Archive for January, 2010

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.

TN hospital will no longer hire smokers

In a decision that could open up the potential for discrimination lawsuits, Memorial Hospital in Chattanooga, TN, will no longer hire employees who smoke, reports The Chattanooga Pulse. Prior to being hired employees undergo a drug screen and the facility will be adding nicotine to the list of drugs that the screen looks for. Even nicotine coming from a patch or gum would be detected in the screening.

The hospital says that it has made this decision because as a healthcare entity it should be promoting good health, which smoking does not exemplify. From a patient safety perspective, yes, this decision is probably a good one. But I wonder how much heat the hospital will take for this decision, unrelated to the health consequences, because of  what it says about hiring practices.

Check out the full article by clicking here.

Patient safety group asks Congress to include device identification system in health reform bill

Members of the Advancing Patient Safety Coalition (APSC) wrote a letter to Congressional leaders yesterday requesting they leave language in the final health reform bill that calls for the creation of a unique device identification (UDI) system. The language was included originally in the version passed by the House, and was actually part of the FDA Amendment Act of 2007, although no deadline was specified with that bill.

The APSC is urging the inclusion of UDI system in the health reform bill because there is currently no standardized way of tracking and recalling medical devices. As it says in the letter, We can simply and quickly identify each and every jar of peanut butter that might have salmonella and remove them from store shelves in hours but we cannot do that reliably today with potentially life threatening defective medical devices.

Members of APSC are hoping that a UDI system will help reduce adverse events by making it easier to recall specific devices. In 2008, more than 700 devices were recalled and since there is no current method of UDI, facilities are left on their own for saying on top of and managing recalls or updates.

You can read the full letter here. Do you think this issue is important enough to be included in the final health reform bill?

The economy may be weakening medication safety, patient safety

A survey undertaken by the Institute for Safe Medication Practices last fall has shown that the economic downturn has forced staff cuts, reduced the amount of technology and equipment that hospitals can purchase, and negatively affected the culture of safety by reducing the amount of time staff members have to report errors. Nearly 850 people took the survey and of those, 41% said the economy had a large to moderate negative impact on medication safety in particular.

Some specific findings concerning medication safety include:

• Forty-two percent of respondents said the staff person who dedicates time to medication safety (either a medication safety officer or quality improvement specialist) has had hours cut or his or her position completely eliminated.
• Less attention is being paid to the purchasing of safe medication equipment, such as using multi-use vials instead of single-use.
• Caregivers are more apt to rush drug administration practices as well as have less time to educate patients about their medications.
• Pharmacists are less likely to have a clinical presence on patients’ units.

To read more about the survey, click here.

Have you found that the economic downturn has negatively affected your patient safety practices?

Minnesota reports zero deaths from patient falls in 2009

Minnesota has been collecting data around and publicly reporting adverse events in hospitals for the past six years. However, 2009 was the first year that officials could say that there were no deaths resulting from patient falls, normally one of the most common adverse events, reports the St. Paul Pioneer Press. The state’s Department of Health released yesterday its sixth annual public report called Adverse Health Events in Minnesota. During the previous year there were ten deaths resulting from patient falls. The state launched a campaign called “Safe from Falls” in 2007 that aimed to bring attention to why patient falls were occurring and implementing best practices to prevent them. It’s because of this (which continued running in 2009) and other techniques that individual hospitals employed that the falls rate dropped to 76 reported events, a decline of 20%. Additionally, falls did not become a reportable adverse event in Minnesota until 2007.

Although this milestone is one to be celebrated, state officials told the Pioneer Press that they were not losing sight of the fact that there were still four patient deaths resulting from adverse events, and many other instances of harm. In total, hospitals reported 301 adverse events between October 2008 and October 2009 (the period of time during which data are collected). This number represented a decline of 3.5% from the prior year.

Pressure ulcers remained the top most reported event. Officials said that for the first time they noticed pressure ulcers were a bigger problem for surgical patients, who perhaps have not had all of the precautions for skin breakdown provided. Additionally, the number of wrong-site, -patient, or-procedure surgeries increased, from 39 to 44. This is most likely because hospitals are doing a better job of recording when they occur during minor procedures, reports the Pioneer Press.

Check out the article here. Does your state publish as thorough a report as Minnesota about adverse events? Do you wish you state was as vigilant about collecting this type of data at all?

Aviation techniques prove to have positive effect on patient safety

Crew Resource Management is not a new topic in healthcare–that is the idea that healthcare as an industry can learn a lot from the aviation industry and many of the concepts used in managing an airplane crew and flight can be used in healthcare to improve patient outcomes. One new study, however, has provided the data to back up this notion, reports American Medical News.

The research, published in the December Archives of Surgery, followed caregivers who had taken a course titled “Lessons from the Cockpit,” which attempts to relate errors in aviation with medical errors and teach how to avoid them. After studying 857 participants of the six-hour course since 2003, researchers concluded that teaching healthcare workers the principles of crew resource management has a positive effect not only on patient care, but on workers’ perception of the culture of safety and self-empowerment.

Some of the most striking results include the use of preoperative checklists (75 % of participants were using them in 2003, and by 2007 100% of participants were using them). Self-initiatied incident reports rose from 709 in the first quarter of 2002 to 1,481 in the first quarter of 2008. However, those involved in the study did conclude that these effects may take years to achieve.

You can read more by checking out the American Medical News article. Although this isn’t really a new idea, I wonder if some larger healthcare systems would take seriously the idea of training all of their staff member in crew resource management.