Archive for February, 2010

Could reprocessed medical equipment be environmentally friendly and keep patients safe?

Healthcare as an industry is looking for ways it can reduce its carbon footprint, being one of the largest environmental offenders.  One of the ways it is increasingly doing so is by reprocessing medical equipment, which can also save hospitals money. In a recent Academic Medicine journal article, researchers from Johns Hopkins examine the practice to see how safe doing so is. Already 25% of hospitals in the U.S. are reprocessing medical equipment, but apparently the adoption rate has slowed in the past five years because of misconceptions of how reprocessing works and its effect on patient safety.

There are three classifications of medical devices that can be reprocessed, according to the article. Most hospitals have no qualms about using reprocessed devices in the first tier, as they are the least hazardous (elastic bandages, general use surgical scissors) and have no premarket notification requirements. The next tier is a  more of a medium hazard, and they must show proof that they are equal to any devices already in the market. These might include ultrasound catheters, compression sleeves, and others. The third tier is a higher risk and most hospitals won’t use reprocessed devices from this tier because of the risks associated. These must prove that they are effective through data, and also show they are equal to devices in the market. Examples would include implanted infusion pumps and others.

With the recession hitting last year, some facilities turned to reprocessed equipment because it can cost up to 50% less than new devices. However, patient safety concerns remain as a barrier. The authors of the article said described these concerns as “the possible malfunction of devices, the risk of infectious diseases, and the ethical dilemma about reprocessing presents given the absence of patient consent to use of such devices as part of treatment.” The government, they say, has gone to lengths to ensure that the use of reprocessed devices are safe through oversight and regulation.

The authors contend that using reprocessed devices are safe, and doing so is a great way to also cut down on healthcare’s environmental impact. What are your thoughts?

Announcing a new Patient Safety Monitor Blog contest!

Our contest last summer was such at hit that we’ve decided to launch a new contest in honor of the upcoming Patient Safety Awareness Week, which takes place from March 7-13. The contest is simple: Send in examples (this can be stories or written accounts, tools/forms, policies/procedures, etc.) of how your hospital is complying with the 2010 National Patient Safety Goals (NPSG).  Have you run any events this year to teach staff about the 2010 NPSGs? Are you planning anything special in honor of Patient Safety Awareness Week?

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. I will post some of the entries a few times a week to showcase what has been sent in. After Patient Safety Awareness Week has passed, a panel of judges here at HCPro will choose which entry piqued their curiosity most and also trains staff best about the 2010 NPSGs. The winner will receive a free copy of The 2010  National Patient Safety Goals Calculator which helps users track NPSG compliance.

Please see the contest rules for full details.

Boston patient dies after heart monitor alarm is turned off

The Boston Globe had a weekend story about a patient’s death at Massachusetts General Hospital. The patient died after the alarm on his or her heart monitor was inadvertently switched off, which caused the nurses to discover too late that he or she was in distress. The nurse discovered the patient was in distress during normal rounding. This type of adverse event is one that happens all too often and is reported to The Joint Commission, as well as ECRI Institute.

Hospital administrators say they don’t believe that the alarm was turned off because it was too annoying . Instead, it was most likely a mistake. Right now the focus is on making sure that a similar mistake does not happen. To that effect, the hospital has implemented a new plan for keeping up with alarms, which involves ensuring that one nurse at every central nursing station is in charge of keeping up with alarms. Also, when the error was discovered, the hospital checked the rest of its 1,100 heart monitor alarms to ensure they were all fully functioning.

One major issue that has come up in the past in hospitals across the country is that some patients are hooked up to numerous alarms, and caregivers become desensitized to the “alarm overload.” Additionally, noisy hospitals are not conducive to such alarms actually acting as an alarm.

However, there are those in the patient safety community who are angry that a medical device that is supposed to alarm caregivers that something is going wrong has the option to be silenced.  This is a good example of device makers not being on-par with the needs of the users.

The issue is not a new one, but I recommend reading the article to remind yourself of how easily a mistake like this can occur.

Fat COWs ‘grazing’ in hall lead to BCMA workarounds

I had an interview with Ross Koppel, PhD, professor of sociology at the University of Pennsylvania last week about human factors engineering and its relation to patient safety. Koppel is also the principal investigator on the study of the hospital as a workplace and medication errors at the Center for Clinical Epidemiology and Biostatistics, School of Medicine at UPenn. We specifically talked about a study he was involved in that was published in the Journal of the American Medical Informatics Association in 2008 about workarounds used in conjunction with barcoded mediation administration systems (BCMA) and how they may affect patient safety.

He was a pleasure to talk to and explained the results of the study very clearly. He and his team found that clinicians used workarounds with BCMAs for 4.2% of patients, accounting for 10.3 % of medications administered. The reasons are numerous and all legitimate. But there is one reason that stuck out in my mind, simply because of the picture it left in my mind:

Fat COWs grazing in the hallway.

Of course COWs are not the kind that go ‘moo’ but are Computers on Wheels, COWs for short. One of the problems that Koppel and his team found was that some medication errors occurred because the COWs were too large to enter the patient’s room or is “tethered” to an electrical outlet, and therefore the nurse responsible for scanning the medication to administer to the right patient did so outside of the patient’s room. When the alarm went off notifying the nurse that the scanned patient ID was incorrect, he or she was already in the room administering the medications to the patient.

“That’s the reality and solving that problem is probably a $12 fix of getting a thinner COW, but only if you do the kind of observational work that I and my colleagues did are you going to figure that out,” said Koppel.

This was just one of the many examples of workarounds that Koppel and his team found, but it illustrates the need to apply human factors engineering to new patient safety projects, especially those that have to do with HIT. In the coming years this will be of the utmost importance. EMR implementation has the potential to really help hospitals unravel many communication issues. It also has the potential to make those issues even more complicated. By taking human factors engineering into account, vendors and clinicians can hopefully accomplish the former.

Field review of revised medication reconciliation NPSG postponed

Field review of National Patient Safety Goal (NPSG) 8, regarding medication reconciliation, has been postponed to later in the year. Originally planned for February, the field review has been moved so that the Joint Commission advisory and board committees can review a draft of the revised Goal.

We originally reported last February on the Patient Safety Monitor Blog that the Joint Commission had decided to make the med rec Goal one with which hospitals had to comply, but about which they would not be surveyed. The 2010 NPSGs contain language about medication reconciliation, but the field has widely expected an announcement about what will become of the Goal. The Joint Commission has not announced when it will release the 2011 NPSGs and if they will contain any other changes (in addition to those made to the med rec goal).

How has your facility been handling medication reconciliation since The Joint Commission backed off surveying the Goal’s requirements?

You can find The Joint Commission’s announcement about postponing field review here.

Preventing HAIs through plasma (It’s not a sci-fi thriller)

The New York Times published an article on Saturday about a new technique and device that hospitals may soon be using to prevent infections. The small box uses plasma to disinfect staff members’ hands. Plasma, the same stuff found in televisions and neon signs, can clean hands in four seconds (which is a lot less time than the traditional thirty seconds to minute of required scrubbing ). Not only does it disinfect, which is ultra important for facilities worried about the preventing healthcare-acquired infections, but it gets rid of fungi and viruses.

Plasma is already in use as a disinfectant for medical devices. However, use on body parts has been unheard of until now, namely because the voltage necessary to make plasma is not also conducive to hands or feet. However, the engineers behind this new device have designed it in a way that would make it impossible for people to accidentally touch the high voltage areas.

Looks like a new, interesting foray into the infection control market to me! Check the article out for yourself here.

Almost half of nurses plan career change. Anyone surprised?

Nearly 1,400 nurses recently completed an AMN Healthcare survey about job satisfaction and career plans and the results show that 44% plan a career change within the next three years and 29% want to get out of nursing altogether. AMN describes itself as the largest healthcare staffing firm in the U.S. and its survey does provide a closer look into the general mood/temperature of nurses as a whole. An overwhelming majority of those who took the survey were older than 40, and 31% were older than 55. The same trends followed for experience: 54% of respondents had been working as a nurse for more than 20 years. Other results include:

• 28% of nurses agree with the statement, “I will not be working in this job a year from now.”
• 46% of nurses agree with the statement “I worry this job is affecting my health.”
• The majority of nurses (55%) believe that the quality of care that nurses provide today has declined compared to when they started in nursing.
• More than one-third of nurses (36%) said they either would not recommend nursing as a career to young people or were not sure that they would.

You can see more in this HealthLeaders Media article (a good summary).

These results are not shocking to me. Are they surprising to you? Although it is important to conduct these surveys to accurately measure how nurses feel about their own profession, it seems like each year the results stay the same.

From a quality/patient safety angle, the most disturbing statistic to me is the one that says nurses think the quality of care has declined. Most nurses would likely say they decided to enter the profession because they wanted to improve the lives of patients. How does the healthcare industry expect to hold onto nurses if they perceive that their efforts are not actually improving quality of care?

QUEST, now in second year, aims to improve healthcare

Although healthcare reform seems to have hit a standstill, there are many quality improvement initiatives out there that continue to work for better patient outcomes. The QUEST program (Quality, Efficiency, Safety, and Transparency), a joint venture between Premier and the Institute for Healthcare Improvement, is helping those hospitals involved collect and compare quality data. My college Philip Betbeze at HealthLeaders Media wrote this column last week about how QUEST has helped those facilities involved dramatically lower costs. The goals of the program are:

• Save lives: Eliminate avoidable hospital mortalities
• Safely reduce the cost of care: Reduce the costs for each patient’s hospitalization
• Deliver the most reliable and effective care: Ensure that patients receive every recommended evidence-based care measure
• Improve patient safety (year two measure): Prevent incidents of harm in more than 30 categories, including healthcare-acquired infections and birth injuries
• Increase satisfaction (year two measure): Improve the patient’s overall care experience and loyalty to the care providing facility

After the first year savings are estimated at$800 million and 8,000 lives. That is a pretty staggering amount of savings. Is your hospital a QUEST hospital? If so, have you noticed a change in how you deliver care?

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.