Patient Safety Focus

Month in "Focus": March Review

March was a busy month that brought us the official launch of PatientSafetyFocus.com, our support for the first Patient Safety Awareness Week, key findings across several states, and some excellent recommendations for the industry.

And, once again, March was a month that delivered too many statistics that are nowhere near where they should be--as those numbers represent lives hurt and lives lost, all due to preventable medical errors.

Here's a wrap-up of what we've been covering over the past month:

Medicare's plan under fire before it begins: Interesting feedback in the Ann Arbor News article titled "Medicare Plan May Backfire in its results, Penalizing of hospitals is overly punitive". According to the piece: "Come October, Medicare will stop paying hospitals for certain medical mistakes." If you recall, they're not the only ones, as major insurers have just started saying no-pay to "never events" (events that never should have happened in the first place). More here.

AARP releases stifling statistics: Key findings from AARP's (American Association of Retired Persons) New Jersey chapter's recent "Does it Make You Sick?" survey shine even more light on the striking issue of preventable medical errors. According to The Record: More than a third of New Jersey residents surveyed say they or a family member have been a victim of a medical error. Read on here.

HRH works to improve trust: In efforts to not only increase patient safety but to maintain trust, Hendricks Regional Health (HRH) in Avon, Indiana formed a Patient Safety Committee in 2006 consisting of 25 members from all levels and buildings of the medical group. Learn about the interesting initiative here.

Celebrity as influencer for patient safety: An unlikely, but altogether welcome Patient Safety Advocate, Dennis Quaid's newborn twin babies were given almost fatal overdoses of an injectable anticoagulant in LA's Cedars-Sinai hospital--the babies were given nearly 1,000 times the normal 10-unit does of the drug Heparin.

While the twins have fortunately recovered, California regulators have fined the hospital $25,000 for giving overdoses of the blood-thinning drug to three children (two of which were Quaid's twins).The result is two-fold: first, it brings attention to the startling statistics now standing at "1 error per patient per day" which adds up to 100,000 deaths per year in the U.S. alone. But, second, it has brought an unlikely patient safety advocate to the fore in Dennis Quaid (view video here).

IHI Seminar Promotes The "Triple Aim" of Health, Care and Costs

On June 23 - June 24 in Washington, D.C., the Institute of Healthcare Improvement (IHI) will host a seminar focused on the "Triple Aim" of excellent health, ideal care and controlled costs.

According to IHI, "These are the concurrent goals of health care systems that serve populations. Many health care organizations are focused on only one or two of these goals, and may deliver results on one dimension to the detriment of the others. Only by addressing all three can we truly optimize health care resources for a population and achieve broad-based, lasting, transformational results. The Institute for Healthcare Improvement (IHI) refers to these three goals, pursued simultaneously, as the Triple Aim."

A group spanning C-Suite Executives, Policy Makers, Directors of Quality or Improvement, Physicians and more will learn a framework for accomplishing the Triple Aim, determine methods for assessing their own per capita costs, develop ideas for testable changes and understand how to set time lines for testing their ideas.

You can also listen to the seminar conference call by visiting this page. More information located here.

Holding Physicians (More) Accountable for Preventable Medical Errors

A post by Bruce Bierhans of InjuryBoard.com provides an insightful and objective look at the pivotal area of accountability. His piece strikes a balance between explaining the extraordinary and positive experiences he has had with medical professionals...yet urges how we must press for more accountability when it comes to preventable medical errors. And he's right (one needn't look further than the deplorable statistics and fatalities).

According to Bierhans,"We all have stories or experiences involving marvelous medical professionals that do what they do every day...save lives. However, our judicial system is one based upon the concept of "accountability"; meaning that our system only works when professionals, including physicians and nurses, are held accountable for the preventable damages that they cause."

This harkens back to the interview we held with Dr. Meghan Dierks a few months ago. As Dr. Meghan Dierks found, in sharing weekly compliance data through the use of Hospital Video Auditing (HVA), hand hygiene compliance increased from 38% to 98% in 4 weeks--and stayed there.

Besides the astounding results from HVA's consistent stream of data reporting and benchmarking, what was particularly noteworthy was the area of responsibility that she homes in on. Dierks posits, "I think with further implementations we're going to realize that no institution can be without this technology. Because it is so effective, it almost seems irresponsible not to employ these techniques to solve this persistent safety issue."

Whether it will be insurance companies pressing on medical institutions by not reimbursing for medical errors, patient advocacy groups leaning on regulators to provide more transparency, hospital administrations re-engineering safety practices from the inside out--or a confluence of support from all sides of the safety spectrum--accountability is the common thread.

As Bierhans writes, "Our challenge in representing our clients is to convince juries that while we all want our doctors to be heroes, they can and do make mistakes; often with horrific consequences. When those mistakes occur, they have to be accountable. Without accountability, in government or the law, we have chaos."

One thing is certain up to 100,000 preventable deaths annually already qualifies as mass chaos within the very hospitals that provide us care.

Bierhans post here. Our interview with Dr. Dierks located here.

IHI's 2008 Progress Report Proposes "New Rules" for Quality Care, Safety

If you've not yet had the chance to review the Institute for Healthcare Improvement's (IHI) 2008 Progress Report, it's worth your while. The report--titled "Quality Rules!"--is extremely thoughtful in setting out 10 "new rules" (as compared to the old rules).

New rules include more continuity, collaboration, control and safety as a system priority (vs. an individual responsibility), transparency as necessary (vs. secrecy), along with giving providers better tools and more efficient systems.

Speaking of IHI, on the left-hand sidebar, we feature several other helpful Patient Safety resources provides by the organization including practices for improving hand hygiene, a hand hygiene improvement report and their central line bundle.

Download the Progress Report (PDF) here. Full IHI website here.

Leading Patient Advocate Argues "Quality control is Cost Control"

In an article that takes on the patient safety issue from a cost argument, Jamie Stevenson, vice president of the Consumer Health Quality Council, writes: "Our health care needs to become safer. The good news is we all can take a role in improving the system. Quality improvement and cost control cannot be separated. Medical errors cost the nation $17 to $29 billion each year.

Quality control is the best form of cost control."

Among the sobering statistics (many located here), according to the Institute of Medicine, medical errors injure nearly one million Americans each year during their hospital stay, and among those injured, nearly 100,000 patients die as a result.

In Massachusetts alone, the New England Healthcare Institute estimates one in every 10 Massachusetts patients suffers an avoidable medication mistake. And according to the Centers for Disease Control and Prevention, one in five inpatient hospital admissions results in a hospital-acquired infection.

 Further advocating for more transparency, Stevenson implores:

"The public has a right to know whether a hospital is struggling with a problem such as infections. Armed with the necessary information, patients and families can make truly informed decisions and participate in improvement efforts. Healthcare transparency is about creating openness, honesty and truth-telling in healthcare."

Full article located here.

Oregon announces increase in deaths from preventable medical errors

Oregon's commission that collects voluntary reports of medical errors has reported that 24 patients died of preventable errors in 2007, compared with 21 in 2006. In 2007, 54 of Oregon's 57 acute care hospitals participated--with those 54 hospitals providing 99 percent of the hospital care provided in Oregon.

Further, Oregon is the only state in the country with a completely operational voluntary reporting program.

According to The Portland Business Journal article, "Issues related to 'communication' were the most often cited fundamental cause. For those events that resulted in death, organizational factors and patient factors become very important as well."

Over the last two years, five types of adverse medical events have accounted for nearly 60 percent of the reports, specifically:

• 18.9 percent of reports were of foreign objects retained inside the body following an invasive procedure.
• Wrong site procedures comprised 10 percent of reports.
• Medication errors accounted for 10.1 percent of reports.
• 9.5 percent of events were related to falls.
• Infections were responsible for 8.8 percent of errors."

In 2003, the state Legislature passed the bill which created the patient safety commission that same year and is supported by fees collected from participating health care organizations. The reports that are collected by the commission span errors including medication mix-ups and hospital-acquired infections...as well as "near-misses" and "lessons learned." Information about these errors is  shared with members to guard against future errors.

Full article can be accessed here.

Celebrities bring needed attention to preventable medical errors

Last November, actor Dennis Quaid's newborn twin babies were given almost fatal overdoses of an injectable anticoagulant in LA's Cedars-Sinai hospital--the babies were given nearly 1,000 times the normal 10-unit does of the drug Heparin.

While the twins have fortunately recovered, California regulators have fined the hospital $25,000 for giving overdoses of the blood-thinning drug to three children (two of which were Quaid's twins), with the California Department of Public Health has concluded that it was due to failure of the staff at Cedars-Sinai to follow their own procedures. The report rules the overdoses as "preventable medication errors."

The result is two-fold: first, it brings attention to the startling statistics now standing at "1 error per patient per day" which adds up to 100,000 deaths per year in the U.S. alone. But, second, it has brought an unlikely patient safety advocate to the fore in Dennis Quaid (see video below).

While insurers are taking aggressive steps to decrease preventable medical errors and patient safety advocacy groups are working to increase awareness through various programs, celebrity advocates can be pivotal in getting this issue to the front pages of our media and into the hearts and minds of people...and, hopefully, continue to place pressure on hospital administrators (and drug manufacturers) to instill every possible precaution and process in place to prevent further errors.

With 1 error per patient per day now the average (see that CNN video here), this issue is bigger than AIDS and breast cancer--but completely preventable. All told, we simply cannot wait any longer to amplify awareness of this issue. While we feel for the trauma that has been placed on the Quaid's, we are thankful that he is using his experience and his celebrity as a platform to advocate for much-needed change. And we hope that the media continues to dedicate coverage to this issue, especially given better processes and solutions that thwart against human error have already been created.

Part of the 60 Minutes featuring Dennis Quaid and wife is below--RSS and email subscribers, click through to the blog to view. A listing of current statistics is located here.

 

Earning the public's trust

The alarming incidents (and skyrocketing statistics) of preventable medical errors are well documented. And improving patient safety necessitates work across many fronts that span increased awareness, communication, innovation, transparency...and building more trust with those that vow, first and foremost, to do no harm.

In efforts to not only increase patient safety but to maintain trust, Hendricks Regional Health (HRH) in Avon, Indiana formed a Patient Safety Committee in 2006 consisting of 25 members from all levels and buildings of the medical group. The members meet on a regular basis to organize and implement patient safety standards from a number of organizations.

According to Indiana's TribStar: “You can’t expect there to be a perfect place,” Patty Owens, director of care coordination, said. “But we take patient safety very seriously. We are working very hard to prevent harm, and if it occurs, we work very hard to find out what happened. We want to be worthy of the trust of our community.”

In 2006, HRH committed to combining all of the initiatives from all of the organizations they worked with — National Patient Safety Foundation, Institute for Healthcare Improvement, Centers for Medicare and Medicaid Services, etc. — and organized them into four categories: preventing hospital-acquired infections, improving the culture of patient safety, improving medical safety, and reducing the risks for patients.

Owens also presents the progress of the committee to the hospital’s board of directors once a month and says, "According to medical research, 1 percent of mistakes in hospitals had to do with human error while the other 99 percent were directly related to the processes in place." She further explains: “We want to teach the staff that it’s OK to report things that didn’t go as well as planned. We consider these a gift to us. It shows us what we need to fix so that it won’t happen again.”

"An important part of continuing patient safety," Owens stressed, "is hospital culture. It’s important to have a culture where staff members feel comfortable reporting mistakes or deviant behavior and patients feel safe addressing staff about questions and concerns."

In order to dramatically improve patient safety, open and transparent cultures in hospitals should not only be the goal--it needs to be the standard. So too is employing systems that provide the ability to institute benchmarks and progress.

Hospitals, like HRH, with strong Patient Safety Boards is a pivotal step towards maintaining the public's trust--and just as hospitals work to improve the diligence of their people, it's paramount that they work to improve their feedback and auditing processes. After all, trust is not given, it's earned. And responsibility must be demonstrated every single day, with every patient, through each and every process.

Full article referenced above can be accessed here.

HVA: Solution to the Medicare Solution

Interesting feedback in the March 7th Ann Arbor News article titled "Medicare Plan May Backfire in its results, Penalizing of hospitals is overly punitive". According to the piece:

"Come October, Medicare will stop paying hospitals for certain medical mistakes. The plan is not unreasonable. However, the list of mistakes that will no longer be reimbursed might go too far.

Few medical providers would quibble with not being paid for serious errors such as operating on the wrong limb, leaving sponges or other surgical equipment inside a patient's body or using the wrong blood type. But not being paid if a patient gets a bed sore or suffers a fall seems overly punitive.

Given the patient population served by Medicare - the elderly and disabled - it's impossible to believe that every fall or bed sore can be prevented. That could require increased staffing to provide virtually 24-hour monitoring for some patients prone to bed sores or who have balance issues. Or it could prompt more intrusive admission policies that require significant time and costs to identify pre-existing conditions before a patient is admitted.

Let's Make Every Week Patient Safety Week

A terrific blog authored by Mark Graban offers some sage advice with, "Patient safety should be a priority every week and every day. Education and support for patient safety issues should be ongoing."

We couldn't agree more.

As we mark an end to the National Patient Safety Foundation's Patient Safety Awareness Week (PSAW), let's vow to make every week (and every day) an opportunity to improve patient safety. This recently launched blog will continue to be a priority of ours with an ongoing focus and key vehicle for increasing awareness. And our technologies and systems (HVA) that dramatically improve hand hygiene compliance, and other critical control benchmarks, are a top priority of ours in providing solutions.

The fact remains, to improve patient safety practices--and significantly decrease preventable medical errors--necessitates communication as much as it does innovation. And with the groundswell of attention, 2008 could be the year that the much-needed change occurs.

Insurers are taking more aggressive measures to improve patient safety by instituting "No Pay" policies on preventable medical errors. Powerhouse organization AARP is focusing more on preventable medical errors through publicity of its recent "Does It Make You Sick" survey that found an alarming one-third of New Jersey citizens have either been affected by preventable medical errors. And the ongoing work from patient advocacy organizations, like IHI and Leapfrog, provide better protocols and more transparency in the industry.

Whether as a result of pressure from the public, press and insurers or from within hospitals, these initiatives help push these attention-needed efforts to the fronts of people's minds...and that's exactly what is needed to facilitate change.

After all, change is what we are all working towards--every day of the year.