An Ounce of Prevention

Making Patient and Employee Safety a Priority

In 2007, Thomas and Zoe Quaid, newborn twins of actor Dennis Quaid and his wife, Kimberly, almost died after they were accidentally given an overdose of heparin, a blood thinner medication, at Cedars-Sinai Hospital in Los Angeles. Medical errors like these get a lot of attention and, unfortunately, they aren’t isolated incidents. Each year, more than 400,000 American deaths can be partly attributed to avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety. In 2008, the most recent year studied, medical errors cost the nation $19.5 billion, most of which was spent on extra care and medication, according to the Journal of Healthcare Finance.

But healthcare professionals are instituting plans and protocols to prevent medical errors and ensure patient safety throughout episodes of care. And, many of these same precautions are just as important in safeguarding healthcare workers.

Recognizing the Risks

Preventable healthcare errors include mistakes at the treatment level as well as diagnosis errors. The Agency for Healthcare Research and Quality (AHRQ) has studied the frequency and scope of medical errors, as well has how to prevent them. According to the agency’s Chartbook on Patient Safety, which was part of its 2017 National Healthcare Quality and Disparities Report, the most common medical errors in hospitals include:

• Adverse drug events
• Pressure ulcers
• Venous thromboembolism
• Healthcare-associated infections, including catheter-associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections and ventilator-associated pneumonia

In ambulatory settings, however, errors most frequently occur during diagnostic workups, notes Jeffrey Brady, M.D., MPH, director of AHRQ’s Center for Quality Improvement and Patient Safety. According to the Institute of Medicine, at least 5 percent of all U.S. adults who receive outpatient care each year will experience a diagnostic error. The AHRQ is updating its toolkit to help prevent miscommunication about the results of lab testing in medical offices, and it is also funding research to better understand how these errors happen in order to prevent them. “Healthcare is complex, and many factors—human, technological, organizational—can contribute to mistakes,” Brady says. “For example, poor communication during patient handoffs, including those between clinicians and between practices and settings, can lead to patient safety threats.”

Medical errors might also stem from a changing regulatory environment for new products and supplies, or a lack of user training, says Suzan Brown, MS, RN, manager of value analysis and nursing associate director of the Medical Simulation Center at WellSpan Health. Absent supply chain standardization, clinicians might be wholly unaware of recalled, backordered or otherwise unavailable products. “It’s challenging to make sure all the key players have a voice in product selection and then to keep everyone apprised of the related product changes.”

Developing Best Practices

Many accrediting bodies and professional organizations provide recommendations, guidelines and position statements that facilities can use as the basis for developing and adopting protocols to help prevent medical errors, says Angie Mitchell, RN, director of nursing services at HealthTrust. “It’s key to integrate these protocols into employee orientation and yearly competency reviews, as well as provide ongoing education for staff,” Mitchell says. “Standardizing processes facilitates consistent and effective care, and can go a long way toward reducing errors. From a HealthTrust clinical and contracting perspective, we maintain current knowledge of these accrediting bodies’ recommendations and work to ensure we have products on contract that will support members’ successful implementation of these protocols.”

The AHRQ conducts research and produces tools to help hospital teams improve key elements of quality and safety. It recommends that facilities establish standard definitions and techniques for measuring “never events,” defined by the National Quality Forum as “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a healthcare facility.” The AHRQ also advises facilities to increase transparency when reporting errors and develop collaborative approaches to preventing them, Brady adds.

For example, use of AHRQ’s Comprehensive Unit-based Safety Program in more than 1,000 hospitals nationwide led to a 41 percent reduction in central line-associated bloodstream infections. The agency is collecting stories about how healthcare organizations are using AHRQ tools and resources to improve care. “These cases demonstrate the impact of applying healthcare research at the local level, where patients actually receive care every day,” Brady says.

A new AHRQ toolkit on patient and family engagement highlights the “warm handoff” between two members of a healthcare team. The intent is to demonstrate that effective clinical communication is taking place. “Not only does this transparent care handoff engage patients and families in the communication, but it also allows all parties to hear what is being said. This provides an opportunity to clarify or correct information or ask related care questions—a key component of a patient-centered practice.”

In 2016, WellSpan Health established a Clinical Equipment Review Team (CERT) to serve as the authoritative body for ensuring that clinical equipment is put into use only after it has been fully vetted by team members and all preparations have been made for its use, cleaning and maintenance, Brown says. The team’s tasks include staff training on disinfecting and cleaning requirements, identifying any preventive maintenance requirements, and ensuring the proper tagging and inventory of the equipment.

Over the past year, the team has been vital to standardizing care and reducing errors. “The CERT process makes sure that all potential users get to review the equipment or reusable item,” Brown says. “We make sure that everything is complete—including staff education—before the product is used.” For instance, WellSpan implemented a policy that all requests for new products or free items provided in a clinical trial must go through its value analysis process. “There are three RNs on the value analysis team, and we review each product to make sure it is safe to bring in,” Brown says. “If the product is free and part of a clinical trial, we ensure it goes into the system on a no-charge purchase order in case of a recall. We can also monitor results of the trials.” While it has taken significant time to implement the CERT process, Brown says most employees have adjusted and understand the intention of the program. “We take the time to do the right thing when instituting these kinds of safety measures,” she says, “because we have to make sure a product is safe and people are educated before we start using it.”

Prioritizing Employee Safety

Ensuring patient safety also means prioritizing the safety of staff. “Practitioners infected with a transmissible pathogen can potentially infect a patient,” says Sharon McNamara, RN, past president of AORN (Association of periOperative Registered Nurses). “The cost to the patient or practitioner can be admittance or extended hospital stay, loss of work, financial and emotional stress, chronic illness, and possibly even death. This can impact both a hospital’s bottom line and its reputation.”

Traditionally, hospital staff have been among the employees most susceptible to illness and injuries. For instance, U.S. hospitals recorded an average of 6.8 work-related injuries and illnesses for every 100 full-time employees in 2011—almost twice the rate for private industry as a whole, according to the Occupational Health and Safety Administration (OSHA). The OSHA figures show that nearly half of injuries to hospital workers are caused by overexertion or bodily reaction when lifting or moving patients. To combat these motion-related injuries such as lifting, bending or reaching, growing numbers of facilities are instituting safe patient handling programs that can have a protective effect on both employees and patients, Mitchell says. Such programs provide education on proper body mechanics, as well as devices that assist in moving, transferring or repositioning patients with minimal push or pull effort.

Recommendations for safe patient handling often suggest the purchase of equipment such as mounted lifts or slide sheets that make patient transfers easier, as well as policies and patient assessment tools to help minimize the need to lift patients. When Cincinnati Children’s Hospital implemented such a program, it reduced lost time by 83 percent in three years, according to OSHA. (A lost-time accident is an OSHA recordable incident that results in an employee being unable to work a full assigned work shift.) Tampa General Hospital reduced patient handling injuries by 65 percent and associated costs by 92 percent after it installed mechanical lifting equipment.

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