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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.

  • Hurting silently: Assessing pain in nonverbal patients

    How patients assess their own pain is a key component to how hospitals are expected to manage pain medications. But what about patients who can’t communicate their level of pain?

  • USP deadline on hazardous drug handling postponed until 2019

    The U.S. Pharmacopeial Convention (USP) has announced it intends to push back the compliance deadline for USP Chapter <800> “Hazardous Drugs; Handling in Healthcare Settings” from July 1, 2018, to December 1, 2019.

  • Patient handoffs: The gap where mistakes are made

    A patient handoff (also known as transitioning) is both the act of passing a patient between caregivers and the information exchanged between the sender (the provider giving away the patient) and the receiver (the provider taking the patient).

    These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine.

    This exchange is a huge weak point in healthcare; each handoff runs the risk of having key treatment information being garbled, forgotten, or not passed on. On September 12, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and their effect on patient care.

    “Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. “When hand-off communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few.”

    Christopher Landrigan, MD, MPH, research director of inpatient pediatrics at Boston Children’s Hospital and the principal investigator of the I-PASS study on patient handoffs, says that just by looking at the data on the role communication plays in medical errors, one can see how huge an impact handoff can have.

    “Our best estimates are that 150,000-250,000 patients are killed each year in the U.S. as a consequence of adverse events, which are injuries due to medical care,” he says. “In data that’s been gathered by The Joint Commission, Department of Defense, and other agencies, communication is a leading cause of sentinel events, which are the most serious adverse events. All told, communication failures contribute to somewhere between 50% to 80% of sentinel events. So it’s the number one cause of the most serious events in hospitals which in turn are a leading cause of death in the U.S.”

    Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, explains that the information provided during a handoff is key in ensuring a seamless transition of patient care.

    “Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information,” she says. “Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.”

    Part of the problem, she says, is that handoff procedures can vary widely within and between facilities, if they are done at all. While there are several good models and formats for healthcare organizations to adapt and develop, like SBAR and I-PASS, it’s up to facilities to adopt and tailor them for their needs.

  • The route to eliminating hospital-acquired conditions

    Editor’s note: This article was written by Janet Spiegel, MS, a Lean-certified management consultant in Portland, Maine, who has advised and coached several payer and provider organizations. For questions or comments, she can be contacted at jmitchellspiegel@gmail.com.

    The newly released hospital safety report from the Agency for Healthcare Research and Quality tells an encouraging story: Hospital-acquired conditions (HAC) are on a double-digit decline. The study showed that these conditions decreased 21% since 2010. While that progress should certainly be commended, we shouldn't celebrate just yet. Research reminds us that patient outcomes overall are still favorable at hospitals that perform well on quality. And as the most common quality grade received by the scored facilities was a C, we know that opportunity to improve remains. 

    Include RCA in corrective action plans
    One of the graded measures is number of methicillin-resistant Staphylococcus aureus (MRSA) events. As CMS notes, length of stay can contribute to the occurrence of MRSA events, and of course MRSA events themselves can impact length of stay. If there is an opportunity for improvement in any of the measures at your facility, it’s important not only to have a corrective action plan (CAP) in place for audit readiness and future safety surveys, but to ensure that the CAP is based on a root cause analysis (RCA).

    For example, consider a hospital that experiences a spike in MRSA events. The hospital may put a CAP in place that focuses its interventions around improving wound care or changing sterilization processes. While these may be wise in theory, without a focused RCA, the facility cannot know for sure that these interventions will reduce these specific MRSA occurrences.

    Recently a hospital group shared that it was incentivizing its providers to discharge patients by noon every day. It was a clear directive that providers bought into: "Let’s move our patients back to their homes as soon as they are ready to reduce the possibility of infection or other conditions and to turn over beds for those who need care."

    The positive impact to patient satisfaction, patient outcome, process, and revenue was undisputable. What unfortunately resulted was that when providers came too close to the noon deadline, they would hold their patients an extra night to meet their metric the next day.
    At times, our metrics can incent unhelpful behaviors. Through an RCA, teams may uncover what MRSA patients have in common—whether the infections are due to delayed discharges, inadequate wound care, ineffective sterilization processes, or something else the teams hadn’t considered. This will ensure they are solving for the right problem.

    Use the Plan-Do-Study-Adjust cycle in your CAP
    Continuous improvement is an experimental cycle, commonly known as Plan-Do-Study-Adjust. Once the problem has been defined and the RCA with data or observation has been performed, only then should teams move into intervention mode where a solution, hypothesis, and action plan are proposed.

    The intervention portion of the cycle is where the experimentation happens. Try the proposed solutions documented in the CAP, and study the results as frequently as possible. It can take a while to gather data on large-scale problems such as MRSA, but it is recommended that teams be vigilant in their quest to improve. Ask what can be done in a week, a month, six months, etc. Test against hypotheses within short time frames rather than waiting for large amounts of data. Through this method, teams will be able to test small ideas, adjust, then cycle back around to learn whether the problem has been solved.

  • Q&A: The hospital, the law, and the patient

    Controversy flared this fall in Salt Lake City after police body camera footage of the July 26 arrest of University Hospital nurse Alex Wubbels went viral. Wubbels had refused a police request to draw blood from a patient, citing hospital policy. Salt Lake City police detective Jeff Payne responded by shouting at Wubbels and handcuffing and arresting her on suspicion of obstruction of justice.

    Wubbels was released after 20 minutes, according to The Salt Lake Tribune, and returned to the burn unit approximately 10 days later. Payne was later fired over the arrest, and his watch commander, Lt. James Tracey, was demoted to the rank of officer.

    The University Hospital in Salt Lake City announced in August that police will no longer have contact with nurses, but rather deal with hospital administrators instead. In addition, law enforcement officials will no longer be allowed to enter the emergency room, burn unit, or other patient areas.

    The Utah case was an example of everything that could go wrong in a law enforcement/healthcare interaction. However, these two groups often have to work closely together. And if a patient comes in who is under arrest, providers need to know the extent and constraints of the law.

    The following is a Q&A with Lisa Terry, CHPA, CPP, vice president of healthcare consulting at US Security Associates, Inc. and author of HCPro’s Active Shooter Response Toolkit for Healthcare Workers. She spoke with PSMJ about police/provider interactions and the rights of patients under arrest.

    Q: How often do hospitals have to work with the police? How closely do these institutions work together?
    Terry: Generally, they work in the emergency department very often. Level I and II trauma centers generally have a police officer there 24/7 in response to injuries sustained in vehicular collisions, fights, or other instances where individuals are injured in a public setting.

    Law enforcement also bring individuals seeking behavioral health/mental health assistance to the ED in an effort to obtain medical treatment for them.

    Q: When it comes to interacting with the police, should that be done by a specific person (e.g., a hospital liaison officer)? Or should all staff be trained for it?
    Terry: In my experience, in order to comply with HIPAA [the Health Insurance Portability and Accountability Act] and the respective state laws, hospitals should have written policies and procedures which detail how and when information is released to external law enforcement agencies. I’ve found these policies to be most successful when they are written in concert with the hospital legal team and the local law enforcement legal teams.

    The policy/procedure should [have] a specific position 24/7 to serve as that contact for all external law enforcement agencies. Typically, that designated individual is a leader from the hospital security department, a clinical house supervisor, etc. All hospital staff should have a general working knowledge of HIPAA, but the policy could perhaps designate your “superusers.”

    And even superusers should have quick reference guides due to the fact that HIPAA and state laws regarding patient health information are very lengthy and very specific; a lot of legalese. A quick reference guide is very necessary to quickly look, review, and determine whether information may be released.

    Q: How does being placed under arrest affect a patient’s rights? What if the patient isn’t under arrest but is in police custody?
    Terry: A patient’s freedom of movement is the most obvious right that is affected when he or she is under arrest. The patient may not be able to refuse certain treatments based on the situation (if he or she is contagious, etc.).

    In many states, the patient may still have certain rights as far as making sure their privacy is maintained. Generally, most hospitals have a policy in place from a safety standpoint for all concerned to cloak (protect) the custodial/forensic patient’s information from being public. A hospital is a place where the security of the custodial/forensic patient is vulnerable. It’s obviously not as secure as a prison.

    Most custodial/forensic patients originate from the Department of Corrections (prisoners who have already been adjudicated) or from state/local law enforcement (individuals under arrest but not adjudicated). Regardless of the type of custodial/forensic patient, most hospitals require that the custodian remain with the patient at all times and that the patient is restrained with a forensic restraint (law enforcement) at all times.

    The only exception to this requirement would be due to a medical necessity or procedure for the custodian to remove the restraint. At that time, a determination would be made (for safety) if a medical restraint (chemical, etc.) should be utilized to ensure that the patient remains secure.

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