Heather Comak is a Managing Editor at HCPro, Inc. , where she is the editor of the monthly publication Briefings on Patient Safety , as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.
The Agency for Healthcare Research and Quality (AHRQ) has released Common Formats Version 1.1, including technical specifications, which will help hospitals further standardize the collection and reporting of data related to patient safety events.
Patient safety events include unsafe conditions, near misses, and incidents of harm. The technical specifications included in this release will help software developers assist hospitals in reporting this type of data electronically, said the AHRQ.
"These technical specifications specify rules for data collection and submission and provide guidance for how data elements are created, their valid values, conditional and go-to logic, and reports," said William Munier, MD, director of AHRQ's Center for Quality Improvement and Patient Safety. "We hope these specifications will be very helpful in expediting the development of software to automate the Common Formats."
The Common Formats were originally developed in conjunction with Patient Safety Organizations (PSO), launched in early 2009. PSOs are a product of the Patient Safety and Quality Improvement Act of 2005 and were anxiously awaited by many in the patient safety field.
The Common Formats offer hospitals stronger data analysis and solutions surrounding quality- and patient safety-related errors, enabling them to create better systems for patient care. There are currently 79 listed PSOs on the AHRQ's Web site.
PSOs submit data into a national registry, called the Network of Patient Safety Databases, which analyzes the data at a higher level, for nationwide benchmarking. This de-identified data must be submitted using the common formats, so they are easy to compare.
The first version of the Common Formats (version 1.0) was released in September 2009, shortly after PSOs began to form and partner with hospitals wanting analysis on their adverse events. However, the AHRQ recognized that they needed refinement and continued to work from them through February 2010 to develop the next version. AHRQ will be soliciting comment on this recently released version, as it did previously.
Version 1.1 of the Common Formats is available only for acute care facilities, although there are versions in development for other settings. There are both generic and event-specific formats. The event specific formats include blood or blood product, device or medical/surgical supply, falls, healthcare-associated infection, medication or other substance, perinatal, pressure ulcer, and surgery or anesthesia.
Version 1.1 contains:
Descriptions of patient safety events and unsafe conditions to be reported
Specifications for patient safety aggregate reports and individual event summaries
Delineation of data elements to be collected for different types of events
A users guide
Technical specifications for collection and reporting of electronic data
In addition to offering guidance for electronically reporting the data, the technical specifications offer guidance, including flow charts, a data dictionary, and clinical documentation architecture guideline.
The Joint Commission has announced the field review of its revised medication reconciliation requirement, which it has designated as National Patient Safety Goal (NPSG) 03.07.01.
The field review comes after The Joint Commission announced it would make the existing medication reconciliation goal (NPSG 8) one with which hospitals had to comply, but about which they would not be surveyed. The 2010 NPSGs contain language about medication reconciliation, but the field has widely expected an announcement about what will become of the goal.
The accreditor had previously said it would update the goal because it had received feedback from the field indicating that hospitals felt the goal was too difficult to implement. Last February, The Joint Commission said it would "evaluate and refine the expectations for accredited organizations." The field review is the result of this refinement.
The revised goal is designed to work in tandem with other medication management requirements. It requires providers to maintain and communicate accurate information regarding a patient's medications. Specifically, the goal would require hospitals to:
Obtain medication information from patients at admission
Compare that information with the medications ordered for the patient and identify discrepancies
Communicate to the patient at discharge information about the medications he or she should be taking
Impress upon the patient the importance of managing his or her medications outside of the facility.
The Joint Commission is asking for feedback from the field through May 11, although it would prefer feedback by April 30. The standard will be tested in the field prior to implementation. If you'd like to offer your feedback, and to see the full text of the proposed goal, visit The Joint Commission's page about the field review.
Today's medical students are not learning enough about patient safety, the importance of teamwork and communication, and safety science, according to a new white paper released by the Lucian Leape Institute at the National Patient Safety Foundation on Wednesday.
"It's apparent to most of us that the major challenge in moving ahead in improving patient safety has been getting physicians up to speed, teaching physicians the science of safety, and the skills they need to make healthcare safe," said Lucian Leape, MD, adjunct professor of health policy at Harvard School of Public Health in Boston, during a press conference Wednesday. "We need to start earlier in medial school, and that's what this is all about."
The report was based on three Roundtable sessions attended by 40 leading experts in medical education, patient safety, healthcare, and healthcare improvement. The report, which is the first in a series on identified priorities, comes 10 years after the release of To Err is Human, the groundbreaking Institute of Medicine report on preventable medical errors.
One main point to come out of the Roundtable discussions was that graduate medical education has focused mostly on clinical knowledge and the science necessary to practice medicine. However, that is not enough for today's complex healthcare system.
"Medical students need to learn the science of safety—why people make mistakes and how to design our systems to prevent them, they need to learn about the practice of safety—how we apply that knowledge in actual practice in our safe systems, and they need to learn about the culture of safety—how we create a work environment that makes that possible," said Leape.
One of the reasons that some graduate medical students leave their residencies unequipped with leadership and communication skills is the toxic atmosphere in which they learn. Many hospitals have struggled to create a culture of safety, an environment that encourages staff members to speak up when they see something going wrong, according to the white paper.
Some of the physicians in charge of teaching the next generation of doctors use intimidating tactics and disruptive behavior in their everyday practice of medicine, which teaches residents a lack of professionalism, the authors added.
"Not only are there the basic science elements of patient safety, but there are also the other skills … teamwork, communication, conflict resolution, leadership—elements that other high reliability organizations train from day one to their environment, trainees, and learners," said David Mayer, MD, associate professor of anesthesiology and associate dean for curriculum at the University of Illinois College of Medicine in Chicago, and a member of the Roundtables, during the press conference.
"Things like mindfulness, calling for help when uncertain—those are signs of a culture of safety outside of healthcare, where in healthcare they are still looked at as signs of weakness that have to be addressed. We need to change the way we teach the next generation of providers," he added.
The report calls on the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) to use their leveraging powers to improve patient safety training for medical graduate students. Additionally, the report calls for the creation of new standards by both of these groups, which would take safety science into consideration.
Although John Prescott, MD, chief academic officer at the Association of American Medical Colleges (AAMC), said that educating new doctors about patient safety has been a top priority for American medical schools and teaching hospitals for the last decade, the report asks for more traction from in this area. There are few schools that take a longitudinal, four-year approach to patient safety, said Mayer. The AAMC is taking a comprehensive approach to enhancing quality and patient safety efforts.
The report mentions financial incentives available federally, from Titles VII and VIII of the Public Health Service Act, as well as on a state level. Because preventable medical errors are the eighth leading cause of death in the U.S., a case could be made for using federal funds to bolster graduate medical education requirements.
Another key theme found in the report is the need to launch intensive faculty training programs to ensure that they have the patient safety and communication skills necessary to teach graduate medical students.
"Not only do we need to reform the curriculum, we need to reform the faculty," said Leape. "We have to get them up-to-speed in safety, to learn the science so they can teach it, to learn to be team players, and most of all, to learn to be appropriate role models. Medical students learn the science of medicine in the classrooms and in the labs; they learn the practice of medication by emulating their professors. Therefore, every teacher must be the kind of physician we want our students to become."
This is part two in a two-part series on human factors engineering and its impact on patient safety. Go here to read part one.
Human Factors Engineering (HFE) principles are often being applied to the design of healthcare information technology (HIT).
HFE is defined by the Human Factors and Ergonomics Society as the "scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance."
As HIT increasingly becomes a part of clinicians' everyday jobs, it's important to consider their design. If HIT is not designed with the end-user or end-facility in mind, it may fail at facilitating patient safety.
Ross Koppel, PhD, thinks that most clinicians are amenable to using HIT, but the current technology systems make doing so effectively difficult. Koppel is professor of sociology at the University of Pennsylvania in Philadelphia and principal investigator on the study of the hospital as a workplace and medication errors at the Center for Clinical Epidemiology and Biostatistics at the UPenn School of Medicine.
"People in IT often denigrate the clinical staff as being incompetent people," says Koppel. "There's a share of blame, but my experience has been that clinicians actually want to do very good work and they find the IT to be a barrier too often."
"That, of course, was just a test of the printing of the barcode, it had nothing to do with the actual administration," says Koppel. "It's like saying if your car never leaves the factory it will never get into an accident. That's true—on the other hand, of what value is that?"
He and his colleagues examined the reasons that some clinicians used work-arounds in conjunction with barcoded medication administration systems (BCMA). To do this, they characterized each work-around as a specific type and compiled the data. BCMAs are supposed to help ensure timely administration of the correct type and amount of medication to the correct patient.
Koppel and his colleagues identified 15 reasons why clinicians needed to use a work-around, accounting for 4.2% of patients. These reasons ranged from technology-related (not having enough scanners necessary to read barcodes and computer connected to scanner not able to fit into patients' rooms) to task-related (clinician threw away packaging accidentally, which prohibited scan), to organizational (patient missing legible wrist band and medication missing a legible bar code) among others.
"All of the work-arounds—and all of them are justified given the problems with the software—all of those are work-arounds that severely deteriorate the patient safety protections," says Koppel.
By examining where these work-arounds occurred, four of the hospitals included in the study were able to dramatically reduce the amount of overrides by analyzing why clinicians were using the work-arounds and deciding on system repairs.
"For instance, if a doctor ordered 20 mg of a pill, and the pharmacy sends up two 10 mg tablets," says Koppel. "The nurse scans the first 10 mg tablet and the bar code says, 'That's no good; I'm looking for a 20,' and the nurse is screaming, 'But 10 and 10 equals 20.'"
The facility could write a software patch that tells the scanner that the two pills equal the total amount prescribed, he says.
This is part one in a two-part series on human factors engineering and its impact on patient safety.
When Barbara Wilson, PhD, RNC, begins any new patient safety project, she first examines the principles of human factors engineering (HFE).
Wilson, assistant professor at Arizona State University's College of Nursing and Health Innovation, Center for Improving Health Outcomes in Children, Teens, & Families, says that to ensure her staff members' success, it's imperative to examine how current processes may fail.
"Every time someone makes a mistake . . . there are processes that failed before that for it to ever get to that place," says Wilson, who worked as a hospital administrator and manager at Intermountain Healthcare in Salt Lake City. "It's rarely just that one person wasn't vigilant. It's almost always a systems problem in the process."
HFE is defined by the Human Factors and Ergonomics Society as the "scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance."
Although other high-reliability industries, such as aviation and nuclear power, have utilized HFE principles for decades, healthcare only recently began looking to HFE when designing processes and systems.
Creating a "culture of safety" is a concept that many healthcare facilities have become familiar with in the past five years. A culture of safety is one that deemphasizes individual blame and looks at errors from a systems perspective.
James Reason, one of the most well-known thought leaders on the topic of human error, brought his idea of the "Swiss cheese model" to healthcare to explain how errors can occur in high-reliability organizations.
"He talks about the ‘blunt end and the sharp end'—the blunt end are the organizational factors: staffing, turnover, poor policies, poor leadership, poor management," says Wilson. "All of those lead to the sharp end problems, which are the nurse and the patient, or doctor and the patient. It's the person who interacts directly with the patient that is the recipient of all of those blunt end problems."
Designing with human factors in mind
Utilizing certain basic human factors principles when starting a new project is essential to its success, says Wilson. Referencing a 2001 Journal of Healthcare Risk Management article, "Safety by design: Ten lessons from human factors research," she says using lessons such as reducing reliance on memory, managing fatigue, and reducing the need for calculations will help these initiatives succeed.
Jacob Seagull, PhD, assistant professor and director of education research in the Division of General Surgery at the University of Maryland in Baltimore, says there needs to be a preoccupation with safety at the organization.
"Everyone is involved in safety," Seagull says. "There is an unwillingness to simplify things and dumb things down. With a high-reliability organization, culture of safety has to be a pervasive issue."
Aim for system designs that are uncomplicated and require the least amount of cognitive processing, especially in emergency situations, says Seagull. He gives the example of a master mechanic's garage in which all of the tools are neatly laid out and organized. By comparison, the tubes and tools in a crash cart are often disorganized and can be a hindrance to workers trying to use them.
"A number of people have taken their crash carts and redesigned them so they are as usable as a box of wrenches," says Seagull.
This means that when the caregiver opens the crash cart drawer, he or she only has the necessary tools laid out, not an overabundance. The medications are arranged so that their labels are easy to read, and those medications that are used more often are easier to reach. This approach has shown positive results.
"Something like organizing the physical environment to support the work at hand" is easily accomplished, says Seagull, who applies human factors to medical care.
Wilson has studied the implementation HFE in relation to the mock code process and will begin a study on the use of HFE principles when designing clinical response teams. Prior to each project, she creates a table that outlines basic HFE principles to consider in relation to that specific process and what type of action is being taken to incorporate HFE thinking.
"We have a column that says, 'Is this amenable to incorporating human factors engineering?' and then we talk about what in the current process creates confusion," says Wilson.
For example, reducing reliance on memory is one important factor that can be applied to nearly any initiative. Wilson and her team will go through every step of a process and find where reliance on memory can be lessened through checklists, protocols, or automated reminders.
"I think back to when I worked as a nurse," Wilson says. "At three in the morning, when you're tired and haven't slept much, the last thing I want is to have a staff who has to rely on their memory when I know they're not functioning at 100%."
Considering each of these factors and understanding the vulnerabilities inherent with employees, Wilson suggests that facilities examine what processes can be put in place to minimize the risk of error. Doing so will require input from the facility's top clinicians. It's important to involve those people who are using the process every day and know where HFE principles could be best applied.
Recommendations for utilizing HFE
Although Seagull recommends enlisting the support of a trained HFE professional, there are some actions that can be taken at a unit or hospital level with existing staff. They include "understanding the personal responsibility of not just making sure your patients are doing well, but that all patients in a similar situation will do well, and working on improving the system because problems usually don't happen because of individuals, but because of systems and the way they're designed," says Seagull.
In addition, ask why clinicians may stray away from using certain technologies, says Emily Patterson, PhD, assistant professor at Ohio State University's College of Medicine, School of Allied Medical Professionals, Health Information Management and Systems Division in Columbus.
Also, when introducing new systems, observe whether staff continue to use the old system for certain features, determine what those are, and investigate why they may be doing this.
"We looked at the ED and asked why, if electronic whiteboards are starting to take off, why is there still a manual whiteboard in most EDs? What about that functionality is not in the new system yet?" asked Patterson.
Identifying patients at risk for suicide has been a requirement of the National Patient Safety Goals since 2007. Since that time, inpatient suicide remains the second most frequently reported sentinel event to The Joint Commission, after wrong-site surgery.
Those patients who arrive at the hospital with a primary diagnosis of an emotional or behavioral disorder must be assessed for their suicide risk, and it's important to document well that the assessment occurs, said Sharon Chaput, RN, C, CSHA, director of standards and quality management at the Brattleboro (VT) Retreat, during a recent HCPro audio conference.
"We all know documentation is critical for risk management and legality issues, but it's also a communication vehicle, and we want to ensure that all members of the treatment team have a very clear picture of the patient's risk level," said Chaput.
Chaput and Tasha Farrar, MD, medical director of outpatient services at the Brattleboro Retreat, spoke on the program titled "Suicide Risk Assessment: Comply With The Joint Commission's National Patient Safety Goal and Keep Your Patients Safe."
The components of a suicide risk assessment, as recommended by the American Psychiatric Association, include looking at whether the patient has any psychiatric illness, family history of suicide or personal history of attempted suicide, individual strengths and vulnerabilities, as well as looking at the patient's psychosocial situation.
Documentation
Times to document a suicide risk assessment include:
At the first psychiatric assessment or admission
With the occurrence of any suicidal behavior, ideation, or statements
Whenever there is a noteworthy clinical change
In addition, for those working in an inpatient psychiatric setting, documentation is important prior to increasing privileges, issuing passes, and discharge, said Chaput. Also, documenting whether firearms are present in the home is of the utmost importance.
"It's extremely important if they're present to always remember to document the instructions given to family or guardians, such as 'Removal of guns from the home,' " said Chaput. "If the patient or client states that they do not have firearms or access to firearms, please be sure to also document that you were informed during the assessment that there were no firearms available to the patient after discharge."
To help staff members remember what to document in a suicide risk assessment, Chaput recommends using the acronym SLAP, which stands for:
Suicidality: Does a patient have active or passive suicidal ideation?
Lethality: How lethal/serious is the suicide plan?
Availability: Is the patient's plan for suicide available to him or her?
Plan: What is the plan of action for the patient's team of caregivers?
Suicide risk scales
Suicide risk scales can be great tools for caregivers who do not specifically have a behavioral health background to assess a patient's suicide risk. These tools work well for patients who are admitted through the ED.
Chaput recommended using the well-known SADPERSONS scale, an acronym originally developed by William Patterson and published in the journal Psychosomatics, which assigns a point for each positive response for certain risk factors.
Suicide contracts
Although suicide contracts are commonly used, they have not been proven to reduce suicide, said Chaput, and cannot be considered a legal document. However, if there is a positive therapeutic relationship, contracts can be helpful.
"Suicide contracts can be a very useful tool to help you determine risk and also to counsel the patient, but they do not necessarily protect you or your organization from citation or reduce liability issues," said Farrar. A suicide contract is really a method for gathering information as well as a way of measuring the patient's risk of committing suicide.
Farrar gave the example of a patient expressing depressed and suicidal thoughts. Farrar would ask that patient about her thoughts and also whether she could commit to seeking care when she has strong thoughts about hurting herself before acting on them.
"Now what I just asked her to do is, in a roundabout way, a suicide contract," said Farrar. "But it is primarily an information-gathering tool. She may say, 'Yes, Dr. Farrar, I do have these thoughts, but I don't think I'm going to act on them. They build up slowly, but I do know that if they came back, I would call you or an emergency hotline or go to an emergency room.' She has, by definition, just contracted for safety."
To read more about evaluating a patient's risk for suicide, please see the April issue of Briefings on Patient Safety, a product of Patient Safety Monitor.
One of the most vital parts of providing adequate healthcare is the exchange of information between patient and caregiver. Without clear communication, it can be difficult, and even dangerous, to treat a patient.
For patients who have limited English proficiency (LEP), as well as providers, the presence of a medical interpreter can allay fears about care. Most importantly, using a qualified medical interpreter to assist with communication keeps patients safe.
Until recently, however, there has been no national standard by which to evaluate medical interpreters. Even national requirements on the part of hospital accreditors were lax. In January 2010, however, The Joint Commission released new standards concerning patient-provider communication, that will be implemented no sooner than January 1, 2011. One standard specifically will address qualifications for language interpreters and translators.
Certification opportunities are opening up as well. In October 2009, the National Board of Certification for Medical Interpreters (NBCMI) launched the National Medical Interpreter Certification and hopes to have the first 500 interpreters certified by June. The certification helps define a qualified, proficient medical interpreter.
"The fact that diversity is a national issue, it really does need a national response," says Louis F. Provenzano, Jr., president and chief operating officer of Language Line Services in Monterey, CA. "There hasn't actually been, up until we launched, a single industry-wide standard for training, education, and evaluation of medical interpreters."
Language Line University, along with the International Medical Interpreters Association (IMIA), was a founding board member of the NBCMI.
In addition, the Certification Commission for Healthcare Interpreters (CCHI) will launch its own separate certification for medical interpreters. CCHI expects its first certification exams to be available in the fall. CCHI's process for establishing a certification has been similar to that of the NBCMI.
These certification opportunities for the estimated 15,000 to 17,000 medical interpreters will bring the field up to par with their court interpreter and sign language interpreter counterparts. It will also provide a national standard in the face of many dozens of smaller certificate programs available that do not have one defined level of achievement.
The need for qualified medical interpreters
As the link between an LEP patient and his or her physician, nurse, or other care provider, the medical interpreter has long had a place at the patient's bedside or patient procedure. However, in the past, the interpreter might have been the only person without a credential.
"In healthcare, credentials are very important—not only for professionalization, but for patient safety's sake," says Izabel Arocha, MEd, president of the IMIA. "What we've seen in all these years is that in an operating room, they might be doing a catheterization with all sorts of professionals there that are credentialed according to their specific boards, except for the medical interpreter, who's always been the missing link, the one individual who has been completely unregulated."
There have been a few highly publicized incidents of medical interpretation gone wrong, one being the 1980 case of Willie Ramirez, a Spanish-speaking teenager from southern Florida. Ramirez reported feeling dizzy and having a headache—the result of an intracerebellar hemorrhage—to doctors at an area hospital.
However, because, among other reasons, he and his family insisted he was intoxicado, his original ailment was diagnosed as an intentional drug overdose. The word intoxicado in Spanish, however, can mean feeling dizzy or nauseous. Ramirez became a quadriplegic as the result of the misdiagnosis.
This case is often referred to as one example of the need to have qualified medical interpreters available in the hospital. It is also a federal requirement. Hospitals that accept federal funding are required to comply with Title VI of the Civil Rights Act of 1964, which prohibits discrimination based on race, color, or national origin. This includes providing a translator for those patients who are not proficient in English.
Similarly, Section 504 of the Rehabilitation Act of 1973, which protects the rights of individuals with disabilities, requires healthcare organizations that receive federal funds to provide effective communication for patients who are deaf or hard of hearing.
Many hospitals subscribe to a telephone interpreting service because of the many languages for which they may have to be responsible. Similarly, because of the lack of one national standard, many facilities had to rely on bilingual staff members who could serve as an interpreter in addition to their normal duties—and many still do.
"What many people don't understand is that in order to be a professional, you have to accurately and completely interpret what has been said," says Marc Friedman, interpreter coordinator at St. Jude Children's Research Hospital in Memphis, TN. "People who are not practiced in the profession are not accustomed to capturing what has been said."
In addition, the practice of using children as interpreters for their parents or relatives is not only dangerous because of the potential lack of understanding of what the patient has said, but because of the situation in which the child is placed.
A great deal of research has been conducted on the link between language proficiency and adverse events. Joint Commission researchers, funded by The Commonwealth Fund, found that LEP patients were more likely to experience an adverse event than English-speaking patients.
"Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study," which was published in the International Journal for Quality in Healthcare in 2007, found that more communication-related adverse events were reported for LEP patients than English-speaking patients.
Certification will change the field
The NBCMI's certification has been developed by a 12-member board and is administered by PSI, a national testing agency. The test comprises a written and oral exam. In this way, the NBCMI is following the National Commission for Certifying Agencies' accreditation guidelines and hopes to become accredited by 2011.
"Unless we have a regulated profession, we're not going to change healthcare quality in this country," says Arocha. "It affects all of the other services. If the provider and specialist is going to be accountable for that patient, they need to know what that patient is saying."
The National Patient Safety Foundation (NPSF) has sponsored Patient Safety Awareness Week (PSAW) since 2002 as a means of making caregivers, other hospital staff, and community members more aware of patient safety issues.
This year, the event is being observed from March 7 to 13, and facilities across the country are using the opportunity to educate and involve their staff and patients.
"The origin of the focus was really to provide a week not just for heightened awareness about patient safety, but very specifically a focus on the role of the patient and the consumer in the work," says Diane C. Pinakiewicz, MBA, president of the NPSF, which has expanded the scope of the week by further focusing on the relationship between patients and healthcare providers.
This year's PSAW theme is "Let's Talk: Healthy Conversations for Safer Healthcare." Members of the NPSF's Stand Up for Patient Safety program received a host of materials from the NPSF to help them coordinate the week in conjunction with the theme.
"We've developed a whole set of tools focused on two hot topics: getting to the right diagnosis and healthcare-acquired infections [HAI]," says Pinakiewicz. The NPSF used its well-known "Ask Me Three" template that urges patients to use the following three questions when receiving care:
What is my main problem?
What do I need to do?
Why is it important for me to do this?
In the PSAW toolkits, patients and caregivers are coached to use these three questions in conjunction with receiving the right diagnosis and preventing HAIs. The materials packets are created in collaboration with other healthcare groups, such as the World Health Organization, Association for Professionals in Infection Control and Epidemiology, Society of Healthcare Epidemiology of America, and the U.S. Department of Health and Human Services. Nonmembers can find more information and materials available in honor of the week on the NPSF Web site.
Whether your facility has observed PSAW for years or has just started using the week as a means to enhance awareness of patient safety across your facility, there are many events you can hold to engage patients and staff members.
Spreading the word about a culture of safety
Anne Marie Pizzi, RNC-OB, accreditation and patient safety specialist at Saint Clare's Health System in Denville, NJ, knows what it's like to try to organize events during PSAW without a strong culture of safety present at the organization. She has seen her facility's culture of safety radically improve in the few years she has planned activities for PSAW and hopes that 2010 will show even further advancement.
When Saint Clare's originally began participating in PSAW in 2007, Pizzi found that staff members were reluctant to talk to them about safety concerns.
Fast-forward to 2010: Pizzi and her fellow accreditation and patient safety specialists have made remarkable progress toward creating a culture of safety and transparency, and as part of this, have a more organized, facility-supported approach to celebrating PSAW.
During the 2009 PSAW, staff entered a poster board competition on the topic of the NPSGs. Pizzi and her partners have a small budget, so they explored creative ways to entice staff members to enter. They provided the poster board supplies to reduce individual costs. In addition, the reward for winning the contest was a premium parking spot for one month. The endoscopy group won with its poster about the Universal Protocol, Pizzi says.
"It's funny, we found that staff like to be recognized when they do a good job," says Pizzi. "They don't require huge bonuses—they'd like a raise—but it was just finding something that would make them happy."
Pizzi has planned a similar poster board competition for this year's PSAW and hopes to receive more entries than the six she got in 2009. During the week, Pizzi and her partners visit each of Saint Clare's facilities and set up the poster boards in the lobby. Volunteers will work these poster board tables and hand out literature about the week to staff members and visitors.
Pizzi runs educational games during PSAW and has found that staff members look forward to these activities and have even come to her with ideas and concerns about safety practices. A favorite is a Jeopardy!-style PowerPoint game, says Pizzi.
In keeping with this year's theme of discussing safe healthcare practices, Pizzi says Saint Clare's is concentrating on the Universal Patient Compact, a document produced by the NPSF that focuses on the relationship between patients and caregivers.
"Sometimes we forget to include the patient in our healthcare planning and conversations," says Pizzi. "So it's really bringing that to the forefront for the staff and really [getting] them to embrace this as, 'We need to partner with our patients in a way to give them better care.' "
To read more about ways to celebrate Patient Safety Awareness Week, see the March issue of Briefings on Patient Safety.
HealthGrades recently released its eight annual HealthGrades Annual Hospital Quality and Clinical Excellence study and the results show that the top 5% of U.S. hospitals are improving faster than the rest of the field. The same top hospitals have a 29% lower risk-adjusted mortality rate, as well as a 9% lower risk-adjusted complication rate than other U.S. hospitals.
"This independent study of mortality and complication rates identifies an elite group of hospitals that are setting the benchmark for outstanding patient outcomes," said Rick May, MD, vice president of clinical excellence research and consulting for HealthGrades and an author of the study. "And what's extraordinary is that these hospitals are not standing still. In fact, the data show that they are continuing to improve their patient outcomes at a faster rate, reflecting a commitment to quality that stands as a model for all other hospitals."
The information on which these conclusions are based comes from Centers for Medicare and Medicaid Services (CMS) data for 26 patient outcomes at all 5,000 non-federal hospitals in the country from 2006 through 2008. Those hospitals that placed in the top 5% of all hospitals for risk-adjusted mortality and complication rates, and who qualified based on quality ratings, patient volumes, and types of care provided, were recognized as one of HealthGrades' Distinguished Hospitals for Clinical Excellence. This year, 269 hospitals received this distinction.
The 2010 study found that patients being cared for at one of the 269 facilities in the top 5% were less likely to have suffered an adverse event. In addition, HealthGrades estimates that more than 150,000 Medicare patients' lives could be saved at hospitals if each hospital were to provide the same quality of care as those hospitals in the top 5%.
Of all of the states, Delaware's hospitals ranked highest, with 50% of the state's hospitals making the list of Distinguished Hospitals for Clinical Excellence. Thirty-six states had at least one hospital representative in the top 5%.
The Joint Commission issued its latest sentinel event alert Tuesday about preventing maternal death. This alert is the first of 2010 and the 44th since The Joint Commission began issuing them in 1998.
The alert highlights maternal death in the U.S. as a serious, although rare problem to which hospitals and caregivers should be paying more attention. However, there seems to be few standard practices that these parties can take to prevent maternal death simply because the reasons that pregnant women may die are numerous and related to differing conditions of the patient. Maternal death is defined as death that occurs within 42 days of birth or termination of pregnancy.
"It is a profound tragedy whenever a mother dies in childbirth. Fortunately, these are rare events," said Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission in a press release. "Achieving our national goal of reducing their frequency even further requires organizations and caregivers to have a thorough understanding of the underlying causes of maternal deaths and a disciplined focus on assuring consistent excellence in the early recognition and management of complications of delivery."
The National Center for Health Statistics of the Centers for Disease Control and Prevention said that 13.3 mothers died per 100,000 live births in 2006. This number represents an increase when compared with rates of maternal death in earlier years. Although the increase may be due to more widespread reporting of maternal death, the issue is not one that is improving, according to the alert.
One of the reasons that researchers speculate the number of maternal deaths is climbing is the growing number of pregnant women with pre-existing health conditions, such as high blood pressure, diabetes, and morbid obesity. Obesity brings with it a host of related health issues, which could factor into the maternal death rate.
The alert provides the following specific actions:
Educate caregivers to inform their female patients with underlying medical conditions, such as high blood pressure, diabetes or morbid obesity, that if they become pregnant, they are putting their bodies at even greater risk. Additionally, offer them contraception and where to find preconceptual counseling.
Identify specific protocols for how to handle changes in a pregnant woman’s vital signs, specifically for conditions such as hemorrhage and pre-eclampsia.
Ensure that ED staff are aware that any woman who is admitted may be pregnant, whether she says so, appears so, or not. If staff are aware a woman is pregnant, they may prescribe different care.
Refer pregnant women, who have high-risk conditions, to experienced prenatal care providers
Ensure pneumatic compression devices are available for women undergoing a Cesarean section and are at risk for a pulmonary embolism. Pregnancy is in itself a risk factor for pulmonary embolism and venous thromboembolism.
Evaluate patients at risk of thromboembolism for the use of low molecular weight heparin for care after delivery.