All Entries Tagged With: "sentinel events"
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
Texting while rounding :(
Everyone knows that texting while driving is dangerous—and illegal in many states. It’s obvious why: The driver gets distracted and takes his or her eyes–and mind–off the road.
But what about frontline care staff? Can they text on the floor? If so, when? Does your hospital have guidelines about this? Many hospitals are worried about the content of texts and other uses of social media, such as Facebook. They worry HIPAA will be violated. But a recent incident exposed on the AHRQ’s “morbidity and mortality rounds on the web” proves that texting while rounding, no matter what the content, can prove distracting and near disastrous, especially when smartphones serve as both a hospital tool for ordering medication and the portal to a resident’s social life.
The case involves a resident and intern who discussed the plan of care for a patient while rounding. An attending told the resident to stop warfarin until an echocardiogram of the heart could be taken.
Here’s a key part to this case: The hospital’s CPOE system allows providers to enter orders in the system through smartphones, a convenient option that allows real-time ordering. The resident began submitting the orders on her smartphone. Then she got a text about an upcoming party. The resident chose to respond to the text. The order for the patient was never completed, and the patient continued to receive warfarin for three days. Because of the CPOE system, no one reviewed the medication list, and everyone thought the order for warfarin was stopped. Though not stated in the case, I’m sure at least some of them thought they actually saw the resident put through the order on her phone.
The problem was realized when the patient developed shortness of breath, tachycardia, and hypotension from blood thinning. He needed emergency open heart surgery, and was in the hospital for three weeks before being discharged.
For those who use smartphones, it’s incredibly easy to understand how this happened. Once the decision is made to view a text (or if it pops up automatically), you are interrupted. Your screen is filled with only this text. You reply. Thoughts are now with that conversation, and there is nothing to remind you that another application is open, that you never finished the task.
Mobile devices and social media have brought personal lives into the workplace. However, when the finished product is a healthy patient, we need stringent rules for such devices. A personal phone call regarding a party would never be allowed on rounds. Nor would her friends, decked in party hats, be allowed to show up in person to disrupt her to find out whether she’s coming. But these scenarios are very similar to texting; you are communicating with others outside of your work, which brings thoughts elsewhere. Forget call lights and pages, this is the ultimate distraction because it’s intimate, private, easily hidden, and has absolutely nothing to do with work. Despite what we want to believe, no one can do two things at once, no matter how many apps you have.
It may be time to consider whether it makes sense to allow work and play to be conducted on the same device in healthcare. Mobile technology has many benefits, but perhaps the mobile devices staff use in the hospital to submit orders should be different than the devices they use to manage their social life. Many workplaces see this as a matter of etiquette. They trust employees to limit personal use of mobile devices during work hours. However, when you’re talking about the difference between sending a smiley face to confirm you’re attending tomorrow night’s party and submitting orders to stop an anticoagulant for a patient in danger of excessive blood thinning, you’re talking about much more than etiquette.
What do you think? What are your hospital’s guidelines on this?
Diagnostic tests testing patient safety?
Diagnostic tests. They help us understand what’s wrong, and generally, they are safe. But lately, there has been concern over the amount of radiation patients receive nowadays, especially as physicians fearful of lawsuits overprescribe tests to protect themselves. There have also been a number of incidents involving CT scanning and x-ray errors that may have been harmful to patients (a trend detailed in the November issue of Patient Safety Monitor Journal).
Now we also have to worry about MRIs.
Magnetic forces, harnessed correctly, don’t harm patients, but possible adverse events when thing go wrong include projectiles, burns, fire, hearing loss, events resulting from incompatability with other medical devices, nerve stimulation, and shock.
A recent HealthLeaders Media article details an alarming rise in patient injuries, recently described at the U.S. Food and Drug Administration’s two-day session on MRI safety. Technicians need more training, guidelines for the point of care need to be better, adverse events need to be reported more, what needs to be reported needs to be better defined, and patients need better education about MRI safety, according to the session.
One thing I keep hearing, no matter the test, is that training is lacking around high-tech medical equipment, such as scanners and imaging devices. Manufacturers are pushing newer, stronger models and technicians are not trained adequately, leaving a widening patient safety gap.
Apologies and action for famous actors only?
Hospital chief Sandra Coletta is making waves throughout the healthcare community after being frank with her audience of hundreds at the 10th annual dinner of Medically Induced Trauma Support Services (MITSS), a widely respected group that aims to support patients, families, and staffs after things go medically wrong.
She spoke about the death of James Woods’ brother in the emergency department at Kent Hospital in Warwick, RI, after orders were not carried out in a timely manner.
“Quite honestly, I did nothing other than what my mother taught me,” Coletta said of apologizing.
James Woods and the hospital settled the suit, in the process created a foundation, the Michael J. Woods Institute, in honor of his brother. The institute aims to recreate healthcare from a human factors perspective.
Similar action was taken after Dennis Quaid’s twins were put in peril because of a medication administration mistake. (According to an April 2010 USA Today story, Quaid said Cedars-Sinai hospital in LA “stepped up to the plate and spent millions of dollars on bedside bar codes.” He and his wife also created the Quaid Foundation, which has merged with the Texas Medical Institute of Technology.) Do you think these cases are addressed more swiftly, and more apologetically, because of their high-profile nature? Or do you think the tides are turning?
Of course, Sorrel King, without being famous (at least then), spurred plenty of action on her own. But are hospitals finally reacting with action and apologies, even without fame and publicity?
Share your thoughts on the blog.
Sentinel events for first half of 2011 available
The November issue of The Joint Commission’s Perspectives gives us an idea of the sentinel events that resulted in death or major permanent loss of function in the beginning half of 2011. This includes 76 incidents of foreign body left after surgery, 67 reports of wrong-patient, wrong-site, or wrong-procedure surgery.
That seems like a lot to me in just six months (especially the wrong-site surgeries).
One other stat that surprised me was 23 criminal events. Perhaps I am just naïve, or maybe there’s just more reporting?
What do you think of these numbers? Do you think it is accurate and unsurprising? Share your thoughts below.
TJC on wrong-site surgery: Count risks, not events
Yesterday, The Joint Commission’s Center for Transforming Healthcare had a live news conference to feature the participants of the Center’s Wrong Site Surgery Project. Largely viewed as a never event, wrong-site surgery may actually be occurring at an estimated 40 times per week, according to The Joint Commission.
Three hospitals/hospital systems and three ambulatory surgery centers discussed their efforts and successes in thwarting the dreaded mistakes—including Mary Reich Cooper, MD, JD, senior vice president and chief quality officer for Lifespan Corporation in Providence, RI. Lifespan includes Rhode Island Hospital, which notoriously had a number of public wrong-site surgeries all within a few years. Cooper says Lifespan eventually installed cameras in the ORs for future auditing and quality improvement, as well as shut down its ORs for an entire day to train staff on new protocol. New staff are subjected to strict orientation as well. They have not had a wrong-site event in the three years since new protocol were implemented, she said.
A few good points were brought up during the call. One is the fundamental understanding that every hospital thinks its protocol works because a wrong-site surgery event hasn’t occurred. However, Mark Chassin, MD, FACP, MPP, MPH, president of The Joint Commission, was quick to point out that these events are relatively rare; therefore, hospitals should count the amount of risks for an event to happen, not the amount of events. Good point—I’m sure most hospitals that have suffered an event didn’t think they were at much risk for one.
Although speakers on the call emphasized that there is no one quick fix, and that each hospital must conduct their own risk assessments to determine weaknesses, there were a couple items that stuck out:
- Surgical scheduling areas need to have a standardized system to collect all patient information, especially patient identification
- Site marking needs to be done using a marker that will not wash off during surgical prep, and no marker that does not meet this standard should be in the room in which site marking occurs. Site marking also needs to be close to incision site, and it’s a good idea to ensure that time outs confirm the mark can be seen after draping.
- Types of surgeries most at-risk include orthopedics, spinal, ophthalmology. Any time multiple surgeries are conducted one after the other on the same patient also creates a higher risk.
Thoughts? Is this a topic your hospital addresses often?
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.
Radiation continues to harm–this time, the victims are preemies
A recent New York Times article has exposed yet another patient safety incident involving radiation, and this time the mistake was on premature infants at State University of New York Downstate Medical Center in Brooklyn, NY.
The incident, which was discovered in July, 2007, is one of several that has prompted the Times to run its “Radiation Boom” series, which explores the increasing use of medical radiation though new and old technologies, including over radiation of cancer and stroke patients, much of which is caused by misuse of equipment.
Over radiation at Downstate Medical Center occurred from too-frequent full body X-rays of premature babies, CT scanners’ radiation levels being set too high, and poorly positioned babies, making it hard to interpret images.
Radiation regulations are sparse. According to the Times, it’s up to states to decide what, if any, standards radiologists and other similar technicians need to meet. In some states, hair dressers might have tougher standards, and many states do not require continuing education for radiology technicians, though equipment is often updated and becoming increasingly more complex.
Are you confident in your hospitals radiation policies? Is it a concern? Post below.
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.
Post-harm action plan: Does your hospital have a plan when an adverse event occurs?
The National Association for Healthcare Quality held its 35th annual education conference in Kansas City, MO, this past week and weekend. HCPro was there, as I’m sure many of you were as well. There were some great presentations, including the opening keynote speaker, Jim Conway, MS, a senior fellow at the Institute of Healthcare Improvement. Conway spoke on “Respecting Those We Are Privileged to Serve Especially When the News Isn’t Good,” emphasizing the need for a defined process of actions to be taken when an adverse event occurs.
Conway said that within the first hour of an error, steps should be taken to notify the appropriate people and support should already be in effect for staff, patients and/or families. Many hospitals have plans for floods and fires, said Conway, but few have action plans for when hospital harms a patient—a much more likely event, he pointed out.
(Look for the December issue of Patient Safety Monitor Journal [formerly Briefings on Patient Safety] in the next month for a more in-depth look at some of the other informative presentations, including interviews with the presenters.)
Does your hospital have an action plan once an adverse event occurs? Would you know what to do? What to say to the patient and/or family? Where to find immediate support if you’ve committed an error?
