Patient Safety Focus

Studies Shed Light on Isolation Precaution Practices -- by Robin Walters, R.N., B.S.N.

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. Be sure to also read Robin's other contributions on bloodstream infections, hand washing compliance, and culture of safety.

Timely and consistent use of isolation measures can prevent untold thousands of hospital-acquired infections each year.  Depending on the infectious agent, required precautions may include:  a private room, dedicated patient-care equipment, room air pressure and ventilation measures, and/or the appropriate use of personal protective equipment such as masks, gowns and gloves.  The following studies highlight strengths and weaknesses in compliance at three major medical centers and may assist other facilities in focusing their improvement efforts.

At the University of North Carolina Hospitals in Chapel Hill, infection control personnel observed staff and visitors in 2004 and 2005, finding the overall rate of compliance by type of isolation ranged from 60-75%.  For contact isolation, which is designed to prevent infections transmitted by direct or indirect contact with a patient or a patient's environment, researchers assessed gown and glove use.  In the ICUs, compliance ranged from 92-100% for both staff and visitors.  But on the adult floors, perhaps as expected, visitor gown (50%) and glove (33%) use was much lower than staff gown (81%) and glove (81%) use.  On the pediatric floors, rates of gown and glove use varied even more between visitors (23% and 5%) and staff (87% and 93%).

Over the same time period, observers at St. John's Mercy Medical Center Hospital in St. Louis, MO documented adherence by health care workers (HCWs) and non-HCW visitors to the facility's modified contact precautions, which include donning gown and gloves before entering a patient's room regardless of whether direct contact is anticipated.  Among HCWs, females and those working in the ICUs complied best.  Visitors in the ICUs complied better than those on the general floors (91% vs. 51%).

New AHRQ Study Finds Surgical Errors Cost Almost $1.5 Billion Each Year

A new study by William E. Encinosa, Ph.D. and Fred J. Hellinger, Ph.D. of the U.S. Agency for Healthcare Research and Quality (AHRQ) reveals that potentially preventable medical errors that occur during or after surgery may cost employers as much as $1.5 billion each year.

Published in the July 28, 2008 issue of Health Services Research, the researchers found that insurers pay additional costs for surgery patients who experienced the following conditions associated with medical errors compared to patients who did not:

• acute respiratory failure - $28,218 (52% more)
• Post-operative infections - $19,480 (48% more)
• errors related to nursing care, such as pressure ulcers and hip fractures -$12,196 (33% more)
• metabolic problems, including kidney failure or uncontrolled blood sugar - $11,797 (32% more)
• blood clots or other vascular or pulmonary problems - $7,838 (25% more)
• wound opening - $1,426 (6% more)

The study is based on a nationwide sample of more than 161,000 patients age 18-64 in employer-based plans who underwent surgery between 2001 and 2002, and used AHRQ's Patient Safety Indicators to identify medical errors. 

The authors conclude that studies focusing only on medical errors incurred during the initial hospital stay may underestimate the financial impact of patient safety events by as much as 30%.

Telephone Errors Lead to Catastrohpic Injuries and Costly Legal Settlements -- by Pat F. Bass III M.D., M.S., M.P.H.

Pat F. Bass III M.D., M.S., M.P.H. is Assistant Professor of Medicine/Pediatrics at Louisiana State University Health Sciences Center - Shreveport.

Medical errors related to telephone care in the ambulatory setting are a significant and costly patient safety and malpractice issue that is tied to quality of care, according to a recent article published in the Journal of General Internal Medicine (J Gen Intern Med 2007; 23(5):517-22).

Harvey P. Katz, MD of the Department of Ambulatory Care and Prevention at Harvard Medical School, along with two colleagues, performed a retrospective case review of closed malpractice claims for 40 provider-defenders from 32 cases coded specifically as telephone-related by a major provider of malpractice insurance.

The study found 24 (60%) cases were settled or awarded in favor of the plaintiff.  Failed diagnosis (68%) and death (44%) were the most common allegation and injury, respectively.  The general medicine ambulatory practice was the most common setting.  Documentation (88%) and faulty triage (84%) were the leading errors.  However, dysfunctional office systems, such as lack of office policies, multiple calls for the same problem without a visit, and covering MD factors, were also a significant aspect of the malpractice claims.  Average compensation per incident was $518,932, with a total plaintiff compensation of $12,454,375.

Antimicrobial Wipes May Spread MRSA -- by Tim Anderson

Tim Anderson is a Kansas City health writer with a background in health care administration.  He writes about medical research and advances, emerging treatments and technologies, and healthy lifestyle choices.  His blog, "The Medical Migrant" appears online each week on several national news sites.

The Centers for Disease Control and Prevention estimates there are 1.7 million hospital-acquired infections in American hospitals each year, resulting in close to 100,000 deaths.  Of particular concern are multidrug-resistant organisms, such as Methicillin-resistant Staphylococcus aureus (MRSA). 

Antimicrobial wipes have become a mainline defense in containing the spread of MRSA, but a new study casts doubt on their effectiveness.  Dr. Jean-Yves Maillard, a microbiologist with Cardiff University's Welsh School of Pharmacy, led a surveillance study of the routine use of antimicrobial wipes in hospital settings.  The findings were later replicated in the laboratory.

Maillard's team found the wipes often contribute to the spread of MRSA and other infectious organisms.  The problem, however, was more a matter of technique than of the wipes themselves.  Used correctly, the wipes can be very effective.

Leapfrog Group Launches Updated Hosptial Ratings Web Site

On August 1st, The Leapfrog Group launced an updated web site with new safety and quality information on hospitals nationwide.  To date, 1,169 hospitals have submitted responses to important questions about quality that consumers can use to compare hosptials.  Many more hospitals are expected to participate in the Leapfrog Hospital Survey over the coming months.  The web site shows individual hospital results, which are freely available and updated monthly. 

Along with questions about whether hospitals have implemented patient safety practices endorsed by the National Quality Forum, for the first time ever, the Leapfrog Survey queries hospitals about their use of resources and efficiency in performing certain procedures.  It also asks for rates of "hospital acquired conditions" such as bed sores, falls and burns.  And based on data submitted by participating hospitals, it also estimates the odds of dying at those hospitals as a result of undergoing certain high-risk surgeries.  For more about what's new in the 2008 Leapfrog Survey, visit: https://leapfrog.medstat.com/pdf/whatsnew.pdf. 

Medicare and Medicaid increasing incentives to reduce "never events"

The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2008 that it is taking several additional actions to improve the quality of care in hospitals and reduce the number of "never events" -- preventable medical errors that result in serious consequences for the patient.

For the Medicare program, CMS has provided additional incentives for hospitals to improve the quality of care provided to people with Medicare, including payment provisions to reduce never events that occur in hospitals.  In addition, CMS sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. Almost 20 states either have already eliminated or are considering eliminating payment for some never events.

Last year, CMS listed eight preventable conditions for which it would not make additional payments.  This year it is adding three:

• Surgical site infections following certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity
• Certain manifestations of poor control of blood sugar levels
• Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Many private insurance companies have now implemented similar policies as covered by Patient Safety Focus earlier.