The ECRI Institute has published its 2017 list of top patient safety hazards and concerns. The Institute publishes the list to highlight and educate healthcare workers on various dangers affecting patients. The list includes guidance on how to effectively respond to these concerns, along with implementing priorities and corrective action plans. This year the list includes:
1. Information Management in electronic health records (EHR)
2. Unrecognized patient deterioration (UPD)
3. Implementation and use of clinical decision support
4. Test result reporting and follow-up
5. Antimicrobial stewardship
6. Patient identification
7. Opioid administration and monitoring in acute care
8. Behavioral health issues in non-behavioral-health settings
9. Management of new oral anticoagulants
10. Inadequate organization systems or processes to improve safety and quality
“The 10 patient safety concerns listed in our report are very real,” Catherine Pusey, RN, ECRI associate director told HealthLeaders. “They are causing harm (often serious harm) to real people.”
The proper use and timely access to EHRs for patient information management was the main concern this year, Lorraine B. Possanza, program director for ECRI’s Partnership for Health IT Patient Safety said in a press release. She says the vast storehouses of patient data now available to physicians have created new challenges.
“The object is still for people to have the information that they need to make the best clinical decision,” she wrote. “Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible.”
The second concern, UPD, has recently been the subject of increased training, education, better clinical protocols, and public awareness campaigns. However, despite faster recognition and response, UPD is still a major concern.
“People have seen how well the campaigns have worked for stroke and STEMI and how much they’ve improved outcomes,” Patricia N. Neumann, RN, ECRI senior patient safety analyst and consultant told HealthLeaders. “What if those same principles could be applied to other conditions that require fast recognition and management? We could have a big impact on improving outcomes.”
Read more at HealthLeaders Media
The Agency of Healthcare Research and Quality (AHRQ) reports that the number of patients sent to the emergency department (ED) for suicidal thoughts has doubled. As of 2013, 1% of all ED visits are related to suicide ideation, which is up from 0.4% in 2006. This is an average increase of 12% annually.
Of the 1% brought in for suicidal thoughts, more than 71% were admitted to the same hospital or transferred to another facility. ED patients with suicidal thoughts often had these behavioral health conditions:
- Mood disorders
- Substance-related disorders
- Alcohol-related disorders
- Anxiety disorders
- Schizophrenia and other psychotic disorders
Visit HealthLeaders Media for more details. And read more on our previous coverage of suicide ideation and prevention.
The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.
The SEA comes with an infographic on the “11 Tenets of a Safety Culture.”
In the March issue of Perspectives, The Joint Commission announced that it had added 2016’s sentinel event data to its database. There were 824 sentinel events reported to The Joint Commission between January 1 and December 31, 2016. And 81% of those events were submitted voluntarily by the organization that experienced them. The most often reported events were:
- Unintended retention of a foreign object – 120
- Wrong patient, wrong site, or wrong procedure – 104
- Falls – 92
- Suicide – 87
- Delay in treatment – 54
- Other unanticipated events – 47
- Operative/postoperative complication – 45
- Medication error – 33
- Criminal event – 32
- Perinatal death/injury – 23
Readers should note that less than 2% of all sentinel events are reported to The Joint Commission, and these numbers can’t show the actual frequency of these events.
“In 2016 the trend for the most frequently reported sentinel events continued to be unintended retention of foreign objects, ‘wrong-patient, wrong-site, wrong procedure’ events, patient falls, patient suicides, and delays in treatment,” wrote Gerard M. Castro, PhD, MPH, Joint Commission project director, in Perspectives. “These are not new problems to health care, which indicates that organizations continue to struggle with how to prevent them.
The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.
“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”
The Joint Commission has updated Sentinel Event Alert, Issue 45: Preventing Violence in the Health Care Setting with new resources:
- Workplace Violence Prevention Resources Portal
- Quick Safety Issue 4: Preparing for active shooter situations, July 2014
- Quick Safety Issue 5: Preventing violent and criminal events, August 2014
In related news, The American Society for Healthcare Risk Management (ASHRM) has released multiple toolkits on how to assess workplace violence risks in healthcare settings. The toolkits also provide guidance and checklists on what to do if violence breaks out and how to protect staff. The toolkits cover five main areas:
- Staff-to-staff violence/harassment
- Physician- or third-party professional-to-staff violence/harassment
- Patient-to-staff violence
- Visitor/family-to-staff violence
- Stranger/nonemployee-to-staff violence
Read Briefings on Accreditation and Quality for more on workplace violence protection.
Last Chance: “How Parkland Health & Hospital System Successfully Implemented a Suicide Risk Screening Program Webinar”
Date: Tuesday, February 7
Kimberly Roaten, PhD, CRC
Celeste Johnson, DNP, APRN, PMH CNS
Level of Program: Intermediate
Suicides were the third most common sentinel event of 2015. Universal screening is the best strategy to identify patients in general healthcare settings whose suicide risk would otherwise go undetected. This webinar will take a case study approach to bring to light proven methods to reduce patient suicide.
Join Parkland Health and Hospital System expert speakers Kimberly Roaten, PhD, CRC, and Celeste Johnson, DNP, APRN, PMH CNS, as they explain how Parkland became the first in the nation to establish a universal suicide screening program in all its departments. Parkland was recognized in Sentinel Event Alert 56 for making significant progress in suicide prevention. Roaten and Johnson will discuss processes for implementation, strategies to obtain support, universal screening data, and lessons learned from implementation.
At the conclusion of this program, participants will be able to:
- Discuss the process for implementation of a hospitalwide suicide screening protocol
- Describe strategies for obtaining nursing and physician stakeholder support for universal suicide screening
- Describe the prevalence data collected from the first two years of a universal screening program
- Apply lessons learned from the implementation of the program in a large hospital system
Accredited organizations now receive a new SAFER Matrix Tool and a user guide, following their first survey with the new matrix. The SAFER Matrix was announced last July as a replacement for the old “Category A and C” method of evaluating safety issues. As of January 1, all accredited organizations now receive the SAFER matrix after their surveys.
The new tool can be used to filters out specific portions of the SAFER report, such as Requirements for Improvement, which then can be saved and sent to people within the facility. The guide shows users how to:
- Use filters
- Select specific survey or review events to view
- Switch between different accreditation programs
- Switch between accreditation and certification
The tool and guide can be found on Joint Commission Connect in the “Post-Survey” section of the “Survey Process” tab.
Earlier this month, the American Society of Health-System Pharmacists (ASHP) released a new set of nationally recognized drug diversion prevention guidelines. The purpose of the guidance is to help healthcare facilities create effective strategies to prevent the theft and misuse of medications and controlled substances.
“Diversion of controlled substances by healthcare workers remains a serious problem that increases the potential for serious patient safety issues, causes harm to the diverter and elevates the liability risk to healthcare organizations,” said David Chen, BSPharm, MBA, senior director of the ASHP Section of Pharmacy Practice Managers, in a press release. “These guidelines give pharmacists tools to not only improve controlled substances management, but also to play a prominent role in systemwide diversion prevention efforts at their practice sites.”
The 2015 National Drug Threat Assessment found that controlled prescription drugs are abused more often than cocaine, methamphetamine, heroin, Ecstasy, and PCP combined. And there have been cases of healthcare workers potentially infecting patients by using needles filled with diverted drugs and putting them back into circulation.
The guidelines can be applied to a number of healthcare settings and is based off best practices and recommendations from the Drug Enforcement Agency, state hospital associations, and scientific literature. You can read the guidelines in full here , along with the ASHP announcement.
The Food and Drug Administration’s (FDA) ban on powdered medical gloves went into effect on January 18. The use, advertising, and marketing of powdered surgeon’s gloves, patient examination gloves, and absorbable powder for surgeon’s gloves at medical clinics and hospitals is now strictly forbidden.
Powders have been used to lubricate gloves for easy removal for more than 100 years. However, the powder currently used in medical gloves has been shown to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. In addition, powdered latex gloves carry the risk of allergic reaction in patients.
“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”
The agency’s most recent push to get rid of powdered gloves came after receiving three citizen petitions between 2008 and 2011. The proposed rule was published last March; the FDA estimates the reduction in patient harm and the rise of affordable powdered glove alternatives will save the health industry between $26.6 million and $29.3 million annually.
“We need to take every measure to ensure patient well-being, complete healing and satisfaction with their surgery,” wrote Linda Gylland, QLS, MLS (ASCP), lab safety officer at Sanford Health, N.D., in an email. “I am surprised it has taken this long (since 1997 when the FDA was aware of this) to reach this decision. We have more good glove alternatives than we had 10 years ago, so in my opinion, this shouldn’t be a factor. We need to be proactive and prevent possible problems to patients with powder.”