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Today is Time Out Day for patient safety

June 14 is National Time Out Day, a Joint Commission and Association of periOperative Registered Nurses (AORN) campaign to promote patient safety before, during, and after surgery. The organizations also implore healthcare facilities to commit to conducting a safe, effective timeouts for each and every surgery.

This year’s theme calls on surgery staff to be a Time Out SUPERHERO, an acronym standing for the nine elements of a surgical timeout:

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

“National Time Out Day is a powerful tool that supports surgical nurses’ ability to speak up for safe practices in the operating room,” AORN wrote in a brief. “It provides an opportunity to educate your community about this practice and become better informed patients (read more about this in Periop Insider). Time Out also demonstrates your role in patient care and commitment to patient safety as the perioperative nurse who cares for them.”

Wrong-site, wrong-procedure and wrong-person surgeries happen every day and surgical timeouts are key to preventing adverse and never events. Everyone on the surgical team has to be fully engaged, accountable, and empowered to speak up during the timeout process to prevent never events.

The Joint Commission has a list of free tools and resources available on surgical timeouts. 

CMS issues Legionella reduction memo

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Accredited facilities should double check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys.

Legionellosis is comprised of a sometimes fatal form of pneumonia called LD as well as Pontiac fever. The bacterium grows in the parts of hospital water systems that are continually wet and is spread through inhalation of aerosolized droplets of contaminated water. Legionellosis poses a particular risk to patients older than 50, who smoke or have chronic lung or immunosuppression conditions. Approximately 9% of reported legionellosis cases are fatal.

Badly maintained water systems have been linked to the 286% increase in legionellosis between 2000-2014. There were 5,000 cases of it reported to the Centers for Disease Control and Prevention (CDC) in 2014 alone. About 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. Just a few items that can spread the contamination include:

•    Decorative fountains
•    Shower heads and hoses
•    Electronic and manual faucets
•    Hot and cold water storage tanks
•    Water heaters and filters
•    Pipes, valves, and fittings
•    Eyewash stations
•    Ice machines
•    Cooling towers
•    Medical devices (e.g., CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)

“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients,” the agency writes in its memo. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”

The memo tells surveyors to review policies, procedures, and reports documenting water management implementation results to ensure facilities:

1.    Conduct a facility risk assessment to identify where Legionella and other waterborne pathogens could grow and spread in the facility water system.

2.    Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

3.    Specify testing protocols and acceptable ranges for control measures. Document the results of testing and corrective actions taken when control limits are not maintained.

The contents of this memo go into effect immediately.

TBT: Building a better self-reporting structure

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Does your organization have a formalized process for debriefing after an adverse event? And if so, is it working? For many organizations, reporting of adverse events can be problematic, with challenges ranging from time management and inefficient processes to the age-old challenge of shame?reporting near misses and adverse events can be a challenge in an industry where everyone pursues the field to help, not hurt.

“Everyone wants to leave work happy and feel like they did a good job,” says Anngail Smith, VP of operations and risk management for CRG Medical, Inc., in Houston. “Someone once said that healthcare is the intersection of care and being able to hurt people. A client told me that healthcare is a courageous activity.”

Because healthcare rides along that fine line between safe care and risk of harm, the industry needs to build an environment where people are willing to report errors and near misses so that the industry as a whole can work on the problem without being afraid.

“I think the fear of hurting someone is always there,” says Douglas Dotan, president and CEO of CRG Medical. “The question is, are you willing to incorporate that into learning how to make your processes better?”

The pressures to report are staggering for providers, Dotan says. Personal liability, risks to reputation, job security, and even peer pressure can all come into play with the issue of reporting. But the industry needs physicians to speak up and identify hazards to patient safety, share their knowledge about near misses, and propose actions to improve the delivery of care. This requires a culture change to create an environment in which providers feel safe to talk about these things without putting themselves at risk.

“If there is something that really stresses caregivers out, we need to find a way to fix it, and we need to share that fix,” says Dotan. “That won’t happen if they’re afraid.”

This is not a new issue, Dotan points out. Donald Berwick’s Institute of Healthcare Improvement talked about these factors 15 years ago, Dotan notes, and yet most events which occur today have occurred in the past, and the latest reports state that the industry has well over 400,000 preventable deaths in healthcare every year.

“That’s about 1,000 deaths that occur every day from preventable medical errors,” says Dotan.

And the contributing factors leading up to these preventable errors occur all the time. The same situation may occur 200 or 300 times before a sentinel event occurs, leading to hundreds of thousands of dollars spent in litigation and reparations because it wasn’t prevented the first 300 times, Dotan says.

This comes down to continual process improvement, he says.

“What we’ve been working on is identifying those hazards and unsafe conditions and putting an easier way for people to communicate in place,” says Dotan. “You need to have a way of documenting and giving feedback. If I continuously give you information I think is important to act on and leadership doesn’t act on it, I will stop communicating that information. So when future problems arise, they will not be reported.”

An open communication system will help overcome the fear of reporting, Smith says.

“Are you good at your job? If you did it badly would you want to tell someone? We spend more time doing our jobs than anything else. For an inexperienced person, if they make a mistake, they might report it. ‘I am new at this; I will make mistakes,’ ” says Smith. “But if the experienced person makes a mistake, they’d think they would be embarrassed to talk about it.”

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Joint Commission issues another warning about improperly cleaned medical devices

For the second time in three years, The Joint Commission has released a Quick Safety issue on the topic of improperly sterilized or high-level disinfection (HLD) equipment and devices. The accreditor writes that despite bringing the problem to light in 2014, there’s an increase in cases of medical devices not being cleaned properly.

“Immediate threat to life (ITL) declarations related to improperly sterilized or high-level disinfected (HLD) equipment have increased significantly from 2013-2016,” wrote Lisa Waldowski, DNP, PNP, CIC, Joint Commission infection control specialist, in a blog post. “In 2016, 74% of all ITL declarations from The Joint Commission were related to improperly sterilized or HLD equipment. As reports of sterilization and HLD-related issues continue to be received by our Office of Quality and Patient Safety, our surveyors also are seeing it firsthand in hospitals, ambulatory care sites and other healthcare settings across the country.”

According to Quick Safety Issue 33, noncompliance with standard IC.02.02.01 (which deals with sterilization) has been on the rise since 2009 in Joint Commission-accredited hospitals, critical access hospitals, ambulatory centers, and office-based surgery facilities.

There are several risks tied to improper reprocessing such as infection and outbreaks, loss of accreditation, litigation, negative publicity, and lost revenue. A prime example of this occurred during the 2015-2016 outbreaks, when it was discovered that the design of the duodenoscopes could prevent them from being properly sterilized.

There are several factors that are causing this rise in noncompliance, according to The Joint Commission. These include:

•    The incorrect assumption that the risk of infection to patients is low or nonexistent
•    Staff either don’t know how to properly sterilize or HLD equipment or they knowingly chose not to follow proper procedures
•    Lack of leadership oversight and the belief that sterilization or HLD is a low priority
•    A culture that discourages the reporting of safety risks
•    No dedicated staff person to oversee the proper sterilization or HLD of equipment
•    Facility design or space issues prevent proper sterilization or HLD of equipment
•    Lack of monitoring or documentation of sterilization or HLD of equipment

“Healthcare organizations need to prioritize improving sterilization and HLD efforts year-round and well before a survey occurs to best protect patients,” says Waldowski. “Together, we can work to change news headlines from reporting on sterilization or HLD-related outbreaks to touting reductions in outbreaks through quality improvement efforts.”

First set of SAFER Matrix data is online

The Joint Commission released the first set of data collected from its new Survey Analysis for Evaluating Risk™ (SAFER™) scoring methodology this May. The SAFER matrix was first rolled out to psychiatric hospitals as part of their accreditation surveys. It has been since implemented for all Joint Commission-accredited programs.

The accreditor made a chart of the most frequently cited compliance challenges for deemed psychiatric hospitals between Aug. 1, 2016 to Feb. 17, 2017.

The Joint Commission writes that it plans to keep analyzing aggregate SAFER data going forward to:

  • Continuously improve consistency
  • Identify potential EPs for revision
  • Assist in identifying areas of high risk noted within each program

Study: ED intervention reduces suicide attempts by 30%

How much of a role can emergency departments (ED) play in preventing suicide attempts? The world’s largest study of 1,376 suicidal patients gave the answer.

By implementing interventions at the ED, hospitals were able to lower the of risk patients attempting suicide again by 20% compared to if they are treated as usual (TAU). Researchers also found that “there were no meaningful differences in risk reduction between the TAU and screening phases.”

The study, called the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE), was the largest suicide intervention trial to date, covering patients from eight EDs and seven states.

“Results indicated that the provision of universal screening, while successful in identifying more participants, did not significantly affect subsequent suicidal behavior compared with that experienced by participants in the TAU phase,” they wrote. “By contrast, those participants who received the intervention had lower rates of suicide attempts and behaviors and fewer total suicide attempts over a 52-week period.”

With around 42,000 deaths annually, suicide is the seventh leading cause of death for American men, the 14th for American women, and the 10th overall. Annually, there are 460,000 ED visits that occur following cases of self-harm and a single ED visit due to self-harm increases future suicide risk by almost sixfold, according to the study.

The study compared a control group of patients who were given TAU, a group that was just screened, and one group that was screened along with interventions.

Intervention efforts included additional suicide screening, suicide prevention info, and a personalized safety plan for dealing with future suicide ideation, and periodic telephone follow-ups. Those who got these interventions made 30% fewer total suicide attempt than others.

“We were happy that we were able to find these results,” said lead author Ivan Miller, PhD, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, in a statement. “We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging.”

Overall, 21% of those studied made at least one suicide attempt within 12 months. Those in the TAU group had a 22.9% suicide attempt rate, while in the screening group it was 21.5%. The intervention group only had a rate of 18.3%. Of all patients studied, there were five fatal suicide attempts.

Study: Single step reduces readmissions by 25%

A new study published in the Journal of the American Geriatrics Society has found that integrating informal, unpaid caregivers into the discharge process can cut readmission rates by a quarter. The study found that by using these caregivers when discharging elderly patients, they were able to reduce readmissions 25% over 90 days.  The study reviewed 4,361 patient cases and 10,715 scientific publications to come up with its results. The study found that:

•    66% of the caregivers were female
•    61% were a spouse or partner
•    35% were adult children

The study also found that informal caregivers significantly reduced time-to-readmission, rehospitalization lengths, and costs of post-discharge care.

“Due to medical advances, shorter hospital stays, and the expansion of home care technology, caregivers are taking on considerable care responsibilities for patients,” said lead author Juleen Rodakowski, OTD, MS, OTR/L, assistant professor in the Department of Occupational Therapy in the University of Pittsburgh’s School of Health and Rehabilitation Sciences, in a statement.

“This includes increasingly complex treatment, such as wound care, managing medications, and operating specialized medical equipment. With proper training and support, caregivers are more likely to be able to fulfill these responsibilities and keep their loved ones from having to return to the hospital.”

“While integrating informal caregivers into the patient discharge process may require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” said senior author A. Everette James, JD, MBA, director of the University of Pittsburgh’s Health Policy Institute, in a statement.

Caregiver statistics aggregated from the AARP, the Family Caregiver Alliance (FCA), the Institute of Medicine (IOM), and the National Alliance for Caregiving (NAC) reveal that:

•    More than 34 million unpaid caregivers provide care to someone age 18 and older who is ill or has a disability (AARP, 2008)
•    Unpaid caregivers provide an estimated 90% of the long-term care (IOM, 2008)
•    The majority (83%) are family caregivers—unpaid persons such as family members, friends, and neighbors of all ages who are providing care for a relative (FCA, 2005)
•    The typical caregiver is a 46-year-old woman with some college experience and provides more than 20 hours of care each week to her mother (NAC, 2004)

See the full article at HealthLeaders Media and read previous Accreditation Insiderarticles for more on readmissions:

Throwback Thursday: Assisting the impaired clinician

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

How to overcome barriers to recognition

By the time the general public hears about an impaired clinician, whether it’s a nurse, technician, or physician, it is often too late to head an incident involving that clinician off at the pass-whether that incident is a medical error, diversion of medication, or something even worse, like the technician recently accused of inadvertently exposing thousands of patients to hepatitis C.

But the healthcare industry is well aware that ­impaired clinicians exist, and it has methods for addressing, confronting, and helping these medical professionals. Where are the industry’s gaps to success in ­preventing this far too common occurrence? BOAQ recently sat down with Jill Pollock, RN, LMFT, administrator of Loma Linda University Behavioral Medicine Center and ­frequent lecturer on chemical dependency recognition and intervention, to discuss this topic.

It takes a case as shocking as the hepatitis C outbreak in New Hampshire to bring a topic like this to light, she says.

“I think it’s difficult for people in healthcare to wrap their heads around it,” says Pollock. “What do you think one of our biggest barriers is to recognition of addiction and confronting it? If I can get people to talk just a little bit, we start hearing how there is a fear that confronting someone’s addiction could ruin someone’s life.”

For many healthcare professionals, the thinking is backward, she says–they’re focused on saving a coworker’s career. But we have a professional responsibility to our patients, our loved ones, and the public in general.

“What happens if someone drives impaired and kills someone in a car crash? Would you worry about their professional life?” says Pollock. “Or if your facility has an outbreak of hepatitis C?”

After talking with audiences about the possible outcomes of not confronting versus trying to help the impaired professional, she has found that the best tactic is to bring in personal, relatable example scenarios. “If someone is diverting drugs, then that patient, that ­mother or father, son or daughter, husband or wife, is not getting their pain medications,” she says. “Or, ­alternately, is being cared for by an impaired nurse. I try to bring it home to something we can all relate to.”

Who would you want taking care of your loved one? Pollock asks. Would you be comfortable with a caregiver who is impaired or thinking about where to find his or her next fix?

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Proposed seven-day limit to opioid bill enters Congress

A new Senate bill would limit the amount of opioids a patient can initially receive for acute pain. If passed, physicians could only prescribe seven days’ worth of opioids when first treating a patient’s condition.

The bill was put forward by Senators John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) as a way to prevent opioid addiction. The limit is backed up by medical literature and is there are nine states with similar opioid laws in place.

“Our legislation builds on the important steps taken by Arizona Governor Doug Ducey last fall to tackle a root cause of this epidemic by limiting the supply of an initial opioid prescription for acute pain to seven days. We have a long way to go to end the scourge of drugs across our communities, but this legislation is an important step forward in preventing people from getting hooked on these deadly drugs,” said McCain in a press release.

“Too many lives have been destroyed, too many families have been torn apart, and too many communities all over New York are suffering because of this tragic epidemic. I am proud to join with Senator McCain in this urgent fight against the overprescription of opioids, and I look forward to seeing it pass through the Senate as quickly as possible,” said Gillibrand in a press release.

ECRI Introduces HIT-based Patient Identification Tools

The toolkit aims to prevent patient misidentification through the use of health information technology.

Patient misidentification is a big and likely underreported problem for hospitals and health systems, as well as for patients.

The consequences can be significant. ECRI Institute research shows that 9% of patient misidentification events lead to temporary or permanent harm or death.

That’s why the ECRI Institute and a stakeholder collaborative it convened, the Partnership for Health IT Patient Safety, has launched a new patient identification resource to help prevent patient misidentification through the use of health information technology.

ECRI is a Pennsylvania-based nonprofit that works to improve the safety, quality, and cost-effectiveness of patient care.

The toolkit divides its recommendations into two sections:

  1. Attributes addresses “the information-gathering aspects of patient identification, including the fields and the formats that are available to accommodate acquisition of required information.”
  2. Technology addresses “new technologies to improve identification and ways to leverage existing technologies for safe patient identification.”

Continue reading at HealthLeaders Media.