Reducing Medical Errors:
State of Florida Mandatory Training

Interventions, Con't.

Introduction

Scope of the Problem

Defining Medical Errors

Patient Safety Organizations

Interventions

Conclusion

Resources

References

Test

Exit to Menu

6. Consider working with a Patient Safety Organization.

   As mentioned earlier in the course, Patient Safety Organizations (PSOs) work to reduce healthcare associated errors. When healthcare agencies/providers work with such organizations, the PSOs efforts can be put to practice. By reporting and sharing patient safety information with PSOs, your data helps others avoid preventable errors. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and healthcare organizations can use common formats to collect, aggregate, and analyze data that can improve quality by identifying and reducing the risks and hazards associated with patient care.

   The term common formats refers to the common definitions and reporting formats, specified by AHRQ, that allow healthcare providers to collect and submit standardized information regarding patient safety events. These formats apply to all patient safety concerns, including:

• Incidents: patient safety events that reached the patient, whether or not there was harm;
• Near misses or close calls: patient safety events that did not reach the patient; and
• Unsafe conditions: circumstances that increase the probability of a patient safety event.

The Patient Safety Act and the Patient Safety Rule authorized the creation of a Network of Patient Safety Databases (NPSD), to which PSOs, health care providers, and others can voluntarily contribute non-identifiable patient safety work product. The NPSD will be maintained as an interactive, evidence-based management resource for health care providers, PSOs, researchers, and other individuals and organizations. AHRQ will use data from the NPSD to analyze national and regional statistics, including trends and patterns, regarding patient safety events. Findings are to be made public and included in AHRQ's annual National Healthcare Quality Report.

Information on PSOs and Common Formats is available at http://www.pso.ahrq.gov/.

7. Use good hospital design principles.

   A growing body of literature describes the link between a hospital's physical design and its key quality and safety outcomes. Hospital planners, expected to spend nearly $250 billion on new construction in the next 10 years, are consulting this evidence and incorporating it into their designs for capital construction projects (AHRQ, 2007).

   Evidence-based design is a term used to describe how the physical design of health care environments affects patients and staff. Key characteristics of evidence-based design in hospital settings include single-patient rooms, use of noise-reducing construction materials, easily accessible workstations, and improved layout for patients and staff (AHRQ, 2007).

Evidence-based design elements can help hospitals reduce avoidable, and costly, incidents of patient harm, such as patient falls, hospital-acquired infections and medication errors (AHRQ, 2007):

Patient falls. Patient falls, common in hospitals, can result in serious injuries, extend a patient's stay, and drive up the cost of care significantly. By 2020 the estimated annual cost of fall injuries for older people will exceed $30 billion. Now that the Centers for Medicare and Medicaid Services no longer reimburse hospitals for the cost of patient falls that occur in their facilities, and insurers are likely to follow its lead, hospitals will bear a greater portion of this cost.

Patient falls can be avoided. Poor placement of handrails and small door openings are two primary causes of patient falls. Many falls can be reduced through providing well-designed patient rooms and bathrooms and creating decentralized nurses' stations that allow nurses easier access to at-risk patients.

Hospital-acquired infections. Single-bed rooms and improved air filtration systems can reduce the transmission of hospital-acquired infections. Infections can also be reduced by providing multiple locations for staff members to sanitize/wash their hands so they spend less time walking to sinks and have more opportunities to sanitize their hands before providing care.

Medication errors. Poor lighting, frequent interruptions and distractions, and inadequate private space can complicate filling prescriptions. Well-illuminated, quiet, private spaces allow pharmacists to fill prescriptions without the distractions that may lead to medication errors.

Patient rooms that can be adapted for the acuity of a patient can also reduce errors. Acuity-adaptable rooms reduce the need to transfer patients around the hospital and lessen the burden on the staff to communicate information to caregivers in the patient's new location.

Improved patient satisfaction is also a result of the improved physical design of hospitals. Reducing noise, providing more privacy, and making it easier for patients to find their way though the hospital can all improve patient satisfaction.

Frequent overhead announcements, pagers, alarms, and noisy equipment in or near patient rooms are stressful for patients and interfere with their rest and recovery. Single-bed rooms with high-performance, sound-absorbing ceilings and limited overhead announcements can substantially improve the healing environment for patients.

Evidence also shows that patients are more satisfied with their care when they are given adequate space to interact with their families. For example, single-patient rooms make it easier for families to stay with patients. Responding to the overwhelming evidence regarding how single-patient rooms improve patient safety, satisfaction, and quality outcomes, the American Institute of Architecture changed its 2006 construction guidelines to recommend that single rooms for medical, surgical, and postpartum nursing units in general hospitals be the standard.

Helping patients effortlessly find their way through hospitals can improve patients' overall care experience and increase satisfaction by reducing feelings of stress, anxiety, and helplessness for them and their families. Better navigation can be addressed architecturally through useful signage and easily navigable corridors.

Several design elements are associated with better quality outcomes for patients. In addition to improving patient satisfaction, reducing hospital noise can improve patient recovery and sleep time and reduce depression. Other factors, such as increased sunlight in patient rooms, views of nature, artwork, and music, also reduce patient stress and can lead to improved outcomes.

Ordering information for a free 50-minute DVD, Transforming Hospitals: Designing for Safety and Quality (AHRQ Publication No. 07-0076-DVD), is available at http://www.ahrq.gov/qual/transform.htm.

8. Measure your hospital's patient safety culture.

   A culture of safety in the hospital is essential to help minimize medical errors. Safety must permeate every aspect of care within the organization. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. Many healthcare organizations are already surveying the safety culture within the organization.

   Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events and patient harm in healthcare organizations. Organizations that want to assess their existing culture of patient safety should consider conducting a safety culture survey.

   Safety culture surveys can be used to:

   • Raise awareness about patient safety issues.
   • Fulfill directives or regulatory requirements.
   • Diagnose the current status of safety culture.
   • Evaluate specific patient safety interventions or programs.
   • Conduct internal and external benchmarking.
   • Track change over time.

   
   Another tool that can be used to survey hospital staff to assess your facility's patient safety culture is AHRQ's free Hospital Survey on Patient Safety Culture and related materials are designed to provide tools for improving the patient safety culture, evaluating the impact of interventions, and tracking changes over time.

   There is also safety culture surveys customized for nursing homes and ambulatory care medical groups. Free patient safety culture surveys for hospitals (AHRQ Publication No. 04-0041), nursing homes (AHRQ Publication No. 08-0060), and medical offices (AHRQ Publication No. 08(09)-0059) are available at http://www.ahrq.gov/qual/patientsafetyculture/.

9. Build better teams and rapid response systems.

   Developed by Department of Defense's Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality, TeamSTEPPS (Team Strategies and Tools to Enhance Performance) is a comprehensive intervention to address patient safety (AHRQ, nd). It is:

   • A powerful solution to improve patient safety within healthcare organizations.
   • An evidence-based teamwork system to improve communication, collaboration and teamwork skills among health care professionals
   • It is one of the key initiatives within patient safety. Patient safety experts agree that communication and other teamwork skills are essential for providing quality health care and preventing and mitigating medical errors. An organization that is ready to focus on teamwork and safety is more likely to benefit from a TeamSTEPPS intervention.
     
     

   The goal of TeamSTEPPS is to provide the safest and highest quality health care. This involves optimizing a complicated delivery system of people and processes and requires change, including recognizing the need for change, developing a culture that will accept change, and fostering change in individuals' approaches to the health care delivery process. This change may involve giving people freedom and discretion, encouraging risk-taking and speaking up, giving permission to find team-driven solutions. Your institution must be willing to change its culture and processes to enhance teamwork and safety (AHRQ, nd).

   TeamSTEPPS has a three-phased process aimed at creating and sustaining a culture of safety with (AHRQ, nd):

   • A pretraining assessment for site readiness.
   • Training for onsite trainers and health care staff.
   • Implementation and sustainment.

   
   TeamSTEPPS provides higher quality, safer patient care by producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients (AHRQ, nd).

   • Increasing team awareness and clarifying team roles and responsibilities.
   • Resolving conflicts and improving information sharing.
   • Eliminating barriers to quality and safety.

   
   Rapid Response Systems are another important "team" in patient safety. A Rapid Response System (RRS), sometimes referred to as Medical Emergency Team (AHRQ, nd) :

   • Brings teams of critical care expertise to the patient bedside when other resources are lacking.
   • Has a wide range of health care professionals coordinating efforts.
   • Treats patients with early warning signs of acute clinical deterioration, namely cardiac arrest.
   • Has a common goal of patient stabilization.

   
   Through implementing RRS initiatives, organizations have found positive results. Some examples include (AHRQ, nd):

   • 50% reduction in non-ICU cardiac arrests (Buist, et al., 2002).
   • Reduced post-operative emergency ICU transfers (58%) and deaths (37%) (Bellomo, et al., 2004).
   • Reduction in cardiac arrest prior to ICU transfer (4% vs. 30%) (Goldhill, et al., 1999).
   • 17% decrease in the incidence of cardiopulmonary arrests (6.5 vs. 5.4 per 1,000 admissions) (DeVita, et al., 2004).

A free, customizable toolkit called TeamSTEPPS™, provides evidence-based techniques for promoting effective communication and other teamwork skills among staff in various units or as part of rapid response teams.

Materials can be tailored to any healthcare setting, from emergency departments to ambulatory clinics. Ordering information for the TeamSTEPPS Multimedia Resource Kit (AHRQ Publication No. 06-0020-3) and information on the training sessions are available at http://teamstepps.ahrq.gov/index.htm.

10. Insert chest tubes safely.

    Chest tube insertion is a life-saving procedure used to relieve tension pneumothorax or hemothorax, the accumulation of air or blood (fluid) under pressure in the pleural space, seen most often in trauma patients. If performed incorrectly, patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury or infection (AHRQ, 2006).

    A series of preventive measures for each type of problem, using an easy-to-remember mnemonic, UWET, was developed from the Joint Commission and stands for:

    • Universal Precautions (achieved by using sterile cap, mask, gown, and gloves).
    • Wider skin prep.
    • Extensive draping.
    • Tray positioning.

    
    Remember UWET when inserting chest tubes. A free 11- minute DVD provides video excerpts of 50 actual chest tube insertions to illustrate problems that can occur during the procedure. Ordering information for Problems and Prevention: Chest Tube Insertion (AHRQ Publication No. 06-0069-DVD) is available at http://www.ahrq.gov/qual/chesttubes.htm.

    For free copies of AHRQ tools, please call the AHRQ Publications Clearinghouse at 1-800-358-9295.

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