing Antibiotics in the Urgent Care Setting

By Christopher Cheney

Antibiotics stewardship at urgent care centers is in the spotlight after the release of a pair of recent studies.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

In July, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting at 45.7% of patient visits. Emergency departments were the second highest at 24.6% of patient visits. The research was based on 2014 data.

“Antibiotic stewardship interventions could help reduce unnecessary antibiotic prescriptions in all ambulatory care settings, and efforts targeting urgent care centers are urgently needed,” the CDC researchers wrote.

This fall, DocuTAP, an urgent care electronic health record company, released an antibiotics stewardship report based on 2017 and 2018 data. The DocuTAP research found inappropriate prescribing of antibiotics for respiratory conditions in urgent care centers at 32.4% of patient visits.

“While we all have work to do when it comes to antibiotic prescribing, this data con?rms that the rate at which urgent cares are inappropriately prescribing antibiotics is in line with other segments of the healthcare market,” the DocuTAP report says.

Laurel Stoimenoff, PT, CEO of the Warrenville, Illinois-based Urgent Care Association, says there are three primary ways that urgent care providers can improve antibiotics stewardship.


Financial Penalties in Hospital Readmissions Linked to Higher Mortality

By John Commins

Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, a new, large-scale study shows.

In an article published last week in JAMA, researchers at Beth Israel Deaconess Medical Center examined the unintended consequences of the Hospital Readmissions Reduction Program, a component of the Affordable Care Act that began in 2012.

Under the HRRP, hospitals have faced financial penalties for higher-than-expected 30-day readmissions for heart failure, pneumonia, and heart attack. Nearly $2 billion in penalties have been imposed on hospitals by the HRRP since 2012.

“Policy makers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable,” study first author Rishi Wadhera, MD, said in comments accompanying the study.

To one extent, HRRP worked. Hospitals made changes to avoid readmissions rates among Medicare beneficiaries and readmissions rates for those three conditions fell. However, a growing chorus of researchers and physicians have raised concerns that the drop in readmissions has led to increased mortality.

“Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care,” Wadhera said. “But the financial penalties imposed by HRRP may have also inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives.”

The researchers examined more than 8 million Medicare fee-for-service hospitalizations from 2005 to 2015. They evaluated mortality among Medicare patients who were hospitalized for heart failure, a heart attack or pneumonia before the establishment of HRRP in 2012.

Then, they compared those trends to determine if there was a significant change in mortality after the HRRP was announced in 2010 and then after the policy was implemented in 2012.

“Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented,” said co-corresponding author Changyu Shen, PhD, senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC.

The team also found mortality rates among patients with pneumonia were stable prior to HRRP, but began increasing after the HRRP. “Whether the HRRP is responsible for this increase in mortality requires further research, but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement,” Shen said.

Readmissions has become a controversial topic among physicians and researchers, with some studies indicating that it leads to a rise in mortality, and other studies indicating that HRRP has improved care delivery.

study published last month in the American Journal of Medicine showed that HRRP is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative.

The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.

EPA announces final rule to set new standards on hazardous waste pharmaceuticals

By A.J. Plunkett

Get the word out to everyone in your organization who handles hazardous waste pharmaceuticals that soon, flushing or rinsing those drugs down a drain into the sewers will be specifically prohibited by the EPA.

That’s harder. On the easier end, you can tell your nurses that the packaging for a patient’s nicotine patch, gum, or lozenge might soon go straight into the regular trash—as long as it is FDA-approved as an over-the-counter nicotine replacement therapy and your state signs off on the exemption of the packaging as hazardous waste under the federal Resource Conservation and Recovery Act (RCRA).

Those are just some of the changes you can expect in handling hazardous waste pharmaceuticals at your facility or business now that the Environmental Protection Agency has finalized its long-awaited “Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine.”

The rule creates a new subpart P under RCRA that manages hazardous waste pharmaceuticals across a wide array of industries, including hospitals, physician offices, ambulatory care, and other providers who “distribute, sell, or dispense pharmaceuticals, including over-the-counter pharmaceuticals, dietary supplements, homeopathic drugs, or prescription pharmaceuticals,” according to the EPA.

The rule has benefits

Under the provision, in general, the EPA says hospitals

  • will no longer have to count hazardous waste pharmaceuticals in calculating generator status (those drugs often sent facilities into large-quantity generator, or LQG, status);
  • can collect and manage hazardous waste pharmaceuticals from satellite facilities as long as they are under the same business umbrella;
  • can accumulate the drugs on site without a RCRA permit for up to 365 days, an increase of 275 days over current regulations;
  • but will have specific basic training requirements associated with those managing hazardous waste pharmaceuticals.

Experts in hazardous waste management in healthcare hailed the ruling as a breakthrough in finally putting a regulatory focus on the need to better control the amount of pharmaceuticals going into the environment while easing up on confusing and often unnecessary restrictions that cost both money and cause aggravation in the healthcare sector.

Another big plus for hospitals in the final rule is that drugs considered controlled substances are no longer considered hazardous waste, erasing concerns about competing regulations between the EPA and the Drug Enforcement Agency.

The rule’s provisions will become effective within six months of its publication in the Federal Register. While the rule has been signed and is expected to be published in the Federal Register before the end of December, there is still the question of when states with their own RCRA-authorized programs will adopt the new regulations.

TJC anticoagulant NPSG updated

The Joint Commission (TJC) announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) on December 7. NPSG 03.05.01 has eight new Elements of Performance (EPs).

All the changes are listed in R3 Report 19 and will take effect on July 1, 2019. The update applies to all TJC accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory health care program.

The update requires impacted facilities too:

  • Have evidence-based protocols for starting, continuing, reversing, and testing anticoagulant treatment.
  • Establish processes for responding to adverse drug events
  • Educate patients and their families on anticoagulant treatment
  • Use programmable IV pumps when administering heparin
  • Use pre-measured products to limit dosing errors

More on this topic will be in future editions of Briefings on Accreditation and Quality

Suicides and drugs cut U.S. life expectancy

U.S. life expectancy dropped to 78.6 years in 2017, according to the CDC, with the main culprits of the decline being drug overdoses and suicides. The research shows that a baby born in 2017 had 1.2 months shaved off its life expectancy compared to one born 12 months earlier.  This is the third year in a row where life expectancy has declined.

“Life expectancy gives us a snapshot of the nation’s overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable,” CDC director Robert Redfield, MD said in a public statement.

The CDC release three reports on November 28—one on suicide mortality, one on drug overdose deaths, and one on mortality overall. And while healthcare organizations have been working hard to treat, prevent, and respond to these issues, the CDC’s numbers show that more work is to be done.

In 2017 there was a grand total of 2.8 million deaths— 69,000 more than the prior year and the most deaths in one year since the government started recording over a century ago. Of those deaths 70,237 were due to drug overdoses and 47,000 were suicides.

Drug overdoses

The spike in drug addiction and deaths was rapid and devastating for many. Drug overdose deaths have increased 16% per year since 2014 says the CDC. And between 2016 and 2017 that number grew 9.6% to 21.7 deaths per 100,000. So far 20 states and the District of Columbia have overdose death rates higher than the national average, and eight have rates comparable to the national average.

Drug Overdoses Statistics

  • The rate of drug overdose deaths in 2017 was 21.7 per 100,000. That’s 3.6 times what it was in 1999 (6.1).
  • While drug use increased in all age groups, overdose rates were much higher for those aged 25–34 (38.4 per 100,000), 35–44 (39.0), and 45–54 (37.7)
  • Men are more likely to die of an overdose than women
  • The number of drug overdoses caused by synthetic opioids increased 45% between 2016 and 2017.


As we’ve written about before, suicide has been the 10th leading cause of death since 2008, with suicide rates on the rise. There’s no single identifiable cause for the increase, though some suggest better reporting, a lack of accessible mental healthcare, economic stresses, and social isolation have played a role.

CMS and other healthcare organizations have made efforts in recent years to reduce ligature risks and patient suicides—new ligature regulations, resources and training, etc. Just on November 28, The Joint Commission released a new R3 report on improving suicide care.

Additional research has shown that many suicide victims visit a healthcare provider in the months leading up to the act. And screening programs, ligature risk checklists for patient rooms, and safety planning for after discharge have been shown to be effective.

Suicide Statistics

  • The CDC report says that between 1999 and 2017 the age-adjusted suicide rate rose 33%, up to 14 deaths per 100,000 from 10.5
  • In 2017 47,000 people died by suicide and 1.3 million made a suicide attempt
  • The number of suicides committed by women (9.7 per 100,000) is lower than for men (22.4). However, suicide rates for women have been growing rapidly and is up 53% since 1999
  • Suicide rates increased for men of every age except those aged 75 and older. However, men in this age group still commit suicide far more often than any other (39.7)
  • Suicides are more common in rural counties (20) than in urban ones (11.1). Between 1999 and 2017, suicide rates for rural areas increase 53%. Meanwhile the rate only grew 16% for urban areas.