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July 2008

Survey Targets Key Elements of a Culture of Safety -- by Robin Walters, R.N., B.S.N.

As part of our guest contributor program, we thank Robin Walters R.N., B.S.N, for her article below that explores progress among hospitals toward building a culture of safety. Be sure to also read Robin's other contributions on bloodstream infections and hand washing compliance.

Studies link a "culture of safety" with reducing hospital-acquired infections and harmful medical errors.  But what qualities define a culture of safety and how do hospitals measure up?

In a culture of safety, an atmosphere of trust exists in which people are free to report mistakes (and close calls) without fear of retribution.  Knowing that errors will occur, the focus is on the system which allowed the error, not the person making the error.  In an institution with a strong culture of safety, personnel learn from their mistakes and seek solutions.  Teamwork is a hallmark ingredient.

Hospitals can both evaluate and learn how to strengthen their safety scores by using the Hospital Survey on Patient Safety Culture.  Funded by the Agency for Healthcare Research and Quality (AHRQ), this confidential survey takes about 10 minutes to complete and is designed to assess staff attitudes and actions in 12 aspects of patient safety culture.

To give hospital administrators a reference for their results, AHRQ sponsored a database. The first Comparative Database Report was released in 2007.  For the 2008 Report, 98 of the 519 hospitals submitting results did so for the second time, allowing the Report to identify trends.  The following are highlights from this latest Report:

  • A strength among hospitals is "Teamwork Within Units" -- staff work together and support each other in an atmosphere of respect.
  • An area for growth is "Nonpunitive Response to Error," as it appears staff do not have faith that event reports will not be used against them and mistakes will not stay in their personnel file.  But those hospitals that improved in this area did tend to show an increase in the number of events reported.
  • Smaller hospitals had the highest average positive scores and improved more between reports.
  • Comparing work units, Rehabilitation scored the highest while ICU and Medicine scored the lowest in "Overall Perceptions of Patient Safety."  Pediatrics and Pharmacy made the most patient safety progress.
  • Hospital Administration/Management viewed conditions more positively than other staff in 11 of the 12 areas measured.
  • Of the trending hospitals, 27% showed a 5% or more decrease in the area of "Staffing," which indicates a decline in confidence that workloads and hours are appropriate.

About the author: Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural.

Interested in submitting content to Please go here to learn more.

Medication error puts most vulnerable at risk

According to the Institute of Medicine, medication errors are among the most common type of preventable medical mistakes to occur in hospitals. Unfortunately, seventeen premature newborns at a hospital in Texas were some of the most recent patients to experience such mistakes. 

According to a statement issued by Bruce Holstien, President and Chief Executive Officer of CHRISTUS Spohn Health System, seventeen newborns in the CHRISTUS Spohn Hospital Corpus Christi–South Neonatal Intensive Care Unit of were given higher than the recommended amount of Heparin over the July 4th weekend.   Heparin is an anti-coagulant often used to flush IV lines of patients to prevent blood clots from forming in the lines.

Once the CHRISTUS Spohn Hospital nursing staff made the discovery, the staff and physicians initiated immediate corrective measures to manage the effects of the medication. Their preliminary investigation indicates the medication error occurred during the mixing process within the hospital pharmacy. They have begun a full investigation to get to the root cause of this preventable medication error, which will take some time to complete.

It is still unkown at this time whether any of the newborns administered the higher-than-recommended doses of heparin have suffered any direct adverse events from the error.  Well-known actor, Dennis Quaid, brought a similar story to the public's attention when his own twin newborns were given overdoses last November. 

There are several different medication safety practices that could have helped to prevent the Heparin from ever making it into the IV lines of these newborns at an improper dose.  From improved medication labeling, to computer physician order entry to barcoding, there are processes hospitals can put into place to prevent medication errors.  Much more work needs to be done.

CEO of Beth Israel Deaconess Medical Center alerts all staff to wrong-site surgery

In keeping with his goal of transparency, Paul Levy, CEO of Boston's Beth Israel Deaconess Medical Center (BIDMC) recently disclosed to the BIDMC community that a wrong-site surgery had occurred in his facility.

As reported in the Boston Globe, the BIDMC care team neglected to notice the marking on the patient's body that signified the side and site that needed surgery, and the OR team failed to take a "time out" in which they could have verified correct patient, correct procedure, correct location. 

These oversights were contributing factors leading to the wrong-site surgery.  However, according to Levy, once the error had occurred, the surgeon immediately notified the administration so it could investigate why and how it happened. The surgeon and other hospital staff also immediately disclosed the error to the patient and apologized.  Finally, the administration and Chiefs of Service met and jointly agreed they should alert the entire community to the incident.

In the past, Levy suggests, the staff would have been more protective of itself and reluctant to disclose such errors to a broader audience.  Not only did the institution decide to be transparent with its most important constituents, but also a board member now suggests they create an educational tool about the experience to help foster a culture of patient safety:  "Transparency as opportunity, social marketing.  It would get people talking and thinking."

Continue reading "CEO of Beth Israel Deaconess Medical Center alerts all staff to wrong-site surgery" »

Joint Commission releases its 2009 National Patient Safety Goals

The Joint Commission has released its 2009 National Patient Safety Goals for each of its accreditation programs.  The Goals are meant to help health care organizations use proven approaches to reducing ongoing failures in patient safety.  Separate, but overlapping goals have been issued for nine different health care settings:  ambulatory care, behavioral health care, critical access hospitals; disease-specific care; home care; hospitals; laboratories; long-term care; and, office-based surgery. 

New in 2009 are there hospital requirements for preventing lethal health care-associated infections from multiple drug-resistant organisms (MDROs), central line-associated bloodstream infections and surgical site infections.  These build on prior Goals in an effort to combat the increasing rate at which patients today are acquiring preventable infections in hospitals.  The new requirements for central line-associated bloodstream infections also apply to ambulatory care and office-based surgery, home care and long-term care.  Prevention of surgical site infections will be a new requirement for ambulatory care facilities and office-based surgery practices.  Health care organizations have a one-year phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.

Hospitals greet success with preventing bloodstream infections-- by Robin Walters, R.N., B.S.N.

As part of our guest contributor program, we thank Robin Walters R.N., B.S.N, for her article below that examines how hospitals are working to prevent bloodstream infections. Be sure to also read Robin's other contribution on hand-washing compliance right here.

Central venous catheter-related bloodstream infections (CR-BSIs) remain among the most common types of healthcare-associated infections and could be costing U.S. hospitals well over $2 billion annually. In the intensive care unit (ICU), the national average rate for these infections is 5.3 per 1,000 catheter days, but some hospitals have reduced their rates, even drastically.

At UCLA Medical Center, concerns about rising rates of CR-BSIs in the medical ICU led to the implementation of new facility guidelines for central venous catheter care and unique strategies to promote compliance. Nurses were given scripted coaching to help them talk with both physicians and coworkers to support use of the new guidelines and were empowered to facilitate proper procedures as they assist physicians in inserting central venous catheters. Subsequently, by 2007, the CR-BSI rates had declined from 7.5 to 2.9 per 1000 catheter days in one unit and from 10.4 to 0 per 1000 catheter days in another.

CR-BSI rates in the ICU at Rochester General Hospital, NY, were well below national benchmarks, but they were on the rise in the non-ICU settings and had reached 6.9 per 1000 catheter days in 2002. Together, the nursing director and the clinical leader of the peripherally inserted central catheter (PICC) team got creative with the budget to expand the role of the PICC team to manage central venous catheters in the general patient areas. A cost benefit analysis supported this change, which was enacted with other measures, and by 2005 the hospital CR-BSI rate had dropped to 1.9 per 1000 catheter days.

Much success in lowering CR-BSI rates has come from using evidence-based prevention strategies, such as those in the Institute for Healthcare Improvement’s Central Line Bundle. And, hospitals that significantly reduced their central venous CR-BSI rates report that the following have also been instrumental: monitoring progress through ongoing data collection, providing routine feedback to patient units, physicians and hospital leaders, and receiving support from hospital leaders.

To find out what fostered the adoption of the most important CR-BSI prevention measures, Mayo Clinic researchers surveyed in 2005 a sampling of hospital infection control coordinators. The results suggest that to improve compliance with these measures, hospitals can start to promote a “culture of safety,” support infection control professional certification and take part in infection prevention collaboratives such as the 5 Million Lives Campaign and the National Healthcare Safety Network.

About the author: Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural.

Interested in submitting content to Please go here to learn more.

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