Archive for July, 2009
Patient Safety Monitor Contest Update
We had some great entries into the Patient Safety Monitor Blog Contest this week, keep those entries coming! I’m looking forward to another week of creative submissions.
This week’s entry that I’d like to showcase is from Susan Davis, RN, QPI specialist at Betsy Johnson Regional Hospital in Dunn, NC. She described a themed safety fair the hospital hosted in 2008 called “Compliance Casino-Where Patient Safety is a Sure Bet”. Davis and her staff organized the fair as a way to test the patient safety and Joint Commission knowledge of other hospital staff members. Prior to the fair, Davis and her colleagues had had hospital employees complete an online education session about the facility’s patient safety practices. The fair was used as a way to measure how much knowledge staff members had actually retained.
Here is how Susan explained the fair:
Employees were invited to the Compliance Casino to “bet” on their knowledge regarding patient safety. Each employee was given five poker chips and they were invited to play casino-type games including black jack, roulette, billiards, and craps in order to win more chips to redeem for small prizes. The trick was that they had to answer questions about patient safety in order to play each game. If an employee answered wrong, he or she lost a chip and weren’t allowed to play the game and received education on the correct answer.
To make it more fun and really help staff members get into the spirit, Davis and her team decorated the room where the fair was held to look like a casino and the educators running the games dressed like card dealers and other casino employees. Davis said she also served snacks, which are often a staple of many patient safety-themed events.
This imaginative and fun event engaged many staff members in thinking about how to integrate patient safety into their daily jobs.
Thanks for entering, Susan, and for those of you who would like to enter, we are running this contest for the next month! I will post another sample next Friday. If you’d like to enter or have any questions, please e-mail me at hcomak@hcpro.com.
USP revises heparin standards
United States Pharmacopeial (USP) Convention released revised written and physical standards for heparin. These revisions reflect changes decided on earlier this week at the third International Heparin Workshop. Earlier this year the Food and Drug Administration requested that the USP revise its heparin standards. This request came after a year during which more than 200 people died when they were administered heparin that had been contaminated.
You can read more about the revised standards by clicking here. The standards will go into effect on October 1, 2009.
Diagnostic errors: Ownership a key problem
The National Patient Safety Foundation’s latest Focus on Patient Safety newsletter has an article about preventing diagnostic error. Though the topic is not one that gets as much attention as medical errors, diagnostic errors are a major patient safety problem and will most likely be focused on in the years to come. The article, written by Mark L. Graber, MD, chief of medical service at the Northport, NY, VA Medical Center, offers suggestions for what physicians, patients, and healthcare organizations can all do to prevent diagnostic error. For physicians, first and foremost is accepting responsibility and ownership of a diagnostic error. However, Graber brings up the valid point that often diagnosis error is spawned from some amount of system error as well, which is why it’s important to involve patients and organizations as well.
Some of his suggestions include physicians encouraging second opinions and recognizing that many diagnoses they make are based on patterns, which leave room for error. He encourages patients to ask physicians if their diagnoses could be anything else and be a part of their own care by staying on top of their own medical histories. He recommends healthcare organizations take a more active role in facilitating communication.
Read his other suggestions by clicking here and finding the most recent issue of the newsletter. The article I referred to starts on page 6.
Has your organization fostered a discussion about preventing diagnosis error? Is it something that you have not talked about?
Reducing rehospitalizations proves to be difficult and costly
Reducing rehospitalizations has become a national focus as health reform plays out. Readmissions are an easy target because they cost the nation’s health system a lot and are often preventable. The Wall Street Journal, however, reports that many facilities that focus on preventing readmissions have often run out of funding for such programs because while the strategies may work, they are not reimbursed by any major health plan or the federal government.
Additionally, hospitals are learning that preventing rehospitalization, especially for patients with specific diagnoses, is as much a matter of quality care in the hospital as it is encouraging patients to focus on healthy strategies once they have been discharged. This seemed like one of the more exasperating points in the article. Hospitals are having to take accountability for poor coordination of care services once a patient has been discharged. Many patients enjoy their (sometimes unhealthy) lifestyles and may revert back to them regardless of care systems in place.
Some of the proposals for health reform include penalizing hospitals with poor rehospitalization rates. One proposal calls out withholding reimbursement for rehospitalized patients who suffered from a heart attack, heart failure, or pneumonia. Another proposal would penalize hospitals in the top quartile for readmissions of specific conditions.
Has your facility found success with any particular programs to prevent rehospitalization? If so, have you also seen a cost savings associated with that program?
CNBC hosting healthcare roundtable tonight
I thought readers of the Patient Safety Monitor blog may be interested in a healthcare debate taking place tonight on CNBC at 9 p.m. The debate, moderated by CNBC’s Maria Bartiromo, is between both industry and government leaders. These include Jennifer Granholm, governor of Michigan; Angela Braly, CEO of Wellpoint; Steven Nissen, MD, chairman of the department of cardiovascular medicine at the Cleveland Clinic; J. James Rohack, MD, president of AMA; Michael Milken, chairman of The Milken Institute; John, Lechieiter, PhD, CEO and President of Eli Lilly; and Bill Frist, MD, Professor of Business and Medicine at Vanderbilt University, Former Majority Leader, U.S. Senator.
To find out more, you can click here. The clip below previews the debate.
Contest in honor of National Patient Safety Day
In honor of National Patient Safety Day taking place Saturday, July 25, the Patient Safety Monitor Blog is launching a month-long contest! I invite all blog readers to submit a description and any accompanying materials to me, Heather Comak, (editor of this blog) at hcomak@hcpro.com of any creative patient safety events that your facility has hosted to promote patient safety. This could be a fair, education program, or hospitalwide campaign (to name a few).
Each Friday I will choose one submission from the prior week to showcase on the blog. At the end of the month, our panel of judges from HCPro (including me) will choose the most creative and the winner will receive a free copy of The Patient Safety Officer’s Handbook, an informative book with tools to improve safety and quality published by HCPro.
Click here to see the contest rules.
I hope to see some great entries out of this contest! Thanks for participating!
National Patient Safety Day taking place Saturday, 7/25
National Patient Safety Day is being held on Saturday, July 25. This annual observance serves as a both a chance to think of those people who have been affected by a medical error and pay tribute to those healthcare workers who make it a part of their jobs to provide the best quality of care that they can. Many healthcare facilities, patients, and consumers honor the day by observing a moment of silence and 
candlelight vigil at noon and 6 p.m. Is your hospital doing anything special to commemorate the day?
In conjunction with the 9th annual National Patient Safety Day, the first annual Florence Nightingale and Dr. E. Codman Patient Safety Day Award is being given to Lucian Leape, MD, a prominent voice in the patient safety field and an adjunct professor at Harvard University. Leape was an author on the Institute of Medicine’s “To Err is Human: Building a Safer Healthcare System” and has helped found the National Patient Safety Foundation, Mass Coalition for the Prevention of Medical Errors, and many other initiatives and groups. We congratulate Dr. Leape!
Visit www.patientsafetyday.com for more information on observing the day.
Patient Safety Advisory Council can provide fresh view of issues
I saw this advice column written yesterday by Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), about how patient safety advisory councils can really open the proverbial eyes of hospitals to how processes can be improved. Patient safety advocates, have helped bring to light some important areas of focus within patient safety for the industry. Patient safety advisory councils can help hospitals get a sense of what gaps exist within their specific community. For example, the AHRQ helped fund a patient safety advisory council at Aurora Healthcare in Milwaukee, WI. The council recommended that Aurora distribute medication lists and bags to each patient as a means of helping patients know which medications they were taking. This step yielded positive results, which you can read about in the column.
The column caught my eye because it mentions CAPS, or Consumers Advancing Patient Safety. I spoke with Sue Sheridan earlier this week for an article I’m writing for an upcoming issue of Briefings on Patient Safety as well as HealthLeaders Media about the importance of letting patients have a voice in error reporting.
Has your hospital taken any steps, such as bringing together a patient safety advisory council, to better involve patients from the community?
Patient safety-related cost savings not always easy to calculate
As hospitals face deeper payment cuts from the federal government, many are considering new methods to cut costs. Indeed, many hospitals have already cut staff members and scaled back existing expansion projects. President Obama has suggested penalizing hospitals for poor rehospitalization rates—those facilities that have higher rates of patients returning for care once they have been discharged.
Unsurprisingly, patient safety officers and quality improvement managers have had to talk the business talk more often this year, often being asked to make a sound financial argument for new quality initiatives.
However, calculating savings from newly implemented quality initiatives or staying the course with sound evidence-based practice is not always easy. This article from American Medical News highlights some ways that hospitals are struggling to quantify any savings they have seen. It’s true that taking part in the important quality projects often does save costs on some end, but that money might not directly go to the bottom line. Click here to read more from American Medical News.
Have you had to “quantify” any patient safety or quality initiatives this year that you or your department has taken part in?
Public reporting of HAIs included in healtchare legislation
Debate continues surrounding the healthcare legislation that is currently being poured over by members of Congress, report the Washington Post and Wall Street Journal Health Blog. However, one part of the healthcare reform that has not been a sticking point, but is important in the world of patient safety, is the requirement of a national reporting system for healthcare-associated infections. The legislation, HR 3200, would require all hospitals and ambulatory surgery centers to report data concerning healthcare-associated infections to a database that already exists with the Centers for Disease Control and Prevention (CDC).
A group of healthcare organizations sent a letter to Congress today, urging the adoption of HR3200. These groups include The Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the Council of State and Territorial Epidemiologists (CSTE), and the Trust for America’s Health (TFAH).
The organizations hope that a national database of HAIs, run through the CDC’s National Healthcare Safety Network, would help improve transparency, as well as reduce rates of HAIs, which claim 99,000 lives annually and run up a bill of $20 billion extra healthcare dollars. The groups noted above also want HR3200 amended to include language about antimicrobial resistant organisms.
