All Entries Tagged With: "Patient falls"
A dozen CA hospitals fined over patient safety issues
The California Department of Public Health (CDPH) has fined 12 hospitals for patient safety-related noncompliance, according to a CDPH release. The fines are for putting patients in “immediate jeopardy” of harm.
Out of 14 fines, eight were for failure to follow proper surgical safety protocol that resulted in objects left inside patients. A portion of the funds received from the fines will go toward improvement projects that focus on preventing this particular type of adverse event.
Hospitals that were cited in 2008 were fined $25,000, but a new law requires hospitals cited in 2009 and beyond to be fined $50,000 for the first citation, $75,000 for the second, and $100,000 for the third.
A detailed run down of each adverse event can be found at HealthLeaders Media. Other events include medication administration errors, medication storage errors, and failure to properly treat pressure ulcers. One patient fell out of bed, causing cardiac monitor to become disconnected. She later died.
Data shows new toolkit reduces patient falls
The November 3, 2010 Journal of the American Medical Association conducted a study showing how a program can reduce patient falls.
The study, “Fall Prevention in Acute Care Hospitals,” found that patients are more inclined to fall because of treatments they are going through, illnesses they have, or because they are in settings that are unfamiliar, according to HealthDay News. A team of researchers created a fall prevention tool kit (FPTK) which contained:
- A fall risk assessment
- A patient-specific fall prevention plan
- An educational handout and poster to hang over the patient’s hospital bed
The data was researched from January to June, 2009 in eight units of four hospitals in urban parts of the U.S. In four of the units, customary care was given to 5,104 patients while the other four units gave 5,160 patients the FPTK, according to HealthDay.
Once the research was complete, data showed a decrease in falls when using the FPTK. Hospital units using the FPTK only had 67 falls while units using the regular care had 87 falls.
The Centers for Disease Control and Prevention website offers useful information on how to prevent falls and keep a home safe after patients leave the hospital.
Could your healthcare facility benefit from the fall prevention tool kit?
Joint Commission tailors “Speak Up” campaign
In late July, The Joint Commission released an update to its popular “Speak Up” campaign, specifically targeting patient falls. The Speak Up campaign has been in existence since 2002 and its main purpose is to encourage patients to become more involved in their own care. Many organizations use the free, downloadable forms on The Joint Commission’s website regarding “Speak Up” to help inform their patients that they can participate in their care.
The latest iteration of the campaign involves preventing patient falls. It’s widely acknowledged that falls are the cause of many minor and major injuries, as well as death. Data from the Centers for Disease Control and Prevention show that falls are the number one reason that elderly patients are admitted to the hospital.
“Falls can cause serious to life-threatening injuries; however, there are steps people can take at home or in a health care facility to reduce their risk of falling,” says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission. “We want people to be aware of these simple yet important precautions and avoid preventable injuries,” says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.
The Joint Commission’s new campaign includes action items to help people reduce their own risk of suffering a fall. Two of these include taking extra precautions in the hospital or in a nursing home and making small changes at home to prevent falls.
To learn more, visit The Joint Commission’s website.
I wrote about another version of the Speak Up campaign almost a year ago. At that time, The Joint Commission had released a campaign encouraging parents to become involved in preventing medical errors in their childrens’ care. Do you think these various versions are useful to hospitals? Do you think the latest “Speak Up” campaign, regarding patient falls, will be something your facility promotes?
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?
Consumer activist group’s list of ten patient safety reforms, could save 85,000 lives
In a new report titled “Back to Basics,” the consumer activist group Public Citizen has devised a list of ten patient safety reforms that, if done correctly, could save the lives of 85,000 patients, as well as $35 billion annually, reports HealthLeaders Media. Most of the reforms listed reiterate basic actions that caregivers are already aware of, as well as process and system changes that individual hospitals can make. Many are also conditions for which Medicare will no long reimburse hospitals.
The top five of these reforms are:
- Use of a checklist to prevent avoidable death and injury during surgery
- Use of best practices to prevent ventilator-associated pneumonia
- Use of best practices to prevent pressure ulcers
- Implementation of safeguards and quality measures to prevent medication errors
- Use of best practices to prevent patient falls
To read more from HealthLeaders Media, click here.
These points don’t seem like anything extremely new to me, but it’s always a good reminder to see the same issues cropping up again and again.
Increased use of restraints may result from deeming patient falls a no-pay condition
A perspective published in the June 4th New England Journal of Medicine suggests that more patients may be placed in restraints as a method to prevent them from falling during a hospital stay. More attention is being paid to patient falls than ever before because the condition appears on the Centers for Medicare’s and Medicaid Services’ list of “no-pay” conditions for which hospitals will not be reimbursed. A patient fall often results in serious injury as well as significant costs associated with further care. The authors of the “perspective” in NEJM worry that hospitals will increasingly turn to restraints as a way to prevent patient falls, even when they are unnecessary.
There are many arguments against using restraints: patients can become restless and confused. They can also develop bedsores because their movement is restricted, and bed sores are deadly in their own right, often leading to sepsis.
Has your hospital resorted to using restraints more often as a means of preventing patient falls? The authors say that they want to ensure that caregivers are aware of the many other options and tactics available to them to prevent patient falls aside from restraints. These include lowered beds and scheduled checkups by a staff member to see if the patient needs to use the bathroom. What are some ideas that your facility has come up with to prevent patient falls?
Read this Boston Globe article about the topic. The article goes more in depth about the lead author’s background and how she has worked to prevent delirium in elderly patients.
You can find the NEJM article here (you’ll need a subscription for full access).
MA report finds patient falls are most common error
Patient falls were the most common “serious reportable event” in Massachusetts hospitals in 2008, according to a new report released yesterday by the Massachusetts Department of Public Health.
There were 338 such events reported by Massachusetts hospitals last year, with falls making up 224 of them, the report found. Other events included medication errors and medical instruments left inside patients. The state found that the events led to 19 deaths.
To read the official press release, visit the Mass. DPH site.
CA hospitals fined for health code violations
The California Department of Public Health this week fined 10 hospitals for a number of health code violations including leaving foreign objects inside patients, medication errors, having faulty anesthesia equipment, and failure to prevent a patient fall. The hospitals were fined $25,000 per violation. All cited hospitals must submit a plan of correction to the state.
The state has issued 71 violations to 49 California hospitals since January 1, 2007.
The violations handed down this week include the following, according to the Associated Press:
- Marin General Hospital in Greenbrae was cited for failing to follow its own policy to count sponges used in surgery, which resulted in a lap pad sponge being left in a patient’s abdominal cavity. The state report said the patient had to undergo another procedure to remove the sponge. The hospital has revised its sponge accounting procedure using sponge counting bags and a dry-erase board in operating rooms to track sponges.
- Ventura County Medical Center’s Santa Paula Hospital also left a sponge inside a patient and needed a second procedure to remove it. An x-ray of the patient’s abdoment five days after the initial surgery discovered the sponge. The facility said it would conduct random audits to monitor compliance with its sponge count policy.
- Fountain Valley Regional Hospital and Medical Center did not follow its medication safety policies when a nurse administered an oral anti-seizure drug to a patient intravenously on May 1, 2008. The error resulted in the patient suffering swelling of the brain from low blood oxygen levels, following a cardiac arrest. The hospital said it provided training to all nursing and pharmacy staff and would increase monitoring.
- Northbay Vacavalley Hospital in Vacaville failed to follow its fall prevention procedures and left a patient unattended. The patient fell off a bedside commode and re-fractured his left hip. The hospital is providing additional staff training.
Go here to read the full list of violations.
NJ hospitals may have to publicize errors
In what’s becoming a familiar refrain, yet another state may soon publish error rates for individual hospitals. A state Senate committee will meet soon to discuss a bill that would require the New Jersey Department of Health and Senior Services to publish how often errors occur at individual hospitals.
Preventable medical errors are already reported to the state and federal government by NJ facilities, but the information is currently only reported on a statewide basis. The bill would also prohibit hospitals and physicians from billing insurers and patients for procedures in which errors were made.
Since the Patient Safety Act of 2004 went into effect in 2004, the state has published two reports on medical errors. In 2006, nearly 40% of the errors reported were patient falls and half of all reported mistakes were attributed to communication problems.
