All Entries in the "National Patient Safety Goals" Category
CAUTIs still a problem
Bit of a plug, but I think my visitors will find HCPro’s webcast on CAUTIs (catheter-associated urinary tract infections) extremely relevant, especially as CAUTIs cause 35% of all hospital-acquired infections every year, with 38,000 patient infections, and costing hospitals $400 million a year, according to an October 2011 National Quality Forum’s Partnership for Patients/ National Priorities Partnership webinar.
And don’t forget that The Joint Commission named CAUTIs a National Patient Safety Goal to be fully implemented by 2013. The Partnership for Patients also aims to reduce preventable CAUTIs by 50% by 2013.
So join nurse practitioner Mikel Gray, PhD, PNP, FNP, CUNP CCCN, FAANP, FAAN, and chief of infection prevention and 2012 APIC conference speaker Brian Koll, MD, FACP, FIDSA, for a live presentation of proven methods on CAUTI reduction, including how Beth Israel Medical Center reduced the number of CAUTIs by 83% using proven organization-wide catheter best practices such as evidence-based practice, staff education, daily need assessments, multidisciplinary teamwork, monitoring, and root-cause analysis. You’ll also get best practices to educate and train your entire staff.
Just a note that now, you can buy the live audio and download the on demand version free.
Patient safety in 140 characters
In honor of patient safety week, the National Patient Safety Foundation hosted a tweet chat, in which participants all follow the same hashtag (#keyword) to have a large conversation. If you missed it, you can read the conversation by searching twitter for “#PSAW2012.” I suggest checking it out (you don’t even have to have Twitter to conduct a search) for the resourceful links alone. Comment below or tweet @PSeditor if you joined and what you liked about it.
Here are some of the topics and facts brought up in conversation:
- Health literacy:
Twelve percent of adults have good health literacy
E-literature might help follow up with patients post-visit
MDs tend to interrupt patients after 18 seconds of speaking
- PSAW:
Getting PSAW recognized by more of the general public to spread awareness beyond the healthcare setting
Why PSAW is observed, recognized, but not celebrated
Next PSAW is March 3 –9, 2013!
Here are some resources brought up in conversation:
NSPF’s new “Ask Me” video
AHRQ’s “Questions are the Answer” video
IMSP has new tools and resources
Health Literacy: Reducing the Burden of a Complex Healthcare System
Patient Safety Week 2012: Informing the Journey, Not Changing the Destination
Checklists that patients and doctors follow can improve hospital care
Dreaming the dream (by Peter Provonost)
Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy
Do Electronic Medical Records Save Money?
What’s in a Name? Safer care, for one.
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
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.
Joint Commission proposes new goal to prevent harm, waste
Last week, The Joint Commission announced it was proposing a new National Patient Safety Goal. The goal would address overuse of treatments, procedures, and tests.
The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.
The proposed goal would have hospitals implement a program to address the issue by selecting a treatment or test to focus on. Pick something, evaluate it, monitor it, and implement new methods to decrease any overuse that’s found.
I find this proposed goal an interesting one. The other goals impose measures to decrease the risk of harm, but the risk here seems more minimal or evidence-based. I don’t mean to say there aren’t risks, I’ve discussed the risks of too much radiation over time, but there is no denying this goal would also reduce waste and cost, and those effects will be much easier to measure. Was this designed to back up physicians who don’t order a test for everything for fear of malpractice suits? Would this help if a physician was charged with negligence for not ordering a test that was not necessary but, as it turns out, would have discovered something?
What do you think of the proposed goal? Post your comments below.
And by the way, the The Joint Commission is taking comments until January 24!
Is preventing wrong-site surgery rocket science?
A very interesting article by Kaiser Health News, in collaboration with The Washington Post, focuses on the fact that despite Universal Protocol®, there is no evidence that wrong-site, wrong-procedure, or wrong-patient surgeries have decreased over the years.
President of Joint Commission Mark Chassin told Kaiser Health News that he’d argue solving the problem “really is rocket science” despite earlier widespread opinion that simple checklists and timeouts would work against mistakes. It seems that it’s not necessarily that checklists and timeouts don’t work; it’s that they exist in a system and culture that is not conducive to using them. Cassin blames, in part, a healthcare system that puts more emphasis on OR turnover than flawless patient safety. Another large part of the problem is cultural, said Peter Provonost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. Physicians are not expected nor taught to follow rules like other staff,
The usual comparisons to the aviation industry are also made—unfortunately, the point is made that pilot mistakes are often widely reported as the repercussions are severe, while many fear wrong-site surgeries are still underreported, as there is no public national database.
What do you think? Is it difficult to get surgeons to comply with appropriate time outs and checklists? Would better reporting help? Would more severe monetary repercussions to the hospital or to the surgeon and/or surgical team help? Has something in particular worked well at your hospital? Share your thoughts below.
Letting patients call a rapid response
Many hospitals have rapid response team providers can use if they feel quick intervention is needed for the patient. But St. Joseph Hospital in Orange, California, lets patients and/or families call a rapid response team. Though many feared Condition H, as the hospital calls it—the “H” stands for help, would become overused with families abusing it with non-emergencies, the hospital says the code is rarely used, and usually for good reason. The program was launched in March, 2008 and is often used because of lack of communication, reports Today’s Hospitalist. But staff members at the hospital say that it is used to put attention on real problems, not as a call light. Patients and families treat it like a 911 phone call.
Most hospitals have a rapid response, but I wonder, how many hospitals allow patients and families to use it? Does your hospital use it? Do you think most hospitals will hop on board?
CAUTI prevention new 2012 NPSG
The Joint Commission has released a new National Patient Safety Goal. NPSG07.06.01 requires hospitals to implement evidence-based practices to prevent catheter-association urinary tract infections (CAUTI).
Basically, the goal requires hospitals to follow The Centers for Disease Control and Prevention (CDC) and/or The Society for Healthcare Epidemiology of America (SHEA) guidelines for the insertion and maintenance of urinary catheters. Hospital must reach full implementation of the goal by January 1, 2013. Hospitals must also measure and monitor CAUTIs, including processes and outcomes in high-volume areas.
Read more on The Joint Commission’s website.
What do you think of the new goal?
Joint Commission news: Note to an NPSG and top compliance issues
In the May 2011 issue of Joint Commission Perspectives, The Joint Commission has announced the top 10 standard compliance issues for 2010. They include some patient safety-related issues, including:
- Complete medical records (#1)
- Safe storage of medication (#6)
- Receiving and recording verbal orders (#7)
- Assessing patient condition (#8)
- Reducing infection associated with equipment and supplies (#9)
- Clear and accurate medication orders (#10)
In other news, The Joint Commission also announced in the May Perspectives that it has added the following note to the anticoagulation National Patient Safety Goal 03.05.01, addressing baseline coagulation assessment:
“The [patient’s] baseline coagulation status can be assessed in a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency, and genetic factors.”
Joint Commission and FDA to focus on alarm fatigue
Good morning, readers! The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue a priority. Alarm fatigue is a concern for many, and it’s no wonder. We wrote about the dangers in the March 2011 issue of Patient Safety Monitor Journal. I remember being surprised when Kathryn Pelczarski, director of the applied solutions group at the ECRI Institute, said that a nurse for an ICU might be dealing with 150-400 physiologic alarms per patient per day. A nurse in those units typically has one or two patients. But that doesn’t mean they don’t hear the alarms for all the other patients. Nurses are hearing hundreds of alarms during their shift, some critical, some less important, and many are false alarms, and patient safety is suffering as a result.
Paul Schyve, senior vice president at TJC, told the Globe alarm fatigue was a “major problem.” TJC plans to meet with the FDA to create a strategy for hospitals to combat the problem. The 2004 National Patient Safety Goal on alarm fatigue is now retired; however, there are a lot more monitors sounding off alarms now than in 2004. After the organization creates some solutions to the problem, Schyve said TJC “could make alarm safety a national patient safety goal again, or issue a special alert advising of immediate specific action, or take some other step.”
Is this a problem at your hospital? What do you think would be some good solutions?
Organizational issues for prevention of HAIs and the systemic nature of the problem
Healthcare-associated infections are no doubt a focal point of every patient safety professional. This month’s column by Catherine Hinz in Patient Safety Monitor Journal explores how organizations might lower their rates.
The following is an excerpt of a Patient Safety Monitor Journal column that explores patient safety from the perspective of a newcomer to the patient safety field. Columnist Catherine Hinz, MHA, currently works at PatientSafe Solutions, Inc. Previously, she was the patient safety 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.
You can’t read anything about patient safety and quality or health reform without running into the topic of healthcare-associated infections (HAI). The issue tops a list of priorities for many health-related government institutions (e.g., Agency for Healthcare Research & Quality, CMS), nonprofit organizations (e.g., IHI, National Patient Safety Foundation), current research and publications, and patient advocacy groups. Popular media has recently been ¬shining a light on the problem as well as the use of tools, such as checklists, as part of the solution for prevention.
Intense process improvement and research efforts in Michigan ICUs have gained a lot of ¬attention for demonstrating significant reductions (and subsequent sustainability of those reductions) of HAIs. The work of Peter Pronovost, Atul Gawande, and others is quickly gaining traction. One of the troubling aspects of HAIs is the systemic nature of how they occur, the complex contributing factors, and the organizational issues of detecting and preventing them (not to mention their breadth of type and severity). HAIs are a problem wrought with cost and reimbursement pressures, challenges in allocating organizational resources, and care team performance factors.
To read Catherine’s full column on HAIs, see the May issue of Patient Safety Monitor Journal (a part of your Patient Safety Monitor subscription for those blog readers out there who are also subscribers.)
