Asking pharmacists to review discharge medication orders at a Minnesota-based hospital dramatically reduced drug-related errors at the facility, according to a Jan. 5 Star Tribune article.
Pharmacists at the Minnesota-based Hennepin County Medical Center (HCMC) examined discharge medication orders before patients are released. HCMC began this project after examining 37 patients who were discharged from the hospital to a nursing home from 2008 to 2009. They found that a medication error occurred in 92 percent of the cases, with only three of the 37 patients receiving the correct prescription.
They found that hospital physicians had prescribed the wrong doses or duplicate medications, or they omitted medications. Under the new system, pharmacists can recognize errors and contact the physician to fix potentially harmful mistakes.
Nine months after implementation, the error rate dropped to nearly 0 percent, which in turn cut the 30-day readmission rate in half to less than five percent.
As the official Medicare Quality-Improvement Organization for Missouri, Primaris is committed to reducing medical errors and unnecessary admissions. Find out more.
According to a Jan. 16 Infection Control Today article, implementing a multi-modal infection prevention program improves hand hygiene guideline compliance among healthcare providers. Researchers from the Center for Innovation in Quality Patient Care at Johns Hopkins developed a healthcare-associated infection prevention program and measured healthcare workers’ hand hygiene practices after implementation over a three-year period. The multi-modal program included a multimedia communications campaign, education, leadership engagement, environment modification, team performance measurement and feedback. Researchers found that hand hygiene compliance increased from 35 percent to 77 percent among nursing providers and from 38 percent to 62 percent among medical providers.
According to a Jan. 3 McKnight’s article, a recent study suggests that healthcare workers who wear gloves when treating patients are less likely to wash their hands between patients.
The study, which was published in Infection Control and Hospital Epidemiology, looked at more than 7,000 patient contacts in 56 intensive care units (ICUs) and geriatric care units in 15 hospitals.
Researchers found that proper hand-hygiene compliance rates were "disappointingly" low at only 47.7 percent. Healthcare workers appear to be substituting glove use for hand washing, according to the study.
"The chances of hands being cleaned before or after patient contact appear to be substantially lower if gloves were being worn," said lead researcher Dr. Sheldon Stone. Investigators point out that some germs can get through latex gloves, increasing the risk of healthcare-associated infections. Read more.
One of the most common types of health care–associated infections is the central line–associated bloodstream infection (CLABSI), which can result when a central venous catheter is not inserted or maintained properly. About 43,000 CLABSIs occurred in U.S. hospitals in 2009—and nearly one of five infected patients died as a result.
A new synthesis report and case study series offer lessons from hospitals that reported that they did not experience any CLABSIs in their intensive care units in 2009. These lessons include: the importance of following evidence-based protocols to prevent infection; the need for dedicated teams to oversee all central line insertions; the value of participation in statewide, national, or regional CLABSI collaboratives or initiatives; and the necessity for close monitoring of infection rates, giving feedback to staff, and applying internal and external goals. The reports also explore ways these hospitals are spreading prevention techniques to non-ICU units, and strategies for preventing other health care–associated infections.
As nearly 20 percent of Medicare patients are rehospitalized within 30 days of discharge, minimizing post-discharge adverse events has become a priority for the US health care system. A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated.
To help ensure safer care transitions and reduce readmissions, hospitals should begin by looking at 3 things prior to patient discharge:
Medication reconciliation: The patient's medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions.
Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians.
Patient education: Patients (and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge.
The MOCPS announces its fourth call for applicants for the Missouri Excellence in Safe Care Award. Applications for award consideration are due to MOCPS no later than December 30, 2011. Visit our conference web page for more information.
Any successful and realistic plan to improve healthcare quality requires clear and current evidence-based guidelines. For providers seeking to prevent Catheter-Associated Urinary Tract Infections (CAUTIs), a new report from The Joint Commission can help.
The report (download here) provides acute care and critical access hospitals with a better understanding of the new requirements under the National Patient Safety Goal effective next year.
Interested in more training to prevent infections? Learn about a series of free training sessions throughout the state!
Missouri nurses and other front-line staff have a chance to hone their infection-prevention skills at a series of free classes around the state in November. Sponsored by the University of Missouri's Sinclair School of Nursing, the program offers Nursing CE Credits to qualified trainees.
Sessions are offered in four Missouri cities. They are each from 8:15 a.m. to 3:45 p.m. at the following locations:
Empowering patients to become part of their own healing process, and even part of the ‘medical team’ has improved the overall quality of healthcare in many cases. By asking questions during a consultant with a healthcare provider, for example, patients can learn more about their treatment and lessen the changes of problems later on. The Agency for Healthcare Research and Quality recently published a small booklet (22 pages, PDF) to help patients become part of the healthcare team. As a free downloadable resources, you can obtain the booklet here – it may be a great resource to distribute to patients.
HHS’ Partnership for Patients has teamed up with the National Quality Forum to launch a series of free patient safety Webinars, the sixth of which focuses on preventing pressure ulcers and falls, is scheduled for September 9.
Featured speakers are Mary Tinetti, M.D., Director, Program on Aging, Yale University School of Medicine, and Dan Berlowitz, M.D., Director, Center for Health Quality Outcomes and Economic Research, Veterans Affairs. The session will discuss the Partnership for Patients' goals of reducing falls while maintaining patient mobility and reducing preventable pressure ulcers in acute-care settings. Future webinars will include topics on obstetrical adverse events and venous thromboembolism.
Register for the Sept. 9, Noon–1:30 p.m., CDT, webinar.
The AHRQ recently released a report that takes a critical look at the effects of HIT on medication management. This evidence-based report, “Enabling Medication Management Through Health Information Technology”, considers the impact of HIT applications related to clinical, economic, and overall effectiveness criteria. The report concludes that IT applications such as clinical decision support and computerized physician order entry have demonstrated a positive impact on patient care processes, although limited studies on clinical outcomes and cost-effectiveness showed only mixed findings. You can view the report in its entirety, or order a print copy by sending an e-mail to AHRQpubs@AHRQ.hhs.gov.
A new article by the Agency for Healthcare Research and Quality (AHRQ) reviews how the Medical Home model is coming back and the importance of Health Information Technology (HIT).
The patient-centered medical home (PCMH) has emerged as a model of care that aims to restore order to the nation's primary care system. It reasserts the role of primary care by taking a team approach to health care and placing the patient at the center of that team. The PCMH model emphasizes the role of primary care practitioners to coordinate their patients' care across multiple locations and settings and over time; creates cost savings by delegating less complex aspects of care (e.g., so that specialists do not spend their time following up on routine chronic diseases); and uses measure-driven incentives to reward the quality of outcomes rather than simply volume of services provided.
The PCMH is a promising development, with even greater potential when it is combined with the harnessing of the power of health information technology (IT) to enable rapid quality improvement. At the time of the PCMH concept (HIT) was just getting started, now with advanced HIT Capabilities include IT's ability to—
Collect, store, manage, and exchange relevant personal health information, including patient-generated data.
Enhance or facilitate communication among providers, patients, and the patients' care teams for care delivery and care management.
Collect, store, measure, and report on the processes and outcomes of individual and population performance and quality of care.
Support providers' decision making on tests and treatments.
Inform patients about their health and medical conditions and facilitate their self-management with input from providers
Read the article to find more or go to http://www.ahrq.gov then click on What’s New at the top of page, then look under News and Information.
As the focus in the healthcare industry continues to transition from the traditional acute-care model to outpatient settings, the approach to preventing infections must also change.
In an effort to help with this transition, the Centers for Disease Control and Prevention offer tools to assist providers in preventing infections in ambulatory care settings.
Primaris can also assist providers in Missouri in the struggle to prevent healthcare-acquired infections. Contact our hospital team for more information.
The Missouri Center for Patient Safety has planned its Annual Patient Safety Conference for April 17, 2012. The conference will again be at the Stoney Creek Inn in Columbia.
A key part of the conference will be the presentation of the Missouri Excellence in Safe Care Award. Applications for this award will be available in October; however, providers interested in entering their patient-safety project are encouraged to start planning ahead now.
The Centers for Disease Control and Prevention (CDC) and its Healthcare Infection Control Practices Advisory Committee (HICPAC) have updated the “Guidelines for the Prevention on Intravascular Catheter-Related Infections.” The guidelines include new recommendations supported by recent research to help eliminate deadly and costly healthcare-associated bloodstream infections.
The guidelines note that the goal of any prevention program should be to reduce the rate of infection as much as possible, given the limitations of current technologies and strategies, the specific patient population, and the presence of microorganisms in the human environment.
Editor's note: Infection Control Todayreported on the new guidelines June 13.
A recent article in the Wall Street Journal provides an overview of patient-safety techniques and strategies discussed in this feature over the years.
Some of the ideas include:
- Time outs: According to the article: "Emergency departments are also adopting time outs before a patient is released to allow nurses to stop the discharge process if they see anything that may have been overlooked, such as a vital sign that remains abnormal, or a patient's statement that didn't come out when a medical history was first taken." - The trigger-system approach: According to the article: "Beth Israel Deaconess Medical Center in Boston has started using a so-called trigger system that looks for abnormalities in five vital signs, including elevated heart rate and blood pressure, to determine which patients should be seen and treated faster. "If they meet one of the five triggers we intervene as quickly as we can," says Carrie Tibbles, associate director of graduate medical education." - Better assess stroke victims: According to the article: "It recommended that younger patients with seemingly minor symptoms like vertigo and nausea be meticulously assessed and that an MRI be performed as soon as possible." - Team huddles: According to the article: "At Taylor Hospital in Ridley Park, Pa., where 30,000 emergency patients are treated annually, emergency chief Gregory Cuculino says maintaining electronic medical records has had an unexpected downside: Staffers type information into the system but don't verbally communicate with each other. "Huddles allow everyone to go over the case, so if someone says, 'Mrs. Smith in room four looks good,' the nurse has a chance to say, 'She just threw up again,' " says Dr. Cuculino." - Move patients to beds so they and physicians can get vitals fast: According to the article: "At Abington Memorial Hospital near Philadelphia, Sue Cissone, clinical coordinator of the Emergency Trauma Center, says a pilot project is moving patients immediately to beds in the treatment area where they can be seen by a doctor and nurse together, helping ensure both hear vital information."
When leaders are dealing with the new challenges and opportunities presented by health reform, impending payment changes, medical homes, accountable care organizations, and more. How can they see the forest for the trees?
They need bifocals, or even trifocals, according to Dr. Karen Boudreau, IHI Senior Vice President and Medical Director for the Continuum Portfolio. Dr. Boudreau feels Partnering with patients and families are the key strategy. Read more.
A new Flash-based Web tool from the U.S. Department of Health and Human Services puts users in the situation surrounding a hospital-acquired infection case. Users can assume the role of a physicians, a nurse, a medical students or a patient-safety advocate.
The interactive tool examines the events leading up to a tragedy at a fictional big-city hospital. Site users can make decisions which effect what happens next.
Download the facilitator's guide to this Web resource
Join the Missouri Center for Patient Safety to celebrate all the important things Missouri healthcare providers are doing to provide safe care. The Center is showing off the great work that has been accomplished by our participants, and has released a summary of its first five years; within this release is a map and listing showing everyone who has been involved with MOCPS projects.
If you would like your hospital to tout the projects you have participated in, contact Marilyn Nichols to request a copy of a press release template designed for use by your facility and celebrate your accomplishments!
More than 770,000 people are hurt or killed each year in hospitals from adverse drug events (ADEs), which may cost up to $5.6 million annually per hospital (depending on hospital size). This estimate does not include ADEs causing admissions, malpractice and litigation costs, or the costs of injuries to patients. National hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between $1.56 and $5.6 billion annually.
To learn more about the cost of ADE’s refer to this article from Agency for Healthcare Research and Quality (AHRQ)
Earlier this year, the Centers for Medicare & Medicaid Services required acute-care hospitals to report Central Line-Associated Bloodstream Infections, or CLABSI. Nearly 1 in 20 patients acquire infections while undergoing medical care in the United States, according to the Centers for Disease Control and Prevention.
Providers can keeping up with the latest evidence-based findings and educate their patients about infection cases by contacting Primaris, or consulting this new section of the CDC's Web site.
Preventable hospital readmissions tax our healthcare system a great deal, both in terms of monetary and quality-related costs. A January study by a nonprofit group in California found preventable readmissions cost the state more than $227 million annually.
Readmissions can be reduced by assigning a staff member to reconcile medications and schedule necessary follow-up medical appointments. This approach is a team effort, in which the staff member leading the medication-reconciliation effort works with co-workers and patients.
Also helpful: a simple, easy-to-understand discharge plan for each patient that contains a medication schedule, a record of all upcoming medical appointments, and names and phone numbers of whom to call if a problem arises. AHRQ-funded research shows that taking these steps can help reduce potentially preventable readmissions by 30 percent.
With the increasingly popularity of online health sites like WebMD or iTriage, more patients are seeking medical information via online tools. But in the opinion of some physicians, this poses a risk to patient safety in the form of misdiagnosis and other problems.
On the other hand, some physicians believe the tools are useful for health education and literacy, and may even start quality discussions between patients and providers.
For more on this current debate, please see this article from the Web site ihealthbeat.org.
The idea of noise as a problem for healthcare workers is not a new one. Florence Nightingale in 1859 dramatically wrote, "unnecessary noise is the cruelest absence of care."
Noise has a documented affect not only on patient satisfaction and consumer surveys, but on patient comfort and healing.
For example, an article published by the firm Healing Healthcare Systems, which provides programming for patient television, states: "Far from benign, erratic sounds that create apprehension and can contribute to the need for restraints, requested pain medication, and nursing assistance calls."
A series of articles by the firm provide a detailed description of the noise problem in hospitals. Also, Healing Healthcare Systems added a new white paper on the topic.
Effective this summer, The Joint Commission (formerly the Joint Commission on Accreditation for Health Care Organizations) will alter its guidelines for reconciling medication. The new guidelines, effective July 1, cover medication reconciliation (also known as "med-rec") parameters for the ambulatory, behavioral health care, critical access hospital, home care, hospital, long term care, and office-based surgery accreditation programs.
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