All Entries Tagged With: "simple patient safety solutions"

Technology, devices and equipment: More than just a purchase

One topic keeps popping up in the patient safety world, and in my humble opinion, I think we’re going to see much more of it. It’s the topic of how the devices we use in hospitals are understood and used. Technology and state-of-the-art equipment have the potential to make healthcare efficient and safer, but only if we slow down to learn how to use it, and in some cases clean it, correctly. I have this feeling that we are getting a bit ahead of ourselves with buying shiny new stuff, not worrying enough about continuing education of proper use, training, cleaning, and maintenance of equipment.

More than one hospital told me they had to take a step backward and re-implement handoffs after implementing electronic medical records. So much was documented in real time, staff often forgot to have conversations about the patient, leaving out a critical time to ask and answer questions.

Alarm fatigue is a prime example of too much technology at once, without forethought of potential side effects. Not only are nurses (understandably) tuned out, but the alarms add to the noisy environment in which the patient is trying to recover.

Endoscopy and colonoscopy equipment that hasn’t been cleaned according to guidelines are causing hospitals and physician offices to send thousands of regretful letters warning patients they may have been exposed to a host of bloodborne pathogens.

And I’ve already written extensively on whether radiation technology’s exponential expansion is too much to handle. We are getting better pictures, but at what cost? The radiation is getting stronger. Just because we can, doesn’t necessarily mean we should. And, there is debate as to whether technicians are undergoing enough training to use complex machinery. Machines only do what we tell them, and if we tell them incorrectly—especially in the case of radiation therapy—we are certainly doing more harm than good.

To echo a well known web-spewing superhero, with the power of new equipment and technology comes great responsibility. Providers should be educated and trained on using the equipment around them properly, and ensure they are well cleaned and maintained. We cannot afford to get distracted by wondrous EMRs or equipment. We must remember that it is all a means to an end that is better care. If the means actually makes care less safe, we are failing.

We need to be constantly asking ourselves whether we are doing everything possible to ensure new technology and equipment make a safer environment for patient care.

5th Annual AHAP Conference to be held in Las Vegas

I wanted to share with our readers the exciting opportunity to attend the next annual Association for Healthcare Accreditation Professionals (AHAP) Conference, taking place in Las Vegas from May 12 –13, 2011.

We’ve heard first-hand how happy attendees were to connect and network with each other—both veterans and rookies said they greatly benefit from the connections they’ve made at this conference.

The agenda has been posted with some timely sessions that will cover Joint Commission and CMS regulatory changes in 2011, improving compliance with core measures, tips for data management, and plenty more.

For more information, including the full agenda, learning objectives, speaker list, continuing education information, hotel, and pricing, visit the AHAP website.

Thinking differently, working together at the IHI forum

Last week, I attended the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Health Care, and I certainly wasn’t the only one. Six thousand of you attended in person, and more than 15,000 attended virtually.

The national conference lives up to its hype. It is invigorating to attend so many sessions dedicated to quality improvement. Keynotes from U.S. Secretary of the Department of Health and Human Services Kathleen Sebelius as well as the new president and CEO of IHI, Maureen Bisognano were just the tip of the iceberg.

Bisognano talked about the triple aim of IHI: improving the health of the population, experience of healthcare, and the cost of care. Many, she said, see two pathways to these goals: cutting costs and rationing care; however, Bisognano championed a third: creating new designs.

This was what many sessions I attended were about: working with others to think differently in order to truly achieve different results. Participants were urged to think differently about what harm is preventable, about why physicians may be reluctant to participate in quality improvement efforts, and about the patient experience as a whole, from ED visit to wherever the patient may end up.

I must also mention one of the other keynote speakers, Cory Booker, mayor of Newark, New Jersey. Booker has no experience in healthcare, but he certainly has a different way of implementing actions that is translatable to healthcare. Newark has seen more than 40% reductions in both shootings and murders (as of July 1, 2008, about midway through his first term). Booker credits this accomplishment with aiming incredibly high and focusing on the power of collaborating. To reach high ambitions, he urged, you must take the collective will of a community and embrace it. Engaging the whole of the community, he said, will create results unimaginable of the individual

Those were some of the highlights of the conference. Stay tuned to the Patient Safety Blog and Patient Safety Monitor Journal for more topics covered at the conference.

Were you at the forum? What did you think? What was your highlight of the week? Please share with your peers below!

New California law prompts healthcare facilities to report radiation overdoses

California hospitals have less than a year to adhere to a new law requiring the state Department of Public Health to be notified any time a patient is given a radiation dose in an imaging scan exceeding 20% of what was intended, reports HealthLeaders Media.

The new bill signed by Arnold Schwarzenegger won’t go into effect until July 1, 2012.

Recent overdoses of radiation in the state have prompted the new bill. Cedars-Sinai Medical Center in Los Angeles admitted to accidently giving 206 stroke victims eight times the dose of a normal radiation procedure, according to an article in The New York Times.

A two-year-old boy in a California hospital was administered an overdose of radiation which allegedly burned parts of his face, according to CW13.

The new law requires hospitals and clinics to record every radiation dose done on CT systems. The recorded doses then must be verified by a medical physicist. Healthcare facilities have five days to inform the Department of Health if anything goes wrong.

Read the rest of this article on California’s new law at HealthLeaders Media.

What do you think of the new law passed by California? Share your comments with us!

Finding the fun in patient safety

Briefings on Patient Safety recently launched a new column that explores patient safety from the perspective of a newcomer to the field. Columnist Catherine Hinz, MHA, is the patient safety lead at HealthEast Care System in St. Paul, MN. Previously, Hinz worked for seven years as an ED health unit coordinator, completed a patient safety internship with the Agency for Healthcare Research and Quality, and finished a residency with The Studer Group.

The Patient Safety Monitor blog will be featuring excerpts of Catherine’s columns on the blog, beginning with the most recent, about finding the fun in patient safety:

This profession requires that I am preoccupied and obsessed with error. I doubt I would be competent in this position if this weren’t the case. Patient safety professionals are always on the hunt for “failure modes” and weaknesses in a process. However, voicing many areas of vulnerability in newly developed policies, procedures, or equipment doesn’t make me the most uplifting person in a meeting; this also goes against my natural disposition.

To keep a strong, positive attitude, I feel it’s necessary to create fun and amusement in unique ways. I find excitement in assembling a new work team, observing a nursing unit, shadowing staff in the operating room, riding along with paramedics, and interacting with our system leadership. Spending time with the heroes who are our caregivers is the most exciting thing I do. Without fail, I walk away from an observational opportunity with new skills, knowledge, and appreciation for healthcare. My time spent with caregivers fuels my spirit because of the camaraderie that often results. I’ve formed relationships with frontline staff and providers I couldn’t have done through e-mails, phone calls, or meetings.

Working on a team to come up with new, creative, and innovative ideas is one of my favorite parts of patient safety. I recently worked with an ad hoc team to examine portions of our patient registration process. We had experienced a near miss concerning a patient registered with another patient’s medical record number. If the error had not been intercepted by a cautious staff member, the results could have been disastrous. Our team devised a new way for registration staff to identify patients that would significantly diminish this from happening again. There is no doubt in my mind that although we improved a nonclinical registration process, the team built in safeguards to prevent harm and protect life.

Those who have chosen to work in healthcare are brilliant, calculating, and altruistic. I don’t think there is another industry that attracts the type of people and teams that healthcare does. It is a pleasure and a joy to be part of this larger team—in our departments, our hospitals, and our industry.

I can find fun in most work in which I am engaged. I get a kick out of changing others’ attitudes toward patient safety—persuading them to consider the safety of our patients as the most important part of delivering care. Recently, I’ve had a great time working with the surgical services team to redesign our timeout process in our operating rooms. The implementation efforts to educate physicians and the staff have been nothing short of vigorous. To initiate the conversation, I created a presentation with all of my audit observations and rationale for the timeout process change set to Tom Petty’s song “Time to Move On.” We’ve had valuable conversations about efficiency, time consumption, power hierarchies, administrative policy, and, of course, the safety of our patients. These types of conversations are as fascinating as they are fun.

MA physician invents infection-preventing stethoscope cover

A Massachusetts physician has designed a new disposable plastic sleeve to fit over a stethoscope, The Boston Globe reports. Physicians responsible for examining patients who have communicable diseases have been guarding their stethoscopes with latex gloves for years, but the latex solution often does not work well, failing to adequately protect the instrument and fitting the stethoscope awkwardly. Richard Ma, creator of the “Stethguard,” the name of the plastic sleeve, says that his invention will help prevent the spread of infection via stethoscope.

Although the rate that infections are spread in a hospital via stethoscopes is unknown, adding another barrier to the spread of infection—specifically those that are hospital-acquired—is vital in helping patients leave the hospital quicker and save facilities money. The CDC advises that all stethoscopes be cleaned between patients, but that often does not happen, according to The Globe. Physicians also shy away from using designated stethoscopes for patients who carry infections, because they do not function as well as their own.

To read more about the Stethguard in the Boston Globe, click here.

Do you think the physicians at your facility would take to an infection prevention product like this?

Three words for patient safety

I came upon a patient safety project done by Abington (PA) Memorial Hospital (AMH) this morning that I wanted to share on the blog. The staff at AMH used the “Your Three Words” segment from the Good Morning America program to brainstorm a patient safety project for the facility. Although I’m not a Good Morning America watcher, I looked up the program and found that it asks viewers to communicate their feelings on a specific topic in three words.

AMH took this idea and asked staffers to communicate their thoughts about patient safety related to their jobs in three words. The result is a nearly five-minute long video, which you can find here. This is another creative way to involve everyone who works at a facility in patient safety!

As a writer/editor who communicates about patient safety, I think my three words would be:

Educate, Inform, Interact

At least that’s what I try to do to/with my audience! What would your three words be? How do you incorporate patient safety into your job each day?

New Universal Protocol video is an easy training tool, offers credits

I wanted to let our readers know that a new video from HCPro’s patient safety market is available! It’s a 20-minute video that helps train staff on the up-to-date Joint Commission Universal Protocol standard. I’m personally excited about this as I helped to create the video (and I’m actually in it), and can tell you that it easily explains each of the three main components of the standard (preprocedure verification, site marking, and time out), and also explains how to avoid common mistakes most hospitals make.

The video even offers continuing education credits. (For more information on how to receive the video and credits, click here.) You can also watch the trailer below!

Yet another source of MRSA: ambulance stethoscopes

As you work hard at preventing infections, you might want to think of where the patient has been just prior to coming to your hospital-the ambulance.

A recent New York Times article reports that stethoscopes used by ambulance staff in New Jersey carried MRSA (16 out of 50 tested had the bacteria). Researchers found that some ambulance workers couldn’t remember the last time they were cleaned.

The findings are part of a report appearing in the current issue of Prehospital Emergency Care.

Florida nurse practitioners fight for their right to prescribe

Although 47 states give nurse practitioners the privilege to prescribe medications, Florida is one of three that does not (the other two are Hawaii and Alabama). For the past 14 years, a bill has been brought to the Florida legislature that gives nurse practitioners the right to prescribe, and it has died each year.

As the 15th year comes to pass, Florida nurse practitioners are gearing up for a fight. Those opposed to the bill say that not all advanced practice nurses have adequate training on how to prescribe addictive drugs, like Valium and Oxycontin. They say it is a matter of patient safety that nurse practitioners not be given this right as physicians have the highest level of training and only caregivers with this background should be allowed to prescribe.

However, proponents of the bill say that not only should nurse practitioners be allowed to prescribe medications, but barring them from doing so often puts patients in harm’s way. In many cases nurse practitioners work at rural clinics and for them to contact a physician to write prescription not only wastes their time, but extends the amount of time that a patient has to wait for his or her medications. Additionally, nurse practitioners argue that the state is preventing them from doing a part of their jobs for which they were trained.

You can read more in this Associated Press article that appeared in the Gainesville Sun about the topic.

What do you think about this issue- should physicians be the only class of trained medical professionals allowed to prescribe medications? Are patients put at risk otherwise?