Best Practices in Patient Safety Still Have Room for Improvement

By Debra Wood, RN, contributor

January 31, 2012 - More than a decade since the Institute of Medicine called attention to the problem of patient safety, with its To Err is Human report indicating as many as 98,000 lives were lost annually as a result of medical errors in hospitals, the institute’s latest paper reports improvements have moved at a glacial pace.

“The bottom line is we have a long way to go in patient safety,” said David C. Classen, M.D., MS, an associate professor of medicine at the University of Utah, senior vice president and chief medical officer of CSC in Salt Lake City and a member of the Institute of Medicine’s Committee on Patient Safety and Health Information Technology, which authored the IOM’s latest report, Health IT and Patient Safety: Building Safer Systems for Better Care.

“We’re not making a whole lot of progress,” Classen added. “We’ve had some reduction in mortality rate, and some measures have improved. But overall, the studies in the IOM report say adverse events are occurring in as many as a quarter to a third of all hospital patients in the United States.”

The Office of the Inspector General for the U.S. Department of Health and Human Services reported in 2010 that 27 percent of Medicare beneficiaries experience an adverse event during their hospitalization, with half of those events being serious.

Classen and colleagues reported in a 2011 Health Affairs paper that adverse events occurred in 33.2 percent of 795 hospital cases they reviewed. Some patients experienced more than one adverse event for an overall rate of 49 events per 100 admissions.

Leah Binder, CEO of The Leapfrog Group in Washington, D.C., reports that her organization has seen progress among the nearly 1,200 Leapfrog reporting hospitals. That includes fewer central-line infections and hospital-acquired conditions.

“But unfortunately, nationally, overall, there isn’t much progress,” Binder said. She expects value- based purchasing, with greater reimbursement going to hospitals with better safety records, will help. “But that alone won’t solve the problem. One of the biggest challenges we have is the lack of transparency. And when there is transparency, no one is looking.”

People spend more time shopping for a car than for a hospital, she added. Until patients start deciding they will only accept care at the safest hospitals, she doesn’t think things will change.

“Hospitals have a tremendous number of competing priorities,” Binder said. “Without transparency and strong payment incentives, it’s hard for safety to be a priority for many hospitals.”

Marcia Faller, Ph.D., RN, chief clinical officer and senior vice president for AMN Healthcare,  agreed that pay-for-performance incentives, including third-party payers not reimbursing for care associated with “never events,” such as wrong-site surgeries, will help hospitals make safety a greater focus.

Safety expert Dennis O’Leary, M.D., chief strategy officer for Awarepoint of San Diego, Calif., and former president of The Joint Commission, maintains that care processes must be redesigned, such as using lean processes or Six Sigma to improve safety, and hospital leadership must make the investment in safety a top priority.

“The second issue is creating a culture of safety, and that’s a leadership-driven responsibility,” O’Leary said. Yet, he added, on surveys hospital CEOs typically do not rank it among the top things that keep them awake at night.

“If it’s not important to you; it’s not going to happen, and that’s the bottom line,” O’Leary said. “Until there are some meaningful incentives--and there aren’t meaningful incentives yet--it’s not likely behavior is going to change.”

Better reporting

One nagging problem remains the lack of reliable data.

“To protect patients, industry and government have a shared responsibility to ensure greater transparency, accountability and reporting of health IT-related medical errors,” said Gail L. Warden, president emeritus of Henry Ford Health System and chair of the IOM committee that wrote the most recent report, in a written statement.

Healthcare needs more dependable measures for assessing the current state and monitoring improvement, since current measurements miss most of the events, according to the report.

“If you are missing 90 percent of the patient-safety problems, it’s going to be hard to make real progress,” Classen said. “You cannot manage it if you cannot measure it. … And if you cannot measure it, you cannot improve it. That’s as much the heart of the issue as anything.”

More than 1,800 hospitals are using the American Nurses Association’s National Database of Nursing Quality Indicators. ANA President Karen A. Daley, Ph.D., MPH, RN, FAAN, reported that nurses have told the association that the data provides them greater insight as they pursue clinical excellence and safer care.

Ambulatory settings

Safety problems are not limited to the in-patient setting.

“We have only begun to address safety in the ambulatory setting and have a long way to go,” said Classen, who coauthored Research in Ambulatory Patient Safety 2000-2010: A Ten-Year Review for the American Medical Association’s Center for Patient Safety.

That report found diagnostic errors, including missed, delayed and incorrect diagnoses, are some of the most common threats to patient safety in ambulatory care settings, followed by a lack of follow up on abnormal test results and office-based surgery.

Tara Bishop, M.D., MPH, and colleagues at Weill Cornell Medical College in New York reported in the Journal of the American Medical Association in 2011 that 52 percent of paid malpractice clams for physician services involved ambulatory services, and two-thirds were associated with a major injury or death.

Don Bauman, CEO of Isabel Healthcare in Ann Arbor, Mich., said clinical tools like Isabel can assist clinicians in the diagnosis decision-making process. Its research has shown that the system has offered alternative diagnoses the provider had not thought of in 83 percent of cases, and in 17 percent of them, the physician changed the working diagnosis because of it.

The IOM’s recent patient safety report indicated that the ambulatory setting will require different interventions than hospitals to improve safety, since the type of errors, regulatory requirements and organizational structures differ. Classen’s AMA report concluded that better communication and more research are needed. 

The human element

The Centers for Medicare and Medicaid Services has established the Partnership for Patients: Better Care, Lower Costs, a public-private partnership that has set a goal to reduce hospital-acquired conditions by 40 percent and to reduce readmissions by 20 percent, both by 2013. As much as $1 billion in Affordable Care Act funding will support the initiative. In addition to hospitals and healthcare organizations, employers, health plans and consumer groups are participating.

The IOM’s latest report and the AMA report discuss the importance of involving patients and their families.

“We must engage patients and families,” Classen said. “There is no choice, because healthcare is relentlessly moving down a path where more and more is left to the patient and family.”

For them to succeed, health professionals will need to teach patients how to stay safer and healthier. LodgeNet Healthcare, which provides patient teaching materials through the onsite television, can help. The system documents patient understanding based on a post test, allowing nurses to focus on what else the patient needs to know or what needs reinforcing. The system also will remind patients not to get out of bed without assistance and let the patient adjust the room temperature or lighting.

“It’s an interactive system that can give messages to keep the patient safe and be a partner in their care,” said Kristi Keegan, RN, BAN, CPHQ, director of clinical strategy at LodgeNet Healthcare, Sioux Falls, S.D.

Gottlieb Memorial Hospital in Melrose Park, Ill., has begun a clinical pharmacist program that helps address patient education. It involves the pharmacists in an active review of patients’ medications and lab values. They also are available for inpatient consults and questions after the person returns home.

Technology also can help give back time with the patient. Peter Witonsky, president of iSirona, a medical device integration system, indicates that his system can save nurses an hour in documentation time, because the devices automatically feed data to the electronic health record. That also leads to more accurate charting of the information.

Awarepoint, a real time location system, allows greater monitoring of hand-washing, with caregivers wearing tags picked up by the sensors in the soap or alcohol dispenser. It has led to a greater than 50 percent increase in compliance. The sensors can monitor refrigerator temperatures and whether an IV pump has received cleaning before being redirected to a different patient and to alert the responsible person.

“They are simple things, but you have to get the basic things right to keep bad things from happening,” O’Leary said.

The Joint Commission released in December 2011 a Sentinel Event Alert, calling attention to the role healthcare worker fatigue plays in adversely affecting patient safety. It urges healthcare organizations to examine processes and implement a fatigue-management plan.

A Robert Wood Johnson Foundation funded study, released in January 2012, found that state-mandated caps on nurses’ mandatory overtime hours are reducing overtime hours, which has been previously found to lead to mistakes.

Faller added that nursing care and having enough nurses who are not tired from working overtime can help to improve safety and quality.

Technology’s role

While the government and others tout the safety benefits of new technologies, including electronic health records, patient portals and health information exchanges, greater implementation of technology is not without risk.

“Just as the potential benefits of health IT are great, so are the possible harms to patient safety if these technologies are not being properly designed and used,” Warden said.

The IOM committee recommends the secretary of the U.S. Department of Health and Human Services publish a plan to minimize patient safety risks associated with health IT and report annually on the progress being made; if the secretary determines that progress toward improving safety is insufficient within a year, the U.S. Food and Drug Administration (FDA) should exercise its authority to regulate these technologies.

“Technological intervention is not going to solve the problem,” O’Leary said. “It’s a matter of getting the basics right.”

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