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Many of the Patient
Safety Organizations above have released goals for patient
safety and have promoted particular interventions for the
improvement of patient safety. This course provides an overview
of some of the recommendations of a sampling of safety organizations.
In particular interventions from the Agency for Healthcare
Research and Quality (AHRQ) and a compilation of safety interventions
focusing on the development of a healthcare partnership between
provider and patient as a means of promoting patient safety
and reducing medical errors.
Interventions from
The Agency for Healthcare Research and Quality (AHRQ)
Medical errors may
occur in different health care settings, and those that happen
in hospitals can have serious consequences. AHRQ, which has
sponsored hundreds of patient safety research and implementation
projects, offers these 10 Evidence-Based Tips to Prevent
Adverse Events (AHRQ, 2009a) from occurring in the hospital
setting. These healthcare "tips" are a result of safety research.
- Prevent central line associated
blood stream infections.
Central venous catheters or central
line catheters, are placed into large veins in a patient's
neck, chest, or groin to administer medication or fluids
or to collect blood samples. Their placement disrupts
skin integrity, allowing for potential infections. An
infection can then cause bacteremia and hemodynamic changes
and organ dysfunction can occur (IHI, 2008).
Each year, an estimated 250,000
cases of central line-associated blood stream infection
(CLABSI) occur in U.S. hospitals, and an estimated 30,000
to 62,000 patients who get the infections die as a result,
according to CDC (AHRQ, 2009). Among patients in an intensive
care unit (ICU), 48% have central venous catheters (IHI,
2008). The case fatality rate for catheter related blood
stream infections is almost 20% (IHI, 2008).
The site with the highest occurrence
of infection is the femoral artery, especially in obese
patients (IHI, 2008). The subclavian site has a lower
risk of infection than the internal jugular vein (IHI,
2007). Risks and benefits for site selection must be weighed
for each patient.
In addition to the high human cost
of central venous catheter infections, the financial burden
is high as well. According to the Institute for Healthcare
Improvement (2008), the attributable cost per bloodstream
infection is up to $29,000 per case. The total financial
burden attributable to HAIs is estimated to be between
$28 billion to $33 billion each year (AHRQ, 2009).
Being vigilant in preventing central
line associated blood stream infections involves taking
five steps every time a central venous catheter
is inserted. These steps are often called "the central
line bundle":
- Wash your hands;
- Use full-barrier precautions;
- Clean the skin with chlorhexidine;
- Avoid femoral lines; and
- Remove unnecessary lines.
Taking these steps consistently reduced this type
of deadly health care-associated infection to zero in
a study at more than 100 large and small hospitals (AHRQ,
2009). The benefits of reducing such infections include
(IHI, 2008):
- Better outcomes for patients;
- Reduced mortality;
- Improved satisfaction among
nurses, physicians, patients and families;
- Financial benefits.
For more information about the prevention of infection
related to central venous line catheters and how to implement
this program, go to http://www.ihi.org/IHI/Programs/Campaign/CentralLineInfection.htm
and download the Updated How-To
Guide.
- Re-engineer hospital discharges.
In the years since hospital stays
have been drastically reduced, discharge planning has
often taken a back seat to the acute needs of the hospitalization.
The transfer of patient care from the hospital to primary
care or other providers in the community, at the time
of discharge, is a high-risk process that is often characterized
by fragmented, non-standardized, and haphazard care leading
to errors and adverse events (Anthony, et al., 2005).
These "principles of the newly
re-engineered hospital discharge", developed as a result
of research, include the following (Anthony, et al., 2005):
- There must be explicit delineation
of roles and responsibilities.
- Patient education must occur
throughout the hospitalization, not only at the time
of discharge.
- Information must flow easily
from the primary care provider (PCP) to the hospital
team, among the hospital team, and back to the PCP.
- Information should be captured
throughout the hospital stay, not only at the time of
(or after) discharge.
- Every discharge must have a
written discharge plan that is comprehensive in scope
and that addresses medications, therapies, dietary and
other lifestyle modifications, follow-up care, patient
education, and instructions about what to do if the
condition worsens.
- This comprehensive discharge
plan should be completed before the patient leaves the
hospital.
- Patients at high risk of re-hospitalization
should have the discharge plan reinforced by contact
from the hospital team after discharge.
- All information about the admission
must be organized and delivered to the PCP within 24
hours.
- Waiting until the discharge
order is written before beginning the discharge process
is likely to increase the risk of errors.
- Efficient and safe hospital
discharge is significantly more difficult to achieve
if the case management staff works only the 7 a.m.-3
p.m. shift (i.e., the "first" shift).
- All patients should have access
to their discharge information in their language and
at their educational level.
Reduce potentially preventable readmissions by implementing
interventions founded on 11 discrete, mutually reinforcing
components and has been proven to reduce re-hospitalizations
and yields high rates of patient satisfaction. Examples
include assigning a staff member to work closely with
patients and other staff to reconcile medications and
schedule necessary follow-up medical appointments, creating
a simple, easy-to-understand discharge plan for each patient
that contains a medication schedule, a record of all upcoming
medical appointments, and names and phone numbers of whom
to call if a problem arises.
AHRQ-funded research conducted
by the Boston University Medical Center's Re-Engineered
hospital Discharge (Project RED) shows that taking
these steps can help reduce potentially preventable readmissions
by 30 percent. An online toolkit is available at http://www.bu.edu/fammed/projectred/.
- Prevent venous thromboembolism.
Pulmonary embolism resulting from
deep vein thrombosis (DVT)-collectively referred to as
venous thromboembolism (VTE)-is the most common preventable
cause of hospital death. Despite the inclusion of prevention
interventions in various consensus guidelines, efforts
at prevention of VTE are underused in the healthcare setting
(Kucher, et al., 2005).
In the absence of prophylaxis,
the risk of VTE across almost all populations of hospitalized
patients is significant, as shown in Table 1. (AHRQ, 2008).
Table 1.
Risk of Deep Vein Thrombosis in Hospitalized Patients
|
Patient Group
|
DVT Incidence
(%)
|
Medical patients |
10-26
|
Major gynecological, urological,
or general surgery |
15-40
|
Neurosurgery |
15-40
|
Stroke |
11-75
|
Hip or knee surgery |
40-60
|
Major trauma |
40-80
|
Spinal cord injury |
60-80
|
Critical care patients |
15-80
|
Fortunately, pharmacologic methods
to prevent VTE are safe, effective, cost-effective, and
advocated by authoritative guidelines. Yet, despite the
reality that hospitalized medical and surgical patients
routinely have multiple risk factors for VTE, making the
risk for VTE nearly universal among inpatients, large prospective
studies continue to demonstrate that these preventive methods
are significantly underutilized. The American Public Health
Association has stated that the "disconnect between evidence
and execution as it relates to DVT prevention amounts to
a public health crisis." (AHRQ, 2008).
Individual health centers have published
results of successful local initiatives for improving prevalence
of VTE prophylaxis, however, no single strategy has proven
yet to be effective, sustainable, and widely applicable
to other centers. Experiences with VTE management are rapidly
evolving, validating the risk assessment techniques and
implementation techniques. To implement effective protocols
that minimize the incidence of hospital-acquired VTE, while
at the same time minimizing adverse outcomes, redesign is
needed in both care delivery and performance tracking (AHRQ,
2008).
Using an evidence-based guide to
create a VTE protocol can eliminate hospital-VTE. One such
evidence-based guide is available from AHRQ, without charge.
This guide explains how to take essential first steps, lay
out the evidence and identify best practices, analyze care
delivery, track performance with metrics, layer interventions,
and continue to improve. Ordering information for Preventing
Hospital-Acquired Venous Thromboembolism: A Guide for Effective
Quality Improvement (AHRQ Publication No. 08-0075) is
available at http://www.ahrq.gov/qual/vtguide/.
- Educate patients about using blood thinners safely.
Surgical patients often leave the
hospital with a new prescription for an anticoagulant,
such as warfarin (brand name: Coumadin®), to prevent the
development of VTE. However, if used incorrectly, such
blood thinners can cause uncontrollable bleeding and are
among the top causes of adverse drug events.
In addition the patient, education
needs to be directed to, families, caregivers, staff and
clinicians. Standardized order sets can be part of this
educational process for staff and clinicians. Anticoagulant
use in the prevention of VTE challenges the in-patient
care system to monitor it's own effectiveness in obtaining
required laboratory studies, following compliance issues,
ensuring dietary restrictions, tracking adverse drug events
and preventing drug interactions when treating patients
with anticoagulants. Another important area is transition
of care from the in-patient to the out-patient setting.
The need to monitor this process to ensure a seamless
transition is stressed. Clearly this intervention dove-tails
with the need to re-engineer hospital discharges.
The management of "high alert"
drugs such as heparin and warfarin are significant challenges
for all institutions. Multiple healthcare safety organization
have the goal to promote best practices on the safe use
of anticoagulant drugs. This goal would standardize care
and implement best practices to reduce the number of medication
errors that could lead to patient harm (HCIF, 2010):
- Demonstrating standardization
through limiting the number of concentrations of heparin,
including therapeutic heparin and heparin flush solutions;
- Developing or refining existing
standard protocols and nomograms for prescribing, dispensing,
administrating and monitoring of anticoagulant therapy;
- Implementing practices or procedures
to avoid unsafe concomitant administration of multiple
anticoagulants.
A free 10-minute patient education
video and companion 24-page booklet, both in English and
Spanish, help patients understand what to expect when taking
these medicines. Ordering information for Staying Active
and Healthy with Blood Thinners (AHRQ Publication No.
09-0086-DVD) and Blood Thinner Pills: Your Guide to Using
Them Safely (AHRQ Publication No. 09-0086-C) is available
at http://www.ahrq.gov/consumer/btpills.htm.
A downloadable version of the booklet appears in the "Resources"
section of this course.
- Limit shift durations for medical
residents and hospital staff whenever possible.
According to the American Nurses
Association (ANA) (2009), "Concern for the long term effects
of overtime leading to fatigue include potential for diminished
quality of care, errors or near misses, as well as the
negative impact on the care-givers health. Research indicates
that risks of making an error are significantly increased
when work shifts are longer than 12 hours, when nurses
worked overtime, or when they worked more than 40 hours
per week." The ANA , in it's Nationwide State Legislative
Agenda, supports state laws and regulations prohibiting
the use of mandatory overtime as well as pursuing federal
legislation with similar goals.
As of 2009, fifteen states have
restrictions on the use of mandatory overtime for nurses.
In thirteen states, these restrictions appear in state
law: CT, IL, MD, MN, NJ, NH, NY, OR, PA, RI, TX, WA, and
WV. In two states, these mandatory overtime limit provisions
appear in state regulations: CA and MO (ANA, 2009).
Evidence shows that acute and chronically
fatigued medical residents are more likely to make mistakes.
Ensure that residents get ample sleep and adhere to 80-hour
workweek limits. Residents who work 30-hour shifts should
only treat patients for up to 16 hours and should have a
5-hour protected sleep period between 10 p.m. and 8 a.m.
Resident Duty Hours: Enhancing Sleep,Supervision, and
Safety is available at http://books.nap.edu/openbook.php?record_id=12508&page=R1.
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