Managing Hospital Safety: Common Safety Concerns (Part 2 of 4)

Needlestick Injuries Are Common and Can Be Avoided Needlestick injuries are frequently underreported1 Top 3 times when needlestick injuries occur1: 1. While giving an injection 2. Before activating the safety feature 3. During disposal of a nonsafety device Needlestick Injuries Are Common and Can Be Avoided A 2008 survey completed by 700 US nurses indicates that needlestick injuries most commonly occur while giving an injection, before activation of the safety feature, and during the disposal of a nonsafety device Reference American Nurses Association. 2008 study of nurses’ views on workplace safety and needlestick injuries. http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles/2008InviroStudy.aspx. Accessed January 29, 2009. More than 80% of needlestick injuries could be avoided with the use of safer needle devices2 1. American Nurses Association. 2008 study of nurses’ views on workplace safety and needlestick injuries. http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles/2008InviroStudy.aspx. Accessed January 29, 2009. 2. American Nurses Association. Needlestick prevention guide. http://nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles/NeedlestickPrevention.aspx. Accessed January 29, 2009.

Implement Practices to Help Avoid Needlestick Injury Use prefilled medication devices1 Train health care workers on proper administration and disposal techniques2 Utilize sharps with engineered sharps injury protection1,2 Document sharps-related injuries1 Encourage nonpunitive, convenient reporting of needlestick injuries3 Evaluate and select safety-engineered devices based on caretaker preference2 Implement Practices to Help Avoid Needlestick Injury Review as stated 1. National Institute for Occupational Safety and Health. Preventing needlestick injuries in health care settings. November 1999. http://www.cdc.gov/NIOSH/pdfs/2000-108.pdf. Accessed January 29, 2009. 2. Occupational Safety and Health Administration. OSHA fact sheet: bloodborne pathogens. http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf. Accessed January 29, 2009. 3. American Nurses Association. 2008 study of nurses’ views on workplace safety and needlestick injuries. http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles/2008InviroStudy.aspx. Accessed January 29, 2009.

“Never” Events Serious, identifiable, and preventable medical errors leading to unfavorable consequences The policies and procedures of health care organizations considerably impact the risk of occurrence of “never” events “Never” Events Review as stated National Quality Forum. Serious Reportable Events in Healthcare, 2006 Update: Executive Summary. Washington, DC: NQF; 2007.

Categories of “Never” Events Surgical Amputation of incorrect body part Product/device Use of contaminated device Patient protection Inability to prevent a patient suicide Care management Medication error leading to hypoglycemic event Environmental Patient fall during hospital stay Criminal Impersonation of a health care provider Categories of “Never” Events “Never” events can be related to surgical procedures, product/device, patient protection, care management, environment, and crime Surgical events include incorrect surgery being done, or surgery performed on the wrong body part or patient Product or device events involve patient death or disability as a result of contaminated drugs or devices, and the occurrence of intravascular embolism Patient protection events include patient suicide or disappearance of a patient resulting in death or serious disability Examples of care management events include patient death/serious disability related to a medication error (eg, wrong drug, dose, patient, time, rate, preparation, or route of administration); and death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility Environmental events include burns, falls, electric shock, and the use of restraints that result in patient death or serious disability Criminal events range from abduction and assault to the ordering of patient care by someone impersonating a licensed health care provider Reference National Quality Forum. Serious Reportable Events in Healthcare, 2006 Update: Executive Summary. Washington, DC: National Quality Forum; 2007. National Quality Forum. Serious Reportable Events in Healthcare, 2006 Update: Executive Summary. Washington, DC: NQF; 2007.

Hospital-Acquired Conditions: “Reasonably Preventable” Events Foreign object left in patient postsurgery Air embolism Blood incompatibility Falls and trauma Pressure ulcers Vascular catheter-related infection Catheter-related urinary tract infection Manifestations of poor glycemic control Certain orthopedic surgical site infections Surgical site infection-mediastinitis following CABG Bariatric surgical site infections Deep vein thrombosis or pulmonary embolism after orthopedic procedures Hospital-Acquired Conditions: “Reasonably Preventable” Events Hospital-acquired conditions (HACs) are defined as “reasonably preventable” with the implementation of evidence-based guidelines HACs include the following: Foreign object left in patient postsurgery Air embolism Blood incompatibility Falls and trauma Pressure ulcers Vascular catheter-related infection Catheter-related urinary tract infection Manifestations of poor glycemic control Certain orthopedic surgical site infections Bariatric surgical site infections Surgical site infection-mediastinitis following CABG Deep vein thrombosis or pulmonary embolism after orthopedic procedures Reference Department of Health and Human Services: Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:48433-49084. Department of Health and Human Services: Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:48433-49084.

CMS Moves Aggressively to Encourage Greater Patient Safety in Hospitals The following selected conditions were added to the list of hospital-acquired conditions on August 19, 2008: Surgical site infections following specific 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 CMS Moves Aggressively to Encourage Greater Patient Safety in Hospitals Review as stated CMS = Centers for Medicare and Medicaid Services. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:48433-49084.

Medicare/Medicaid Cease to Reimburse for Preventable Complications For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which 1 of the selected conditions is not present on admission1 New York and Massachusetts have further limited Medicaid reimbursement of complications due to medication errors2 Foreign object left in patient postsurgery Air embolism Blood incompatibility Falls and trauma Pressure ulcers Vascular catheter-related infection Catheter-related urinary tract infection Manifestations of poor glycemic control Certain orthopedic surgical site infections Surgical site infection-mediastinitis following CABG Bariatric surgical site infections Deep vein thrombosis or pulmonary embolism after orthopedic procedures Medicare/Medicaid Cease to Reimburse for Preventable Complications Review as stated 1. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:48433-49084. 2. National Conference of State Legislatures. "Never Events" become ever present as more states refuse to pay for mistakes. July 2008. http://www.ncsl.org/programs/health/shn/2008/sn519b.htm. Accessed January 29, 2009.

Who Is Responsible for Maintaining Hospital Safety?

Health Care Team Must Work Together to Provide a Safe Atmosphere Physicians, pharmacists, nurses and support staff must work collectively to provide a safe atmosphere for patients1 A safety officer is often assigned to implement and enforce safety practices within the hospital2 Most medication errors are not a direct result of one causative factor or individual3 Errors are generally caused by a flawed system, or lack of structured practices4 Health Care Team Must Work Together to Provide a Safe Atmosphere Members of the health care team work in collaboration to provide a safe atmosphere for patients1 Physicians, pharmacists, nurses, support staff A safety officer is often assigned to implement and enforce safety practices within the hospital2 Most medication errors are not a direct result of one causative factor or individual3 Errors are generally caused by a flawed system, or a lack of structured practices4 Poor communication Unmanageable patient loads Lack of backup or double-checks References Hellman R. Patient safety and inpatient glycemic control: translating concepts into action. Endocr Pract. 2006;12(suppl 3):49-55. Institute for Healthcare Improvement. Develop a culture of safety: designate a patient safety officer. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Designate%20a%20Patient%20Safety%20Officer. Accessed January 29, 2009. Institute of Medicine. To err is human: building a safer health system. November 1999. http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Accessed January 29, 2009. Hellman R. Endocr Pract. A systems approach to reducing errors in insulin therapy in the inpatient setting. 2004;10(suppl 2):100-108. 1. Hellman R. Endocr Pract. 2006;12(suppl 3):49-55. 2. Institute for Healthcare Improvement. Develop a culture of safety: designate a patient safety officer. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Designate%20a%20Patient%20Safety%20Officer. Accessed January 29, 2009. 3. Institute of Medicine. To err is human: building a safer health system. November 1999. http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Accessed January 29, 2009. 4. Hellman R. Endocr Pract. 2004;10(suppl 2):100-108.

Culture of Safety Can Improve Patient Outcomes Unintended injury Defective culture No barriers Initial physician orders Scope of awareness Intended therapeutic result TIME Correction by physician Culture of Safety Can Improve Patient Outcomes The establishment of a “culture of safety” means having a wide scope of awareness about patient-specific clinical information with backup assessments present in critical areas Teamwork is the key to protecting patients from unintentional harm attributable to medical errors Reference Adapted from Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10(suppl 2):100-108. Nurse and pharmacist on team Backup check by peer Adapted from Hellman R. Endocr Pract. 2004;10(suppl 2):100-108. No injury “Culture of safety”

Major Safety Organizations Strive to Improve Patient Safety The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Institute for Safe Medication Practices (ISMP) Institute for Healthcare Improvement (IHI) Occupational Safety and Health Administration (OSHA) Centers for Medicare and Medicaid Services (CMS) Major Safety Organizations Strive to Improve Patient Safety The major hospital safety organizations include: The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)1 Mission is to “…continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations…” Institute for Safe Medication Practices (ISMP)2 Nonprofit group dedicated to safe medication use and the prevention of medication errors Institute for Healthcare Improvement (IHI)3 Independent nonprofit organization that works to improve health care throughout the world Occupational Safety and Health Administration (OSHA)4 Focus on preventing injuries and protecting workers by fostering a safe work environment Centers for Medicare and Medicaid Services (CMS)5 Mission is “to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries” References The Joint Commission. About us: facts about the Joint Commission. http://www.jointcommission.org/AboutUs/Fact_Sheets/joint_commission_facts.htm. Accessed January 29, 2009. Institute for Safe Medication Practices. About ISMP. http://www.ismp.org/about/default.asp. Accessed January 29, 2009. Institute for Healthcare Improvement. About us. http://www.ihi.org/ihi/about. Accessed January 29, 2009. Occupational Safety and Health Administration. OSHA’s role. http://www.osha.gov/oshinfo/mission.html. Accessed January 29, 2009. Centers for Medicare and Medicaid Services. http://www.cms.hhs.gov/MissionVisionGoals. Accessed January 29, 2009.

Points to Consider What best practices does your hospital follow to promote patient safety? In light of CMS’s initiative to not reimburse for preventable complications, what protocols are being implemented in your hospital? How can you raise awareness about medication errors and improve communication with your health care team? Points to Consider Review as stated