RSSAuthor Archive for Michelle Clarke

Michelle Clarke is the Managing Editor for Nursing at HCPro.

Patient Safety Movement Announces Progress Toward Goal, Change in Leadership

By Jay Kumar

This first appeared on PSQH on January 18, 2019.

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?”

Eight new anticoagulant EPs added to NPSG

By Accreditation Insider

The Joint Commission 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). The accreditor wrote that the changes are a response to a rise in adverse drug events tied to direct oral anticoagulants.

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

The update comes nine days after The Joint Commission released updates to its suicide prevention NPSG. Those changes will also go into effect in July.

The update requires impacted facilities to:

  • Have evidence-based protocols for starting, continuing, and reversing anticoagulant treatment
  • Establish processes for responding to adverse drug events and bleeding
  • Educate patients on anticoagulant treatment
  • Use devices desinged to reduce dosing errors, such as programmable pumps and pre-filled syringes

Before the Plane Crash

In January 2009, all eyes were focused on the Hudson River after a plane flying out of New York’s LaGuardia Airport struck a flock of geese and crash landed in the river. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries, in the disaster dubbed “the Miracle on the Hudson.” However, trouble emerged in the aftermath when people tried to find out which hospital their loved ones had been sent to.

“Some of the patients went to New York and some went to New Jersey. And because of HIPAA laws, it was very difficult for airline authorities to get the names of who was where,” says Sharon Carlson, RN, director of Emergency Preparedness at Sharp HealthCare in San Diego, CA. “As a family member you can imagine your terror knowing that your loved one was in a plane crash and not knowing where they are. That’s a big issue we always have, reunifying people after a disaster.”

“Because of [the Miracle on the Hudson] we decided in San Diego that we needed to make relationships before an event happens,” she adds. “Get to know each other, work together, know each other by first name, know each other’s number.”

Using the lessons learned from the Hudson, Carlson and her health system joined a disaster partnership with their local airport, San Diego International (SAN.) The airport has been growing steadily over the past decade, with over 22 million people flying in and out of it in 2017. The airport partnership was started originally in 2010 by UC San Diego Health system.

The transportation administration requires SAN to conduct major disaster drills periodically. As part of the partnership, Sharp Healthcare is included in those drills, Carlson says. They practice their communication process once a year to ensure everybody is on the same page and that there’s been no changes in the contact information.

“We have a partnership with the airports, so they know who to contact at our hospitals,” she says. “And we’ve sent it through our compliance and legal departments, they know what kind of information we can give them.”

In the event of a plane crash or disaster, airport staff have a list of hospital contacts so they can reach out, then read names off the plane’s manifest and the hospital will be able to tell them which people on the list are there or not.

“We don’t give out conditions, injuries, or illnesses,” she says. “We just say if they’re here or not. Because the airline is wanting to tell the family members ‘ok, go over here, your loved one is at this hospital.’”

HFAP Ligature Standard Remain Same After CMS Memo

This first appeared August 23, 2018 in Hospital Safety Insider.

HFAP, one of the oldest accrediting organizations for U.S. hospitals, recently updated 13 of its standards to align with the expectations on ligature risk and other hazards that CMS outlined in a memo in December. The standards have been approved by CMS, but will not be revised again in light of the July memo, says Alise Howlett, AIA, CFPE, CHFM, HFAP’s emergency management, physical environment, and life safety standards advisor.

The July CMS memo states that surveyors would use Joint Commission ligature recommendations. Howlett says that the additional guidance is simply that, additional guidance.

The updated HFAP standards range from staff training on identifying patients for risk of self-harm to building safety policies and monitoring, from building security to life safety compliance, from privacy and safety concerns in a safe setting to requirements for environmental risk assessments.

“The HFAP standards have been approved by CMS and simply outline updates for accreditation expectations. They will be enforced per the direction of CMS which stated that AOs will use their judgment as to the identification of ligature and safety risks, what level of citation will be made for deficiencies, and the corrective action to be taken for mitigation and remedy. This is all outlined in QSO 18-21,” says Howlett.

HFAP was not part of The Joint Commission’s panel of experts, but “all accrediting organizations with deeming authority are working from the same playbook: the CMS regulations,” says Howlett.

IHI Launches Maternal Care Improvement Project

This first appeared August 22, 2018 on PSQH.

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

Become an HCPro Author

Last summer, we asked you to join our Nursing Book Review Group and the response was overwhelming. We are thrilled with how many of you were eager to share your thoughts and ideas for a variety of our nursing products.

We are looking for enthusiastic nurse managers, nurse leaders, and nurse educators who are willing to become authors and share their experiences, success stories, and lessons learned with fellow colleagues.

We’re currently looking for authors for an upcoming critical thinking text as well as an upcoming nursing program orientation text. If this is something you’re interested in, please email me at mclarke@hcpro.com. You don’t have to be an experienced author, we’ll provide you with the tools and guidance needed.

If you have an idea for a different book than the topics already mentioned, please email us. We’re always looking for new topics that will help you do your jobs better.

Note: If you didn’t have a chance to join our Nursing Book Review Group last year, keep an eye on this spot for an upcoming announcement about the group.

We look forward to hearing from you!