All Entries Tagged With: "adverse events"

Another case of hospitals behaving badly

St. Francis Hospital and Medical Center in Hartford CT is the latest facility to make headlines for violating state regulations concerning patient care. The hospital was placed on probation by the Connecticut Department of Health, according to the Hartford Courant. One of the more recent instances involved a heart surgery patient who sustained a brain injury during a May18 surgery. The patient later died on June 18, and on July 2, the hospital stopped offering non emergent cardiac surgeries.

The major problem in this case stemmed from a pump failure with the pump used for cardiopulmonary bypass, according to the Courant. The hospital did not address the pump failure adequately. Specifically, the hospital didn’t report the pump failure to the Food and Drug Administration or the manufacturer or communicate the failure to hospital leaders and other members of the medical staff. Additionally some of those providers involved in the surgery did not participate in a cause analysis, and what I think constitutes the worst offense, the hospital put the pump that failed back into use just three or four days after the incident.

The hospital has issued a statement saying that it has made administrative changes, updated OR procedures, and  revised equipment and maintenance protocols. You can find the full article here.

I wrote this post last week about a Rhode Island hospital that was fined by the state’s Department of Health. I know that these two cases are gaining media attention, so that’s not to say that other facilities in their area are not committing similar errors. But in reading the descriptions of how the situations were handled, it seems to me that neither facility really placed much emphasis on learning from their mistakes, which I think is what is most startling.

RI hospital commits fifth wrong-site surgery since January 2007

Staff members at Rhode Island Hospital in Providence, have committed the facility’s fifth wrong-site surgery since January 2007, resulting in a $150,000 fine levied by the state’s Department of Health (DOH), reports The Providence Journal. This is only the second time that the hospital has been fined, the first being after the hospital’s third incorrect neurosurgery occurred in 2007. The latest wrong-site surgery involved a procedure done on a patient’s incorrect finger. In addition, the DOH is requiring that the hospital

• install video and audio monitors in each operating room
• allow a licensed clinical professional who isn’t part of the surgical team to observe every surgery for a year
• adopt the statewide procedure for using safety checklists and marking the surgical site
• summarize each wrong-site surgery since 2005 to send to accrediting and government agencies
• conduct mandatory training sessions for all staff members who work in the operating room to review procedures

Readers, I’m wondering what you, as people who work in hospitals each day, make of this? This hospital, which should have been by all accounts been following the Universal Protocol as well as the state’s guidelines for preventing wrong-site surgery, did not. However, many readers of this blog may know and understand the culture necessary to ensure that the correct steps are taken to prevent a wrong-site surgery. Do you think the requirements made by the Health Department will prove to help this facility sort out its patient safety issues? Do you have any general thought about this instance?

In a related note, the president and CEO of Rhode Island Hospital, Timothy Babineau, MD, has offered to answer questions on the hospital’s Web site through November 9 (not specifically related to this event, but you could get any questions on this topic to him if you so desire).

Please see the Providence Journal article, it does a good job of explaining the story.

The sleep factor: Do less tired physicians deliver safer care?

The debate on whether reducing the number of hours that graduate medical students can work consecutively, as well as per week, has had any effect on the safety of patient care continues, reports American Medical News. Last year the Institute of Medicine made even further recommendations for reducing the number of hours that residents can work, based on sleep science. Those suggestions have yet to be implemented. However, there is evidence both for and against further reducing the amount of hours that residents can work.

Since 2003, residents are allowed to work no more than 80 hours each work week. However, each time residents’ shifts are over, they must hand their patients off to new residents. More handoffs often lead to an increase in poor patient safety outcomes. However, tired residents also may not able to make appropriate decisions regarding patient care. Sleep deprivation affects each person differently. Additionally, it’s difficult to truly measure patient safety and what may affect it.

To read more from American Medical News, click here. Has your facility had any open discussions regarding resident hours?

The role of accountability in a culture of safety

Two well-known names in the patient safety field, Robert Wachter, MD, professor and associate chairman of the department of medicine at the University of California, San Francisco, and Peter Pronovost, MD, PhD, medical director for the Johns Hopkins Center for Innovation in Quality Patient Care, have published an article in the New England Journal of Medicine (NEJM) about the need to make accountability a larger part of the discussion when it comes to patient safety and a no-blame culture. The whole patient safety movement was set in motion ten years ago with the publication of the Institute of Medicine’s To Err is Humanreport. Wachter and Pronovost say that the industry has come a long way since then, and important steps have been taken in the name of patient safety.

However, it’s time to move past simply acknowledging that the majority of adverse events are the result of human factors, not malicious intent, say Wachter and Pronovost. It’s time that hospital leaders take responsibility for those staff members who routinely fail to perform simple safety checks and actions that would prevent adverse events from occurring. In Wachter’s most recent blog post on his blog “Wachter’s World”, he discusses how he and Pronovost are expecting a backlash from the field for asking for more accountability in the patient safety world. It is time to ask for more from leaders and caregivers to do simple things like handwashing or using a checklist before surgery, though. If the steps have been taken to change how processes work and to emphasize a culture that acknowledges that most errors are systems-based accidents, and those errors continue to occur, it is time to move on and incorporate some amount of accountability into the system, say Wachter and Pronovost.

You can find the NEJM excerpt here, but Wachter’s posts a good summary on his blog if you don’ t have full access to the journal.

This is a topic that touches many emotions, and you may have differing opinions on the topic. I’d welcome any comments on the blog post or how your hospital has attempted to address the culture of safety.

Study: Medical errors may not increase during July, contrary to popular belief

A study published in the September 2009 Journal of the American College of Surgeons has concluded that medical errors do not in fact increase during the month of July specifically in a Level I trauma center. Researchers tested the popularly held belief that during the months of July and August the amount of medical errors increases because that is the time of year during which new medical residents begin practicing at hospitals around the country.

To test this belief, researchers reviewed data from 12,525 blunt trauma patients by month and 14,798 by quarter over a five-year period from an academic, tertiary Level I trauma care center. Results showed that the month or quarter of the year during which patients were admitted had no correlation to mortality rates.

Click here to read the full abstract from the Journal of the American College of Surgeons.

Readers, have you ever personally felt that the “July phenomenon” exists at your facility?

Google treats e-mail outage as “sentinel event”

On Tuesday, Gmail, the e-mail arm of Google, suffered an outage for about an hour and forty minutes. Although Gmail is an e-mail service, it has many functions including a chat capability which many business use to speak to other businesses and for staff members within a business to speak to each other. So, when Gmail was inaccessible for that period of time, it negatively affected many people and companies.

Why I’m mentioning the incident on the Patient Safety Monitor Blog is because shortly after Gmail came back online, the engineers at Google published their own blog post (on the Gmail blog, of course) apologizing to Gmail users, as well as hashing out just what went wrong to cause the outage. Throughout the post, the repeatedly tell readers that they were treating the outage as a major event and are working to ensure that it never happens again.

After reading the post, it occurred to me that Gmail had suffered a “sentinel event” of its own, and Google was treating it as such. The post describes the “route cause analysis” that was undertaken to determine what went wrong, as well as the “process changes” made to make sure the problem occurs again (albeit, in different language).

Of course, when Gmail suffers a “sentinel event” it inconveniences, annoys, and perhaps even really upsets users. However, it doesn’t cause permanent harm or worse to its users, which is what makes this event very different from a medical error. However, the lessons struck me as similar.

How often does your organization evaluate how it treats sentinel events, and the steps taken after one occurs?

Joint Commission releases Sentinel Event Alert

The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of  the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)

The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.

The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.

You can read the full list of recommendations, as well as the Sentinel Event Alert here.

Joint Commission releases latest sentinel event data

Coming off of yesterday’s post about The Joint Commission’s newest Speak Up campaign, which is geared toward preventing medical errors with pediatric patients, today’s post is about the latest sentinel event data released by The Joint Commission. As of June 30, 2009, wrong-site surgery is still the most commonly reported sentinel event, making up 13.4% of all reported events. In the first two quarters of 2009, 53 wrong-site surgeries were reported to The Joint Commission. In 2008, 116 wrong-site surgeries were reported during the entire year, to give you some background.

Close behind wrong-site surgery is suicide for reported sentinel events, making up 12% of all reported events. The top five most frequently reported sentinel events through the first two quarters of 2009 are:

• wrong-site surgery
• suicide
• operative/ post operative complication
• medication error
• delay in treatment

To read the full list, click here. To find The Joint Commission’s Web page about sentinel events, click here.

Joint Commission tailors “Speak Up” campaign to care of children

In an effort to make parents more aware of the medical errors their children are in danger of while in the hospital, The Joint Commission is launching an education campaign as part of its existing Speak Up program. The original Speak Up program encourages all patients to become involved in their care and make their voices heard to prevent potential medical errors. This new version, called “Speak Up to Prevent Errors in Your Child’s Care”  is aimed at parents and encourages them to ask the right questions to prevent a potential error from occurring while their child is at a healthcare facility.

You can find some videos on The Joint Commission’s Web site, one of which shows Marc Chassin, MD, president of The Joint Commission, reminding parents that there’s no such thing as a dumb question. According to a 2008 study from the National Initiative for Children’s Health Care Quality, 1 in 15 children are harmed by a medical error. The Joint Commission is encouraging parents to take action before, during, and even after their child has been cared for to help this number go down.

To read more about the campaign, click here.

Has your hospital used the existing Speak Up campaign? Have you seen success with it? Do you think you’ll use this new version?

Rhode Island hospitals agree on protocol for preventing surgical errors

After a span of two years that has produced five wrong-site surgeries, Rhode Island’s (RI) 12 hospitals and 21 ambulatory surgery centers (ASC) have all agreed on a protocol for preventing surgical errors, reports the Providence Journal.  The Hospital Association of Rhode Island announced yesterday that RI is the first state to employ a uniform procedure for preventing surgical errors.

Many hospitals around the country are now using The Joint Commission’s Universal Protocol^TM or a variation, and many are using the WHO’s surgical checklist. The procedure agreed upon by hospitals and ASCs in RI include four steps:

1. The surgical site is marked, and after agreement from a surgeon, LIP, and patient or family member, the surgeon initials the site.
2. The operating team introduce themselves and discuss specifics about the case at hand.
3. A time out is performed prior to the surgery to confirm the patient, procedure, and site, and that the surgeon’s initials as well as surgical site are visible after the patient has been draped.
4. After the surgery has been completed, the surgeon leads a debriefing session to discuss the case.

Among some of the reasons why surgical errors have occurred in the past include staff members not following the well defined procedures set out for them.

To read more from the Providence Journal, click here.

Do you think RI is on the right track? Would your state benefit from a standard, statewide process?