Professional radiation organization calls for new safety protocols

The American Society for Radiation Oncology (ASTRO) has issued a six point plan for improving quality and patient safety, as well as reducing medical errors, reports the New York Times. This comes after the paper published two articles recently about the potential for radiation therapy-related errors due to the complicated technology necessary for administering the treatment, and the role of human error. You can read my original blog post about this article here.

Although radiation errors are rare, the damage that results when they do occur can be extremely serious and sometimes deadly. ASTRO has called for the creation of a database to report errors in conjunction with linear accelerators and CT scanners. This would be a large step for the field because there doesn’t currently exist a system for tracking radiation therapy-related errors. Also, the group will work to ensure that medical technology manufacturers create radiation therapy machines that can easily transfer patient data to one another.

To read more about ASTRO’s call for more safety measures in the New York Times, click here.

Friday is a good day to watch Atul Gawande on The Daily Show

Atul Gawande, MD, MPH, has been making the rounds lately promoting his book, The Checklist Manifesto. You may already be familiar with Gawande as a surgeon at Brigham and Women’s Hospital in Boston, a Harvard University professor, the head of the WHO’s Safe Surgery Saves Lives program, and an occasional writer for The New Yorker.  He’s a busy guy.

He made time for speaking with Jon Stewart on The Daily Show this week, though, to talk about his book and why checklists are such a useful thing in healthcare. He also spent some time spelling out why such common sense, simple methods of ensuring patient safety are difficult thing to push on some members of the medical community.

Here’s the clip, hope you enjoy.

Middle managers: One important piece of the patient safety puzzle

I was perusing the IHI’s Web site this morning and came across a paper written by Frank Federico, RPh, executive director, strategic partners for the IHI, and Doug Bonacum, CSP, CPHRM, vice president, safety management for the IHI, about the importance of middle managers in patient safety. Middle managers are leaders in their own right and must be able to ensure the goals of the facility at large are also the goals of their specific units. In addition, middle managers are the ones who get staff members “fired up” to take part in initiatives and lead by example.

The paper says that thus far, healthcare has done a lousy job of preparing middle managers to take on the responsibilities required of them. However, there are actions that senior leaders can take to help their middle managers acquire some of the skills. These include:

• leading an improvement project with a mentor’s help
• attending a national conference on quality improvement
• leading a workshop on quality improvement for other staff members

The full paper can be found here. Check it out if you’d like some tips on how to better prepare your middle managers to make patients safer. Do you find that middle management in patient safety is a gray area at your facility? Are there defined roles and training programs?

GAO says not enough information yet about PSO system to assess progress

The Government Accountability Office (GAO) was required by the Patient Safety and Quality Improvement Act of 2005 to assess the effectiveness of the law by February 1, 2010. In its report released on January 29, the GAO found that although the Agency for Healthcare Research and Quality (AHRQ), under the direction of the Department of Health and Human Service (HHS), has taken action to carry out the intent of the Patient Safety Act. However, because much of the action took place within the last year (final regulations became effective on January 19, 2009), the GAO is unable to evaluate at this time if the intent of the Patient Safety Act is being carried out.

The Patient Safety Act required a few things:

• The establishment of Patient Safety Organizations (PSO) to work with hospitals in collecting patient safety data
• A set of “common formats” in which data should be collected
• The creation of a Network of Patient Safety Databases (NPSD), to which PSOs would submit de-identified patient safety data. The data would eventually be analyzed and used to improve nationwide patient safety practices.

After consulting with administrators at the AHRQ, HHS, and 17 out of the 65 registered PSOs, the GAO found that although solid groundwork has been laid for carrying out the intent of the law, it is too early to tell if the law is being effective, as many of the requirements are in the midst of being completed. However, the GAO cautions, because it is voluntary for hospitals to contract with a PSO in the first place, the full value of the law may never be realized even when all of the work of listing PSOs, establishing the NPSD, and analyzing data is finished.

You can find the full report from the GAO here.

I’m curious about what you make of this report. It was required by law to be undertaken, but it seems to me like it would have been more logical to assess that there’s not been enough action taken yet to fully report on the effectiveness of the Patient Safety Act, and to shelve the report for a year or two. That being said, one of the striking things that did come out of the report seems to be the overall lack of hospital engagement with existing PSOs. Of the PSOs interviewed, only three had already collected data from contracted hospitals. What’s more, only four PSOs reported having contracts to work with hospitals to collect data for the NPSD.

Has your hospital elected to work with a PSO? Do you know why or why not?

Enter to win a free registration for AHAP 2010 conference

One of my sister blogs at HCPro, the Association for Healthcare Accreditation Professionals Blog, is running a contest between now and the end of April to give away free registrations to the 4th Annual AHAP Conference on May 6 and 7, 2010. The AHAP conference is theannual event for those who work in healthcare accreditation. Many attendees leave the conference armed with new ideas and plans of action to help them address their most pressing issues.

To find out more about the contest and how to enter, click here to see the AHAP Blog post.

California penalizes 13 hospitals for putting health and safety of patients in ‘immediate jeopardy’

The California Department of Public Health (CDPH) has fined 13 hospitals for placing the health and safety of patients in immediate jeopardy on 16 occasions in 2008 and 2009. The facilities were fined because their noncompliance with state regulations “has caused, or was likely to cause, serious injury or death to patients,” according to a news release.

California changed its law on January 1, 2007, to allow for monetary fines for these types of incidents, which was $25,000 per incident through 2008. Starting on January 1, 2009, that amount rose to $50,000 for the first incident, $75,000 for the second, and $100,000 for the third and any subsequent incidents at the same facility. Most of the fines announced today are from 2009. The CDPH did not announce them until now because there is a review process that each incident must go through.

To find a complete list of the incidents for which facilities were fined, click here to find a story from HealthLeaders Media.

What do you think about these state charges for adverse events? Since the fines were imposed, the state has assessed $3.675 million in fines, which according to the CDPH, will be used to prevent the events from occurring in the future.

NQF considers change of ’serious reportable event’ definition

The National Quality Forum (NQF) is mulling a change of the definition of “serious reportable event” (SRE) and although the change is only involves one word, that word could truly effect the intent of the term. Currently the definition is:

preventable, serious, and unambiguous adverse events that should never occur.

The proposed change would replace the word “never” to “not” so the new definition would read:

preventable, serious, and unambiguous adverse events that should not occur.

The NQF’s steering committee on the topic has developed a rationale for this proposed change, and has solicited public comment through today on the topic. The rationale contains many reasons (which you can find by clicking here and scrolling to the “Comment on the revised SRE definition” section of the page, and then clicking on “draft definitions”) but they mostly all boil down to the idea that proclaiming that an event should “never” occur, and categorizing it as such, may be unrealistic in the healthcare setting. Additionally, if an event is considered something that should never occur, there should be a viable solution available, which may not always the case either. The committee is hoping that by dropping the “never” from the definition, more harmful events could be included into what is reported by hospitals, leading to further quality improvement.

Anyway, if you want to share your opinion with the NQF steering committee, click here.  Judging from the already submitted comments, there are many people out there who are against dropping the “never” from the definition of SRE because it will not convey the seriousness of the events included in the list.

What do you think?

Joint Commission issues latest Sentinel Event Alert on preventing maternal death

The Joint Commission issued its latest sentinel event alert on Tuesday about preventing maternal death. This alert is the first of 2010 and the 44th since The Joint Commission began issuing them in 1998. The alert highlights maternal death in the U.S. as a serious problem to which hospitals and caregivers should be paying more attention, although it is rare. Unfortunately, there seems to be few standard practices that these parties can take to prevent maternal death simply because the reasons that pregnant women may die are numerous and related to differing conditions of the patient. Maternal death is defined as death that occurs within 42 days of birth or termination of pregnancy.

The National Center for Health Statistics of the Centers for Disease Control and Prevention said that 13.3 mothers died per 100,000 live births in 2006. This number represents an increase when compared with rates of maternal death in earlier years. Although the increase may be due to more widespread reporting of maternal death, the issue is not one that is improving, according to the alert.

One of the reasons that researchers speculate the number of maternal deaths is climbing is the growing number of obese women who become pregnant. Obesity brings with it a host of related health issues, which could factor into the maternal death rate.

The Joint Commission recommends that hospitals comply with PC.02.01.19, which is where the 2009 National Patient Safety Goal requiring that hospital staff recognize and respond to changes in patient’s conditions was moved to for 2010. In addition, the alert provides the following specific actions:

• Educate caregivers to inform their female patients with underlying medical conditions such as high blood pressure, diabetes or morbid obesity, that if they become pregnant, they are putting their bodies at even greater risk. Additionally, offer them contraception and where to find preconceptual counseling.
• Identify specific protocols for how to handle changes in a pregnant woman’s vital signs, specifically for conditions such as hemorrhage and pre-eclampsia.
• Ensure that ED staff are aware that any woman who is admitted may be pregnant, whether she says so, appears so, or not. If staff are aware a woman is pregnant, they may prescribe different care.
• Refer those pregnant woman who have high risk conditions to experienced prenatal care providers
• Ensure pneumatic compression devices are available for women undergoing a Cesarean section and are at risk for a pulmonary embolism. Pregnancy is in itself a risk factor for pulmonary embolism and venous thromboembolism.
• Evaluate patients at risk for thromboembolism for the use of low molecular weight heparin for care after delivery

Do you think this SEA is one that your hospital will pay attention to?

New York Times article exposes radiation therapy errors

In a horrifying and emotional account, the New York Times explored the topic of radiation therapy errors in a recent article, one which I would recommend when you have 10 or 15 minutes to sit down and read. Although radiation therapy errors are severely underreported, the New York Times reviewed cases from New York State, which is one of the most progressive states when it comes to reporting this type of error. Between 2001 and 2008, 621 radiotherapy mistakes were reported or recorded, many of which were minor. However, those that were not proved to be deadly and painful for the recipients along the way.

At the heart of the two major errors described in the story is technology failure, combined with human failure. Radiation therapy is delivered to cancer patients via complex technological equipment which in turn must be worked by well-trained medical physicists. If both components (the technology and the staff) are not doing their jobs as they should be, an error can occur. The harrowing accounts of two patients involve repeated error–equipment not functioning correctly and staff not catching the error for many days in a row.

Although the story is about radiation therapy, and not surgery, I couldn’t help but think about the Universal Protocol (UP) throughout reading it. If the surgical team is supposed to do a last minute time out to ensure that the correct patient is about to recieve the correct procedure to the correct area of the body, why are there not similar protocols in place for something like radiation therapy? Perhaps because these errors are less reported, there is less known about how to prevent them? Perhaps there are and this story did not bring them to light? Perhaps there are but (as with the UP sometimes) technologists ignore some steps?

Anyway, be sure to check out the article yourself. As a patient safety professional you may be interested to see it highlight many aspects of an error that can be found in much more minor errors (communication failures, human factors, software malfunction), perhaps something you experience during your more often than extreme radiation errors.

Nurses should have more influence on healthcare, survey says

A new Gallup poll done on behalf of the Robert Woods Johnson Foundation (RWJF) has found that opinion leaders on the nursing profession think that nurses should have a greater influence on healthcare as a whole. The survey asked the thoughts of more than 1,500 nursing industry, insurance, corporate, health services, and government workers, as well as university faculty, their thoughts on the topic. Overwhelmingly they said that nurses should be exerting more power over healthcare, but are often not given the opportunity.

Some of the areas that nurses should have more influence over, according to the poll include

• reducing medical error
• increasing the quality of care
• promoting wellness
• improving efficiency
• reducing costs

Additionally, those polled thought nurses should have more say over health policy and health reform, but only 14% of those polled think nurses actually will have influence.

One of the more striking points that came out of the survey includes the top barriers identified to why nurses are not being given the chance to influence healthcare is they are not perceived as important decision makers or revenue generators. To me, this perception seems backwards–take nurses out of the equation at a hospital and who would be there to care for patients on a daily basis? When providing care for patients is the business, decision making is inherently part of the process, and revenue streams from that business.

You can check out the full survey by clicking here.