Archive for January, 2012
Bloodstream infections in pediatric ICUs
A Consumers Report study has found that many pediatric ICUs have high rates of bloodstream infections, often higher than adult ICUs—on average, 20% higher.
As you may recall, Josie King, whose unfortunate story has been made famous by her mother who now advocates for better patient safety, had complications after a central-line bloodstream infection.
Hospitals may want to look at the strategy of 2010 Baldrige-award winner Children’s Hospital at Providence in Anchorage, AK. Children’s cut catheter-related bloodstream infections in the neonatal ICU. Though they didn’t focus on central lines, the strategies might be of interest. They resisted the typical “see one, do one, teach one” method and instead implementing standard teaching methods. The hospital also ensured peace and quiet upon insertion by moving the patient into a quiet room during the procedure. Read more about this in Patient Safety Monitor Journal.
Still, there’s a problem a bit more concerning than the infections: a lot of pediatric ICUs aren’t reporting the data publicly, according to the report::
Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.
The investigation was left to focus on the 92 pediatric intensive-care units in 31 states plus Washington, D.C. that did report rates.
What can be done? What’s missing? Why aren’t we reporting rates? How can hospitals emulate others that have low rates if we can’t identify which ones they are?
Providence-based play tackles medical errors
Providence has dealt with its share of medical errors. Perhaps as a result, the issue is moving outside the health system and into artistic realm in the form of Love Alone, presented by the Trinity Reparatory Company.
Written by Deborah Salem Smith, whose partner is a physician, the play dives into the emotional turmoil of what happens after patient Susan dies on the operating table. The emotions of both family and physician are explored, along with the disconnect between hospital protocol toward the shocked and grieving family.
In a short audio recording of a pivotal scene from the play, the physician assures Susan’s daughter that she is a competent doctor:
“I’m not a monster. I was doing everything I could to save her. I’m a good doctor. Look at me, please. I’m a good doctor.”
“So what?”
“So what?”
“You’re a good doctor. I’m a good daughter.”
Medical-based dramas have always been popular, but is this a bringing things a step further? Do you think medical errors are being brought to the forefront of the general public would perhaps have a positive effect on hospitals, especially in regards to diminishing a punitive culture?
Share your thoughts below.
Understanding HIT nationally and on the local front lines
Editor’s note: Columnist Catherine Hinz, MHA, works at PatientSafe Solutions, Inc. Previously, she served as the patient lead at HealthEast Care System in St. Paul, MN, worked for seven years as an ED health unit coordinator, and has completed a patient safety internship with the Agency for Healthcare Research and Quality. The following is an excerpt from the January 2011 issue of Patient Safety Monitor Journal.
In the past couple of months, there have been numerous publications around health information technology (HIT) and patient safety. In November 2011, the Institute of Medicine (IOM) released its report, Health IT and Patient Safety: Building Safer Systems for Better Care. Right on its heels, the ECRI Institute released its top 10 list of technologies1 posing hazards to healthcare delivery. The list exposed dangerous medical devices and other technology systems. It was inclusive of everything from surgical fires to radiation therapy exposure risks. Through these reports and a variety of other publications in recent months, one of the primary take-home messages is clear: It is exceedingly difficult to prioritize where attention should be focused given the breadth and scope of HIT and its potential effects on patient safety and care delivery.
The work of the IOM was particularly interesting as its charge was threefold: summarize the existing knowledge of the effects of HIT on patient safety, make recommendations to the Department of Health and Human Services regarding specific actions that federal agencies should take to maximize safety, and make recommendations concerning how private actors can promote the safety of HIT-assisted care.2 The confluence of those goals came down to understanding the broader design of a safe system, of which HIT is a component part. Indeed, after our patients and caregivers, HIT could be the most significant part of care delivery going forward; it is permeating almost every aspect of the care delivery process.
1. www.ecri.org/Pages/default.aspx
2. www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx
Visitation rights and restrictions
I wanted to share with you an opportunity to learn more about patient visitation rights and restrictions because who can and cannot visit a patient while he or she is in the hospital has changed in recent years.
Heavily covered in national news, new federal mandates give patients more authority and autonomy to decide who may visit them as they try to recover. To align with these mandates, The Joint Commission updated two Elements of Performance (EP) under its Patient Rights (RI) chapter. These changes were announced July 13, 2011, and were retroactively effective as of July 1, 2011.
Both changes were made under standard RI.01.01.01, which states that the hospital must promote, respect, and promote patient rights. EP 1 requires hospitals to have written policies on patient rights, and a new note for hospitals that use Joint Commission accreditation for deemed status, says the EP now requires hospitals address in those policies visitation rights procedures, such as restrictions or limitations (including those clinically necessary).
It’s safe to say that any hospital that either accidentally or purposely infringes on those rights is going to end up big trouble. And it’s not just implementing policy–educating patients to be empowered to know their rights, including their rights regarding visitation, is critical. It also enhances patient experience and satisfaction, another area laying heavy on the minds of quality professionals these days as reimbursement is now partially tied to HCAHPS scores.
Wouldn’t it be nice to have a patient safety expert and veteran guide you through this change? To help you do your job in ensuring your organization is compliant with federal and Joint Commission standards? Join Barbara Balik, RN, MS, EdD, senior faculty at the Institute for Healthcare Improvement (IHI), principal of Common Fire Healthcare Consulting, and a member of the National Patient Safety Foundation Board of Governors, for a January 26 webcast to learn what must be done.
You can’t improve without knowing what’s wrong
In the healthcare quality improvement field, there has been much talk about reporting errors, about a just culture, about using occurrence reporting data to implement quality improvement initiatives, and sharing results with staff. But it seems, according the latest Office of the Inspector General (OIG) report that many of you have probably seen, that hospitals aren’t cutting it.
In summary, the report concludes:
Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).
So, the majority of events go unreported because staff didn’t think the event qualified for the reporting system.
A list of common events is coming (via AHRQ and CMS), and it’s sure to be helpful. Until then, hospitals should work on what Occurrence Reporting: Building a Robust Problem Identification and Resolution Process author Ken Rohde calls this a reporting threshold.
“If your staff question whether they should report something, they are asking themselves a threshold question,” says Rohde. He advises the threshold to be either low or nonexistent.
“A good way to communicate a lower threshold is to tell staff: ‘If it was important enough for you to think about it or if it disrupted your day, then report it,’” says Rohde.
Though a higher reporting volume may require a more efficient screening process, more information about adverse events is usually better.
Here’s a quick tip sheet from Rohde’s best-selling book for improving your error reporting in your system: http://patientsafetymonitor.com/tools-library (starred, at the bottom, free for download).
Top 10 most read blogs posts from 2011
The new year is upon us. I thought before we dive into what’s to come for patient safety and quality in 2012, we might want to look back at 2011 and see what grabbed the attention of the patient safety world.I calculated the top ten by how many times each post was viewed. They are:
10. Joint Commission and FDA to focus on alarm fatigue
The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue—a worrisome problem in most hospitals—a priority.
9. Disruptive behavior, negligence, endangered patients, and millions of dollars
In August, settlements for old patient safety incidents in Boston and recent investigations in Dallas found more recent patient safety infarctions.
8. Rewarding near-miss reporting
This post discusses the importance–and challenge–of getting staff to report near misses, highlighting an example in one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards.
7. Joint Commission issues Sentinel Event Alert about workplace violence
The Joint Commission issued an alert on workplace violence in July 2010, but workplace violence was a hot enough topic to remain at the top in 2011.
My personal story of a patient and family whose anger and frustration grew as they faced an elusive plan of care and a care team who seemed uncommunicative.
5. New York Times article exposes radiation therapy errors
Another post that was published in 2010, but the issue of radiation errors and over-radiation remained hot in 2011. This post highlights one of the first articles in a series The New York Times ran from 2010 and into 2011 on radiation concerns.
4. Medication error prompts lawsuit for Massachusetts General Hospital
A medication error that resulted in a death and a lawsuit was met with a communicative response from hospital representatives, who said systematic improvements implemented since the error now help staff to avoid making similar errors.
3. Boston hospital admits three spinal surgery errors in two months
Published at the very end of 2010, this is yet another post on a hospital admitting to errors—this time surgical site errors—that did not need to happen. Beth Israel Deaconess Medical Center in Boston is in the spotlight after its surgeons made errors in three separate spinal operations in two months.
This post explaining how a resident failed to carry out an order on her mobile device after she was interrupted by a personal text messaged grabbed the attention of Patient Safety Blog readers. With this anecdote as proof, social media concerns have leaped from HIPAA violations to immediate threats to patient safety.
1. Can a video really help curb infections?
Perhaps videos are just more fun to watch. This post embedded the winning video of the APIC Infection Prevention Film Festival, which lays blame on frontline providers who fail to do everything they can to “do no harm—” in this case, failing to wash their hands.
What do you think? Any of your favorites missing? Let me know.
