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Patient Safety Monitor Journal

Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.

  • CDC updates SSI guideline for the first time in 18 years

    In May 2017, the CDC released its new guideline for surgical site infection (SSI) prevention, the first such update since the turn of the century.

    Between 2006 and 2009, roughly 1.9% of surgical procedures in the United States resulted in SSI complications; however, it’s likely that number is much higher since about 50% of SSIs don’t become evident until after discharge. Estimated costs of SSIs range from $10,443 to $25,546 per infection, although it can cost more than $90,000 to treat an SSI involving a prosthetic joint implant or an antimicrobial-resistant organism.    

    “There is increasing demand for evidence-based interventions for the prevention of SSI,” wrote lead author Sandra Berríos-Torres, MD, in the guideline. “The last version of the CDC Guideline for Prevention of Surgical Site Infection was published in 1999. While the guideline was evidence informed, most recommendations were based on expert opinion, in the era before evidence-based guideline methods.”

    Answering the call of healthcare professionals, the CDC updated the guideline using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process to condense thousands of studies into 170 high-quality trials. The results were then categorized by the strength of the evidence supporting them.

    The news was published in JAMA Surgery and includes an accompanying editorial.
    “The [updated] CDC guidelines use a strict process for literature review, development of consensus, public reporting, and refinement of their final recommendations,” wrote Pamela A. Lipsett, MD, MHPE, MCCM, in the accompanying editorial. “The article from the CDC by Berríos-Torres et al in this issue of JAMA Surgery is useful to every surgeon because it is brief and summarizes the recommendations, with their level of support. It tells us what we should do and what we do not know. The supplementary material is inclusive and recommended for anyone with a thirst for the evidence supporting these recommendations.”

    Peggy Prinz Luebbert, MS, CIC, CHSP, CSPT, an infection prevention and healthcare safety professional and consultant, says that having guidance based on expert opinion rather than evidence is par for the course in our society right now. It’s difficult and expensive to scientifically validate medical recommendations, which unfortunately means physicians often have to depend on opinions. That’s what makes the CDC’s update such a breath of fresh air.

    “I’d say it’s easier for us to present information to our surgeons when the science is there and has been validated,” she says. “Unfortunately, that’s so difficult to do. It’s going to be hard unless time and money are put in by either private parties or the government to be able to [do the research and] get the validation we need. So we’re not going to see very many [of these kinds] of updates.”

  • Burned out or under the influence?

    Editor’s note: By the time the general public hears about an impaired clinician, whether it’s a nurse, technician, or physician, it’s usually after something bad has already happened. The infamous case of a New Hampshire technician who stole painkiller syringes and exposed thousands of patients to hepatitis C is just one example. The following is an edited Q&A with Judy Kees, a regional coach leader at Studer Group with human resource executive experience at several health systems. PSMJ spoke with Kees on how to deal with an impaired employee, how to identify the problem before harm is done, and what your obligations are afterwards.

    PSMJ: As a whole, how does the healthcare industry do at preventing nurses, physicians, technicians, etc., from working impaired? 
    Kees: I would like to say we are 100% successful in our efforts. We are not at that percentage. I don’t have an exact number, yet we know some people “slip through.”  That’s why we have policies and procedures in place.
    In today’s environment, this is continual work in progress. Ideally, we’d identify history during pre-hire via upfront referencing and licensing verification (if applicable). But that only identifies those with impairment issues which have been reported. Providing safe, high-quality patient care is of highest priority in our industry. As such, we as leaders are trained to watch for disruptive behaviors, monitor actions, and set a regular process and standard to audit our medications and administration records. In organizations where there is a real commitment to coworkers, staff reporting is essential to creating the environment we all seek.

    PSMJ: How can you determine when someone is impaired and needs to stop working? Ideally, you’d like to catch them before they make a mistake, but is that always feasible? 
    Kees: You would look for nontraditional or unexpected behavior. They may have slurred speech; it may be their eyes. It may be that they don’t appear to care anymore or are anxious in their daily routines. In some cases, they are [acting] mean, yelling in their workplace at patients and others.
    Another thing is if they’re missing work. An old thing we always researched was, “Are they missing a lot of Mondays and Fridays?” if they typically work Monday through Friday.
    You look for those behavior changes, and as you see them, you’ve got to be ready to address the issue and not just say, “Oh, that’s just the way Judy is.” You’ve got to get in there and start dealing with issues as soon as they happen.
    We rely on each other as well. I spent a long time in hospitals, and it was important for someone to feel like they could come and talk with me anonymously if they felt something was wrong with one of their peers or someone in another department. A lot of times they’re worried about their anonymity because they don’t want to get anybody in trouble. It’s not unusual during investigatory and discipline session for those in question to ask, “Who told you that?!” You don’t have to say who told you that. “It doesn’t matter” are my famous words—“It’s been reported and I’ve got to consider it.”
    Leaders must be out and about, talking with their direct reports, making sure they are appreciated as well as working per organizational expectations/standards. When you do have an occurrence or incident, best practice is to immediately remove them from their work assignment and follow your organization’s policy. That may be immediate substance testing; it may be Employee Assistance Program (EAP) counseling. In either case, you want to temporarily remove them from their assignment, get them taken home, and begin your investigative work.

  • How to get readmission rates under control

    To say readmissions are a big deal in medicine is a massive understatement. The Hospital Readmissions Reduction Program (HRRP) was enacted in 2010 specifically to take on this problem and has imposed nearly $1 billion in penalties. An estimated $17 billion in Medicare spending is spent annually on avoidable hospital readmissions. Readmission rates are currently used in CMS’s hospital star ratings system, and the agency financially penalizes hospitals that have high readmission rates. In August 2016, CMS announced a few changes to the HRRP that are expected to save CMS $538 million by increasing the number of hospitals penalized and the amount they’re fined. By the end of 2017, it’s expected that more than half of hospitals will be fined for high 30-day readmission rates, according to CMS projections. That’s 2,588 hospitals expected to lose up to 3% of their Medicare payment.

    There’s been much discussion over how much control physicians actually have on readmission rates. Some studies have even found that readmissions sometimes improve outcomes.

    However, the fact remains that facilities are paying millions in readmission fines and penalties, which hospitals and clinics could be using for promoting patient safety and quality improvement projects. Here are some methods to make sure patients who leave the hospital don’t wind up right back in the lobby.  

    Create a readmissions reduction team
    One of the reasons hospitals struggle is that the causes of readmissions are all over the map, says Michelle Schneidermann, MD, a professor of clinical medicine at Zuckerberg San Francisco General Hospital (SFGH) and medical director of San Francisco’s Medical Respite. There are system-level problems that are within a hospital’s control, such as poor discharge planning and care coordination. Then there are patient-level factors that hospitals can’t do much about, such as substance abuse or mental illness.

    “Furthermore, I don’t think there’s clear consensus on what proportion of readmissions are even preventable,” she says. “Last I checked, the literature cites rates somewhere between 5% and 80%, and there’s more emerging evidence that it’s going to shake out somewhere in the 20% range. But it’s really hard to know how to benchmark this measure, and I think it’s unfair for hospitals.”

  • Right dose, right drug: WHO challenges hospitals to cut med errors in half

    At the end of March, the World Health Organization (WHO) announced its third global safety initiative, the Global Patient Safety Challenge on Medication Safety, which calls on facilities to cut the rate of medication-related errors in half by 2022. The organization hopes to do this by:
    •    Addressing weaknesses and flaws in how drugs are prescribed, distributed, and consumed
    •    Providing education on safer and more effective prescribing habits and methods
    •    Increasing patient and provider awareness on the dangers of medication errors

    Worldwide, medication errors cause at least one death per day and cost an estimated $43 billion annually (1% of global health expenditures). In the U.S. alone, 1.3 million people are injured annually due to medication errors. All these errors are potentially avoidable, says the WHO, so long as the right systems and procedures are put into action.

    “We all expect to be helped, not harmed, when we take medication,” wrote Dr. Margaret Chan, WHO director-general, in the press release (https://goo.gl/4pRbYB). “Apart from the human cost, medication errors place an enormous and unnecessary strain on health budgets. Preventing errors saves money and saves lives.”

    Can it be done?
    Joe Kiani, founder of the Patient Safety Movement Foundation (PSMF) and chair and CEO of the Masimo Corporation, has high hopes the WHO will achieve its goal of 50% harm reduction; as proof, he points to the success of the organization’s first global patient safety challenge on hand hygiene (www.who.int/gpsc/en). 

    “I think over 50 countries and nearly 20,000 hospitals have joined [the Clean Care Is Safe Care challenge],” he says. “They’ve reported that they are saving 7–8 million lives a year from it. So yes, I believe they can do it [with medication errors].”

    He says the people behind the project are very serious, dedicated, and caring, and he’s excited at the initiative’s potential.

    “This is one of the areas we’ve been pushing for at [PSMF],” he says. “Safe medications, dosage, and prescription. We’re delighted to get this reinforcement from WHO.”

    Megan Maddox, PharmD, BCPS, CDE, medication safety officer at Sanford Medical Center in Sioux Falls, South Dakota, says she’s thrilled that the WHO is shining a spotlight on medication safety.

    “This [medicine] is what we send people home on from the hospital,” she says. “They don’t go home and do procedures on themselves or surgery. That’s done at the hospital, and what we do to keep them well and out of the hospital is treat them with medication. Making medication safety a priority and having people really emphasizing patient understanding in what they’re taking and what for—I think it’ll have a very positive impact on keeping our patients safe and really keeping sure medications effectively work for our patients.”

  • Q&A: IHI and NPSF merge to push patient safety initiatives

    Editor’s note: In March, the Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) announced that they would merge starting May 1. The two organizations have been leaders in the patient safety field for years, and there is much hope stemming from their collaboration. The following is a lightly edited Q&A with Tejal K. Gandhi, MD, MPH, CPPS, NPSF president and CEO, about what the merger will mean for the combined organization, now called the Institute for Healthcare Improvement. As of May 1, she is the Institute’s new chief clinical and safety officer.

    PSMJ: How did this merger come to be, and how long have you been planning it?
    Gandhi: The rationale behind our merger is straightforward: We want to ensure that safety is a central part of every organization’s improvement strategy today, and that the safety of patients and the healthcare workforce becomes a core value of healthcare systems around the world.
    IHI and NPSF have actually worked together intermittently for many years. More recently, however, we’ve shared a concern that while progress is being made in patient safety, there are also many other competing priorities in healthcare. With that in mind, we started talking about working more closely together to further raise the profile and urgency of patient safety.
    Over time, we came to the conclusion that the way to offer health professionals and patient safety advocates (including patients) the best resources, tools, and teaching to deliver the safest care would be to formally combine our strengths into a single organization.

    PSMJ: What do you hope the outcome of this merger will be for your combined organization and for healthcare in general?
    Gandhi: The governing boards and senior leaders of both organizations strongly believe that together, IHI and NPSF can advance their missions more effectively than they could by continuing to work apart. Together, we believe our combined knowledge, skills, and resources will be more effective in helping leaders and frontline clinicians meet all of today’s challenges, and together, we intend to develop some fresh approaches to focus and energize the patient safety agenda.
    Both organizations have put a strong emphasis on the importance of organizational culture and systems of safety rather than approaching patient safety as a series of projects. We also want to see greater emphasis on the continuum of care, because while most patient safety research and improvements have focused on hospitals, most care is delivered in the outpatient setting.
    IHI recently released A Framework for Safe, Reliable, and Effective Care (www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx), [which] really describes a system of safety and how it can be achieved in healthcare.

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