Hospitals are in the business of saving lives. Yet, gaps in care continue to result in harm. According to a report last year by the National Commission on Quality Assurance, "One thousand Americans or more die each week because the health care system regularly fails to deliver appropriate care."
An article in the June 2003 New England Journal of Medicine reported that clinicians failed to provide appropriate care in nearly half of all cases.
But, there are relatively inexpensive and simple steps that hospitals can take to reduce the number of avoidable deaths in their facilities. Although most of these concepts have been around for years and have solid scientific backing, they are not common practice in many organizations.
"There's still a relative degree of complacency within health care organizations," says James Reinertsen, M.D., head of The Reinertsen Group, a health care consulting firm in Alta, Wyo., and a senior fellow at the Institute for Healthcare Improvement (IHI), Boston.
"Many organizations are satisfied with being close to the benchmark in their practices. But, being close to the benchmark means there are still flaws in the system often resulting in needless deaths."
Part of the problem is that some errors occur so rarely that clinicians feel immune to them. "It's not until someone reputable makes an error that people start to see gaps in the system," says Paul Schyve, M.D., senior vice president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Oakbrook Terrace, Ill.
Another challenging issue is physician autonomy. "We really honor autonomy and independent behaviors in health care," says Don Berwick, M.D., president and CEO of IHI. As a result, hospital leaders worry about creating too many restrictions in clinical practice. "That concern is misaligned," he says, "because clinicians are looking to hospital executives and the board for direction."
Executives and boards can start by identifying physician and nurse champions to spearhead efforts to incorporate evidence-based practices in their work. And, they should present a clear case for change. For example, executives could show physicians overall mortality rates for acute myocardial infarction, as well as comparison data showing physicians how they rank against their peers.
Data collection is key, says Paul Keckley, M.D., executive director of the Vanderbilt Center for Evidence-based Medicine, Nashville. "Hospitals must take a close look at their current practices. They will see there are substantially more lives to be saved," he says.
Hospital leaders must realize that change will not occur without their direct involvement. Blair Sadler, president and CEO of San Diego Children's Hospital, estimates he spends 15 percent of his time directly involved in safety and quality issues.
"A CEO in today's environment has to make a fundamental decision that supporting quality and safety is a core part of the job," he says. "It's a critical mind-shift the CEO has to make to get from a project-to-project quality improvement process to organizationwide transformation."
Ultimately, outside pressure may be needed to spur safer practices. "There isn't sufficient positive or negative consequences to push these practices in the direction of universal compliance," says Ken Kizer, M.D., president and CEO of the National Quality Forum, Washington, D.C.
The experts quoted have made 25 recommendations about steps that can be taken to save lives (this list is not comprehensive, nor is it in order of importance). Many other steps have been identified by patient safety experts and still others may exist in organizations around the country.
1 CLEAN HANDS. As many as 10 percent of hospitalized patients get an infection during their stay. Infections can largely be traced to clinicians doing a poor job of washing their hands. Some studies suggest that fewer than 50 percent of clinicians follow hand-washing protocols.
Hospitals should institute stringent policies requiring that hands be washed with either a hygienic hand rub or a disinfectant soap prior to and after direct contact with patients.
2 THE RIGHT READ. Even the most basic protocol can be overlooked. For instance, putting the correct label on radiographs. Incorrect labeling can lead to clinicians misinterpreting an X-ray or CT scan. Establish such simple policies as marking "right" or "left" on every image to alleviate confusion when it's put on a light box.
3 KIDNEY ALERT. Contrast media is regularly used during radiological procedures. Some patients can develop allergic reactions to dyes resulting in kidney failure. As many as one-third of all hospital-acquired renal failures are linked to intravenous contrast agents. Hospitals should develop evidence-based protocols to evaluate patients at risk of kidney damage due to contrast media.
4 RIGHT DOSE. Nearly 40 percent of medication errors occur during drug administration, according to pharmacy industry reports. One way to cut the likelihood of errors is to store medications in unit-dose or unit-of-use packages, and when feasible, in single-unit packages. Every unit dose should have a bar code.
The FDA has mandated that pharmaceutical manufacturers put bar codes on unit-dose packages of some drugs by 2006. Industry estimates suggest that 30 percent to 50 percent of unit-dose packages currently have bar codes.
5 RAPID RESPONSE. Initially, rapid response teams were used to help transport seriously ill patients to critical care units. Today, they can be summoned by anyone, including patients and families, when a patient's condition appears to be worsening.
The idea is to detect and treat as early as possible any changes in a patient's condition, such as blood pressure, level of consciousness or respiratory rate, which can be early signs of cardiac arrest.
Getting staff to call the teams requires a big cultural change, mainly because nurses are concerned that physicians will question their actions. To address that issue, a set of objective criteria can be established to help clinicians know when to call a team. With the teams in place, incidents of cardiopulmonary arrests have decreased by 17 percent at some hospitals.
6 BEING ALERT. Long hours are nothing new to health care workers. Interns regularly work 80-plus hours a week and nurses often work long shifts, including overtime. Hospitals should teach staff to recognize the signs of fatigue, especially second- and third-shift workers and to work with employees on strategies to minimize fatigue.
7 CLOT WATCHERS. Nearly two million Americans suffer from deep vein thrombosis every year. As many as 600,000 of these patients develop pulmonary embolism; and 200,000 of them die. Clinicians should evaluate patients upon admission and during stay for risk of deep vein thrombosis. Each patient should be evaluated regularly for risk of aspiration.
8 SORE SPOTTERS. Between 7 percent and 25 percent of hospital and nursing home patients develop pressure ulcers. This delays recovery and increases morbidity. Also, it slows the availability of beds. Patients should be evaluated upon admission for risk of developing bed sores and reassessed regularly during their stay. Bedsore prevention plans should be documented in a patient's record.
9 PATIENT AND FAMILY INVOLVEMENT. A high-profile death from a medication error involving a Boston Globe columnist in 1994 led the Dana-Farber Cancer Institute to transform patient care. Among the myriad changes was to involve patients and their families proactively in the care process.
"There's not a lot of scientific evidence to support the belief that patient and family involvement helps reduce the likelihood for errors," says Saul Weingart, M.D., vice president for patient safety. "However, clinicians believe it's true because everyone has a story about how a patient has made a statement that prevented an error or harm."
Patients participate on all safety committees. Moreover, there are two voluntary patient/family councils--one for adults and one for pediatrics--that address safety concerns. Council members visit patients and their families to ask about safety issues and help identify potential problems.
Patients and families are engaged in the medication administration process to avoid adverse drug events. Patients review their medication histories to ensure they are up-to-date. Medication errors are now rare, occurring about one in every 800,000 outpatient doses since 1994.
"Our patients and their families hold us accountable to provide good care," says Weingart. "They don't let us get away with much and that's a good thing."
10 RISKY MEDICATIONS. Almost 6,000 people die every year because of medication errors. Five of the top seven drugs involved in errors are so-called high alert, according to U.S. Pharmacopeia. Lists of high-alert drugs should be made available to all staff. Orders should be double-checked by a clinician once they are filled. A multidisciplinary team should regularly review safeguards for all high-alert medications.
11 KNOW THE DIFFERENCE. A large number of medications share similar names or look similar. Between January 2000 and March 2004, 31,932 reports were submitted to U.S. Pharmacopeia's medication errors reporting program that listed look-alike or sound-alike drug product names, packaging, and/or labeling as a cause for an error.
Hospitals should maintain a list of look-alike and sound-alike drugs. Problem drugs should be stored in an alternate location from those that sound similar. The purpose of the medication could also be written on the bottle. Policies should be instituted to ensure that verbal medication orders are read back to the physician.
12 MATCH THE MEDS. Researchers say that 46 percent of all medication errors occur when a patient is moved from one care setting to another during admission to or discharge from a hospital, or when transferred between units. A standardized protocol should be established requiring clinicians to perform a side-by-side review of a patient's current medications with new orders every time a patient is moved to a new setting. This process is also known as medication reconciliation.
13 CATHETER CONCERNS. Researchers estimate 14,000 to 28,000 deaths a year are caused by central venous catheter-related bloodstream infection.
The IHI recommends a five-step central line bundle: hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, appropriate catheter site and administration system care, and no routine line replacement.
14 MEDICAL MISHAPS. Although rare, wrong-site, wrong-person and wrong-implant surgeries can have devastating consequences.
According to the JCAHO, communication failures are the biggest cause of wrong-site surgeries, followed by insufficient orientation and training on hospital protocol.
The Veterans Health Administration's National Center for Patient Safety, Washington, D.C., is at the forefront of developing safe surgical practices.
The process is used in consort with the VA's Ensuring Correct Surgery Directive, which requires that surgical sites are marked by a surgeon or a member of the operating team with his initials; the patient or family member reviews and signs a consent form that lists the procedure, side, and the name and reason for a procedure; patients are actively identified; and, at least two members of the operating team review images taken for the procedure.
The checklist is reviewed in the operating room while a patient is still awake. The steps call for the surgery team to:
STEP 1: Discuss with a patient the procedure and body part on which the operation is to occur.
STEP 2:Review a patient's medication history.
STEP 3: Review and administer appropriate prophylactic antibiotics to prevent surgical-site infections.
STEP 4: Ensure the proper positioning of a patient.
STEP 5:Review such special equipment as implants and blood products that will be required during surgery.
STEP 6:Discuss such potential anesthesia issues as changes in blood pressure that may prevent the anesthesia from working properly. Since the process was put in place at a Houston facility, at least two operations have been canceled.
In one instance, a patient revealed prior to surgery that he had failed to stop taking an anticoagulant as directed.
In another case, a patient's elevated blood pressure raised concerns and members of the operating team decided it was best to postpone the procedure.
Communication is also enhanced by the use of a white board in the OR that lists important factors related to a procedure and the first names of the surgical team.
"The use of first names helps foster a team environment and encourages team members to speak up when they see a problem," says Beverly Rashad, R.N., operating care line nurse executive.
15 HEART ATTACKS. About 1.1 million Americans experience an acute myocardial infarction (AMI) each year, and a third of them will die during the acute phase, according to the American College of Cardiology, Bethesda, Md., and the American Heart Association, Dallas. Studies show that relatively simple interventions can significantly reduce mortality rates.
McLeod Regional Medical Center, Florence, S.C., in 2002 established a physician-led, multidisciplinary team to review the literature and recommend changes in care.
The team called for reducing wait time for reperfusion--the restoration of blood to the heart muscle--to 90 minutes. The best practice for reperfusion time was between 90 and 120 minutes. McLeod was averaging 176 minutes.
Other recommendations included administering aspirin upon arrival and discharge, administering a beta-blocker upon arrival and discharge, using ACE-inhibitors or angiotensin receptor blockers at the time of discharge for patients with systolic dysfunction and counseling smokers on how to quit.
Between January 2001 and November 2003, compliance with the AMI measures increased from 80 percent to 100 percent. As a result, the average inpatient mortality rate for AMI dropped to 4 percent from 8.6 percent.
The compliance rate is consistently in the upper 90 percent range, says Daphne Heffler, associate vice president. The wait time for reperfusion averaged 85 minutes in 2004.
16 VENTILATOR FALLOUT. Ventilator-associated pneumonia (VAP) occurs in up to 15 percent of patients who receive mechanical ventilation, according to a 2001 article in the journal Chest. The hospital mortality rate for ventilator patients who develop VAP is 46 percent, compared with 32 percent of ventilator patients who do not develop VAP.
The IHI calls for a five-step ventilator bundle: elevate the head to at least 30 degrees, give the patient daily "sedation vacations," every day assess if a patient is ready to be extubated, and provide preventive treatments to avoid peptic ulcer disease and deep vein thrombosis.
17 SHORTHAND RULES. Between January 2000 and August 2004, nearly 19,000 medication errors at 498 health care facilities were attributed to misread abbreviations, according to U.S. Pharmacopeia's error reporting program.
Hospitals should standardize drug abbreviations, and share a list of unacceptable abbreviations and symbols with all prescribers.
Hospitals also should develop poli-cies to ensure that medical staff refer to the list and take steps to guarantee compliance.
18 CARE TEAMS. The opening of an expanded ICU in 2002 inspired Baptist Memorial HospitalDeSoto, Southaven, Miss., to find and adopt best practices in critical care.
One result: The hospital established multidisciplinary rounds to improve care in its 28-bed ICU and step-down unit.
Every morning, a care team of eight to 10 members spends about an hour visiting all patients to discuss the plan of care and a patient's goals for the day.
The team usually consists of a physician; nurse; respiratory, physical and occupational therapists; dietician; pharmacist; social worker; and case manager.
"By and large, this is an easy program to implement," says William Richards, M.D., medical director of the ICU. "It provides everyone an equal voice in the care of a patient. It helps us see where we've been and where we're going."
The hospital's quality indicators show that the undertaking is paying off. Average lengths of stay for ICU patients dropped to 4.5 days in 2004, down from 5.9 days in 2001.
Among other things, the process helped facilitate the adoption of bundles--sets of practices to address conditions--for ventilator-associated infections and central line-associated bloodstream infections.
Despite initial concerns from clinicians that the rounds would increase workloads, they now recognize the benefits. "People like to be associated with good practices," Richards says.
19 PREVENT FALLS. Reducing patient risk of injury due to falls is one of the JCAHO's patient safety goals this year.
While it's up to individual organizations to define what a fall is, clinicians should routinely assess each patient's risk of falling, including noting the medication regime. Bed alarms could also be installed; and fall prevention should be added to patient education programs.
20 FLU SHOTS. Every winter, hospital emergency departments are hit with a wave of patients sick with the flu. Hospital staff are at risk of catching the illness from those who come in for treatment and passing it on to high-risk patients.
Health care workers should be vaccinated against influenza, and hospitals should have explicit policies in place to ensure compliance.
21 SAY AGAIN? Miscommunication is a frequent cause of errors in health care, one that could often be avoided if clinicians simply repeated verbal or phone orders to ensure accuracy.
The JCAHO recommends that a nurse or pharmacist write down a doctor's order and read it back, providing another level of certainty.
Don't assume clinicians are already doing this as a matter of course. National Quality Forum (NQF), Washington, D.C., recommends that hospitals develop clear policies and procedures regarding verbal orders, and to outright prohibit verbal orders for chemotherapy.
The big challenge is getting staff to change their behaviors, says Paul Schyve, M.D., senior vice president at the
JCAHO. "Obviously, McDonald's thinks this is important when it comes to ensuring that your hamburger order is correct," Kizer adds.
22 STOP THE LINE. In an all-too-common scenario, a nurse is berated by a physician because she questioned his orders.
But, the nurse doesn't take it quietly. She issues a patient safety alert, which instantly brings the treatment process to a halt. The physician's orders are examined, treatment is revised and a potential error is averted.
After hospital executives and the department head review the incident, the physician is required to take remedial training in the course of treatment in question as well as an anger management class.
At Virginia Mason Medical Center, Seattle, every member of the clinical staff is empowered to "stop the line" (stop or slow down practices they deem unsafe) ranging anywhere from potential medication errors to staff misconduct.
A patient safety alert notifies senior executives and the appropriate staff members and managers. The incident is immediately reviewed and corrective action is taken to prevent recurrence.
Virginia Mason's patient safety alert system is modeled on Toyota's stop-the-line practice in which any employee can interrupt the production process to prevent a potential problem.
Putting the process in place required no financial investment; it did, however, require a change in the organization's patient safety culture.
Virginia Mason merged its risk management and quality departments to form a patient safety department. It also began developing a blame-free culture.
As that culture takes hold, an alert system is being used more frequently. In 2002, the first year of the program, the hospital averaged three alerts a month. In 2004, there was an average of 15 a month.
Administrators set a goal of 800 alerts per year as a way of getting staff to pay attention and actually follow through on the policy.
23 WOUND INFECTIONS. About 500,000 surgical site infections occur annually, the Centers for Disease Control and Prevention, Atlanta, estimates.
They can contribute to increased length of stay, higher costs of care and increased mortality.
When surgical patients with nosocomial infections died, 77 percent of the deaths were related to the infection, according to the CDC's 1999 Guideline for Preventing Surgical Site Infection.
Mercy Health Center, Oklahoma City, joined the Centers for Medicare & Medicaid Service's National Surgical Site Infection Prevention Collaborative in 2002.
Participants implement a so-called "SSI bundle" consisting of three steps: following guideline-based use of prophylactic antibiotics, appropriate hair removal, and perioperative glucose control.
With those steps in place, surgical site infections at Mercy Health Center plummeted 78 percent after one year.
Getting the bundle in place required a thorough, multidisciplinary review of practices. The review revealed that medications found their way to the operating room in four official ways and about 15 unofficial ways.
The hospital established a standardized delivery system and developed a formulary for OR medications. The hospital also educated staff on the benefits of clipping hair compared with shaving a surgical site.
Prior to implementing the SSI bundle, Mercy Health averaged about one infection for every 101 procedures. As of early March, the hospital had performed more than 1,000 surgeries without an infection.
24 WHO'S WHO? Improper patient identification remains a common source of medical errors. Hospital staff rely too heavily on room numbers as the main source for matching patients with a service or treatment.
The JCAHO recommends that hospitals go a step further and find two additional and distinct identifiers.
West Georgia Health System, LaGrange, uses ID bands that list a patient's name and medical record number. Patients receiving blood products get an additional armband, and two nurses are required to verify a patient's identification before a product is administered; same for high-alert medications.
25 HANDLING DRUGS. Improper labeling, packaging and storing of medications are frequently cited problems in hospitals. There's ample evidence proving that improvements in this area can reduce errors dramatically.
NQF and other patient safety groups suggest standardizing labeling, packaging and storing methods.
Drug lot numbers, expiration date and identification of persons preparing and checking the medication should all be documented.
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