April 30, 2007

Patient Safety is Everybody’s Business
By Mary Anne Gates
For The Record
Vol. 19 No. 9 P. 12

Who will stop the madness of medical errors? Experts agree that it’s going to take a team effort to remedy the situation.

Consider the following statistics from the Institute of Medicine (IOM):

• An estimated 7,000 deaths occur annually due to medication errors.

• The cost of medication-related errors for hospitalized patients is approximately $2 billion annually.

• It is estimated that between 44,000 and 98,000 Americans die each year due to medical errors.

• Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents.

• Every day, 247 deaths in the United States are due to a healthcare-related infection.
How does the healthcare industry fix these numbers?

Increased patient safety may be best achieved by a top-down approach, say some healthcare experts. Today, everyone from the CEO to the bedside patient aide is responsible for patient safety, but shouldering the responsibility has not always been so widely distributed.

“Ten years ago, errors made in healthcare facilities were blamed on the people [staff], not the institution or its procedures. They [the institutions] could have fired all the people involved in an error and done nothing to reduce the chance of it happening again,” says Jim Conway, senior vice president of the Institute for Healthcare Improvement (IHI).

Eventually, an awareness of better ways to achieve patient safety came to the forefront, and changes could be implemented. “What we found out was the vast majority of errors occur because of a bad system, not bad people. A good system puts in place methods that prevent harm to the patient and supports safe practices,” says Conway.

Conway’s advice to those charged with creating a program focused on improving patient safety is to look at what’s wrong in their facility. “The first rule of increased patient safety is to understand the extent of harm in their organization,” he says.

Reducing medication errors and other kinds of medical errors can be accomplished using a system-based approach that incorporates both general and specific initiatives focusing on patient safety, says Martin Hatlie, JD, president of the nonprofit group Partnership for Patient Safety.

“The whole push in safety is a system-based approach,” he says.

General Initiatives
Hatlie cites education and accountability as initiatives that can lead to better safety. “There is a lot of work in a system-based approach [toward] education. There is more focus on the organization and less on individuals. The emphasis is on improving the system as opposed to punishing doctors and nurses [or other staff] who make mistakes,” he says.

Likewise, accountability in the most restricted sense usually holds an individual or group of individuals responsible for a mistake. System-based accountability casts a wider net and holds the organization accountable. Senior management and even the board are accountable for patient safety, says Hatlie. “Patient safety should be on the agenda of every board meeting,” he says.

Hatlie also stresses that compliance and vigilance play significant roles in creating a safer environment.

“The organization must have a culture that supports improvement, is open to examining the way things are done, and is willing to make changes,” says Kenneth Hirsch, PhD, MD, of Medical Risk Management Associates LLC.

Specific Initiatives and Other Interventions
When it comes to patient safety, there are many areas of concern, and several organizations are working on strategies to decrease specific areas of potential. For example, the IHI recently launched the 5 Million Lives campaign. Scheduled to run until December 2008, the campaign has developed six new interventions that are expected to help decrease potential harm to patients. Thousands of hospitals across the country are joining the campaign and implementing these interventions, which include preventing pressure ulcers or bedsores, reducing surgical complications, and reducing harm from high-alert medications such as anticoagulants, insulin, narcotics, and sedatives.

Hatlie also cites other instances of specific initiatives by entities such as The Joint Commission and the FDA, which has developed a plan to reduce medication errors.

Mistakes in a Bottle
Medication errors occur when a patient is given the wrong medication or an incorrect dosage, or when the medication is given to the wrong patient, says Hatlie. Using the wrong route to deliver medication or giving it at the wrong time are other equally serious errors.

“Putting programs in place to change this is a priority. We have the most evidence of medication errors because it has been measured more effectively than other kinds of errors,” Hatlie says.

A program for reducing medication errors has been developed by the FDA. In April 2004, it instituted a bar code labeling system for prescription drugs, over-the-counter drugs, and biological products such as vaccines, blood, and blood products to reduce errors. Bar codes on these products are scanned and matched against a bar-coded wristband worn by the patient.

According to a report, the FDA estimates nearly 500,000 adverse events and transfusion errors will be avoided over the next 20 years. Additionally, during that time, the FDA expects to see savings of $93 billion in health-related costs.

However, there is a caveat. Despite the expected success of the bar code system and the expected savings, the FDA does not have the legal authority over healthcare facilities to implement the system. The agency can mandate bar codes be put on targeted products, but it cannot mandate facilities use them.

“We don’t have jurisdiction over them. We can only suggest, not require, them to pick up the scanner [for bar-coded medications],” says Philip L. Chao, of the FDA Office of Policy and Planning.

Trouble in the OR
Surgical mistakes can be decreased or eliminated, says Hatlie, by implementing a Joint Commission-inspired universal protocol.

Effective for all Joint Commission-accredited organizations since July 1, 2004, the protocol includes a preoperative verification process intended to gather and review relevant documents, ascertaining that the procedure is consistent with patient expectations and the surgical team’s understanding of it. The protocol requires identifying and initializing the correct surgery site.

Another component of the protocol observes a brief time out prior to starting surgery to verify the patient, procedure, site, and that any other applicable materials, such as implants, have been assembled. Additionally, the time out is an opportunity for communication and clarification for the surgical team.

Prior to implementing the protocol, Hatlie says, the surgical team would dive into the procedure, trusting the surgeon knew every detail about the patient, as well as the surgery.

Infection Control
One of the most effective methods of controlling infection while dramatically increasing patient safety is proper hand-washing techniques. According to the World Health Organization Guidelines on Hand Hygiene in Health Care, consistent and thorough hand hygiene has been shown to reduce the frequency of infection throughout the healthcare community.

For example, The University of Geneva Hospitals in Switzerland reported a decrease in nosocomial infections and methicillin-resistant Staphylococcus aureus (MRSA) cross-transmission . Additionally, the IHI’s 5 Million Lives Campaign also focuses on reducing MRSA infections.

“There is a huge, new emphasis on hand hygiene,” says Hatlie. The University of Pennsylvania saw an increase in hand hygiene when it involved both the patients and staff in a Partners in Your Care program. A brochure and visit from a health educator helped newly admitted patients understand the importance of clean hands. They were told to ask if their healthcare providers had washed their hands before touching them. A hand-shaped sign and a small toy were also given to help the patient to inject an element of fun in the program.

To judge the program’s success, the facility measured the difference in the amount of soap and paper towels used before and during the program. Prior to the program, the facility estimated only enough soap was used for staff to wash their hands approximately twice per day. When patients started asking staff if they had washed their hands, soap usage increased by 34%.

Teamwork Reduces Errors
According to Hatlie, a lack of teamwork contributes to increased errors in healthcare. “We haven’t taught hospital personnel to work in teams yet,” he says.

Reducing medical errors in the military began when someone asked how they could apply proven battlefield teamwork techniques in the healthcare arena. For example, the military saw a great reduction of operating room (OR) errors when it applied the same kind of teamwork training to the OR staff that battlefield personnel are taught.

The demand for teamwork in some combat situations and the demands made on personnel working the frontlines of healthcare can be similar, says Hatlie. Further, he emphasizes, teamwork needs to include all team members because someone at the lowest level may observe something not seen by others.

Suggestions From the Partnership for Patient Safety
According to Hatlie, there are various ways to increase patient safety in every area of a facility, including the following:

• Restrict the number of hours a resident can work because more mistakes are made when you’re tired.

• Use an alarm system on anesthesia equipment to alert staff to a potential problem.

• Make sure medication labels are correct.

• Mark the limb (or site) to be operated on.

The Patient’s Role
According to the IOM Fact Sheet 2006, there are many steps a patient can take to avoid becoming the victim of a medication error whether at home, in the hospital, or at an outpatient facility.

Ways to avoid personal or home care medication errors include the following:

• Keep a list of all your medications, including prescriptions, nonprescriptions, and supplements, such as vitamins or minerals.

• Share your list with all your healthcare providers and ask them to review it.

• Know where to find medication information from community resources to knowledgeable Web sites.

At the Pharmacy
• Make sure the brand or generic name of the drug and the directions on your medicine match the prescription.

• Review your list of medications with the pharmacist when necessary for added safety.

• Know you have the right to receive counseling from the pharmacist, who can answer questions about how to take your medication, side effects, and what to do if you have any side effects.

• Ask for written information about your medications.

At the Hospital
• Ask the doctor or nurse what drugs you are being given.

• Do not take a drug without being told its purpose.

• Exercise your right to have a surrogate present whenever you are receiving medication and are unable to monitor the medication-use process yourself.

• Prior to surgery, ask if there are medications—especially prescription antibiotics—you should take or if there are any medications you should stop taking before surgery.

• Prior to discharge, ask for a list of medications you should take at home. Have a provider review them with you, and be sure to understand how these medications should be taken.

Ambulatory Care or Outpatient Clinic
• Ask for complete instructions in writing about your medications. This includes the brand or generic name, its purpose, dosage, and frequency.

• Ask how to use the drug properly.

• Ask about side effects and what to do if you experience any.

— Mary Anne Gates is a medical writer based in the Chicago area.

On A Personal Note
Imagine you’ve been working in the yard all day when something goes wrong. Suddenly, you’re in the hospital after a serious accident involving your riding lawn mower.

A black, spongelike material fills a large hole in your left hand extending from the base of your thumb past your wrist. The tips of three fingers are gone. Sutures keep the remaining fingertip intact. You’re numb but feel lucky to still have most of your hand. Resting quietly in your room, you try to figure out what happened.

Soon, a young nurse walks in with two small packets. She smiles and says, “Here’s your medicine.” Fortunately, you ask what the medications are for. The nurse responds, “Your heart and blood pressure.” Confused, you say, “I’ve never been diagnosed with heart or blood pressure problems.” Now, she looks confused and turns away.

Suddenly, you realize questioning her was the only thing that stopped her from giving you the wrong medication. That’s what happened to me nearly three years ago at a large Midwestern hospital.

— MAG