Preventing patient falls and fall-related injuries is the focus of the Sentinel Event Alert: Issue 55 released by The Joint Commission. The new alert examines the contributing factors to patient falls and includes suggested solutions to be implemented by health care organizations to help reduce patient falls and falls with injury, according to the press release.
This topic was chosen for Sentinel Event Alert because patient falls with serious injury are among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database. The Joint Commission has received 465 reports of patient falls with injuries since 2009, and approximately 63 percent of those falls resulted in death. The Joint Commission defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm where intervention is required to sustain life. Although the majority of falls reported to The Joint Commission occurred in hospitals, the ECRI Institute also reports a significant number of falls occurring in non-hospital settings such as long-term care facilities.
An analysis of falls with injury reported to The Joint Commission Sentinel Event Database from January 2009 through October 2014 showed the most common contributing factors include:
- Inadequate assessment
- Communication failures
- Lack of adherence to protocols and safety practices
- Inadequate staff orientation, supervision, staffing levels or skill mix
- Deficiencies in the physical environment
- Lack of leadership
The suggested actions in the Sentinel Event Alert address all of the identified contributing factors to patient falls. Listed resources in the alert include links to toolkits and research on falls prevention, and it introduces the Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool®.
“Fall prevention is the responsibility of everyone in the organization and success is highly dependent on leadership playing a primary role. It is their commitment and approach that determines an organization’s ability to significantly reduce and sustain the reduction in falls,” said Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “There are several proactive steps in the Sentinel Event Alert that leaders can initiate such as educating and raising awareness of the need to prevent falls resulting in injury, ensuring the implementation of a validated tool to identify the risk factors for falls, and establishing an interdisciplinary falls injury prevention team.”
Sentinel Event Alert is published periodically by The Joint Commission for health care professionals. It describes the common underlying causes of sentinel and adverse events and recommends steps to reduce risk and prevent future occurrences. Sentinel Event Alert topics are determined by the Joint Commission’s Patient Safety Advisory Group comprised of external members with significant expertise in health care and patient safety, and presided over by Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission.
For more information about the sentinel event statistics and previous issues of Sentinel Event Alert, please visit The Joint Commission’s Sentinel Event Alert Web page.
Source: The Joint Commission
A study published in the October 2015 issue of Anesthesiology reports on the frequency of medication errors and adverse events in the perioperative setting. The rates of errors and events were significantly higher than documented by previous studies. The recent study found:
- A drug error or adverse drug event occurred in approximately 1 in 20 medication administrations and in half of the operations observed
- More than one-third of the errors caused patient harm
- About one-third of the errors resulted in an adverse drug event
Following training as observers, three anesthesiologists and one nurse anesthetist documented all medications administered, medication errors, and adverse drug events during 277 randomly selected operations. In addition to the data collected by direct observation, the study discovered medication errors and adverse drug events through chart review. The anesthesia information system was queried for errors and adverse events related to the same operations. Those cases were further reviewed for duplication; errors and events that had been missed by the observers were then recorded. The study was performed at the Massachusetts General Hospital (MGH), a large academic medical center in Boston.
The study is an important contribution to published literature about rates of perioperative medication errors. Most previous studies relied on self-reported data, which may be one reason why those rates were lower than the rates found in the study performed at MGH.
In an effort to promote transparency around how electronic health records (EHRs) are designed and user-tested, and drive improvements in clinician support and patient safety, the American Medical Association (AMA) and MedStar Health’s National Center for Human Factors in Healthcare have developed a comparative EHR User-Centered Design Evaluation Framework that reveals a lack of focus among regulators and industry on user-centered design and usability testing.
The EHR User-Centered Design Evaluation Framework evaluates design and testing processes for optimizing usability in 20 common EHR products using information reported by EHR vendors to meet usability certification requirements set by the Office of the National Coordinator for Health Information Technology (ONC). The framework goes beyond the low gauge set by federal usability certification criteria and evaluates the vendor’s compliance with best practices for user-centered design (UCD) processes according to a 15-point scale developed by MedStar’s Human Factors Center in collaboration with the AMA.
“It is important to recognize that this framework evaluates conformity with best practices identified in human factors and usability literature for user-centered design and testing. We are not evaluating the actual usability of the product as experienced by end users,” said Raj Ratwani, Ph.D., scientific director of the Human Factors Center and a principle developer of the framework. “Alignment with best practices for user-centered design and testing is a starting point that regulators and industry should meet and exceed. The framework we developed is the first step in bringing greater transparency to the usability processes of EHR vendors.”
Comprehensive user-centered design and testing for EHR products is essential for ensuring that systems are useful clinical tools that will help improve patient safety and meet the cognitive workflow and information needs of physicians and other health professionals. This is emphasized by the AMA and MedStar Health in the goals of the framework, which state: “We believe EHRs should be designed with the end user in mind and that the ONC’s requirements do not go far enough to encourage fully functional and usable products. This framework can be used by the ONC to improve their certification program, and as a method to track improvements EHR vendors make as they recertify their products over time.”
The ONC requires vendors to report on the UCD processes they followed for only a handful of EHR capabilities. Since the design and testing of most EHR functions goes unverified by the ONC’s certification criteria, an optimal evaluation presented by the framework should not be considered reflective of actual usability experienced by physicians and other end-users. As such, the framework should not be interpreted as a buyer’s guide.
“Physician experiences documented by the AMA demonstrate that most EHR systems fail to support effective and efficient clinical work, and continued issues with usability are a key factor driving low satisfaction with many EHR products,” said AMA President Steven J. Stack, M.D. “Our goal is to shine light on the low-bar of the certification process and how EHRs are designed and user-tested in order to drive improvements that respond to the urgent physician need for better designed EHR systems.”
Ratwani added, “To improve the usability of EHRs we need to promote rigorous usability development processes based on recognized methods and standards.”
The framework builds on a study Ratwani wrote on EHR usability that was published by the Journal of the American Medical Association in September 2015. In that study, Ratwani et al., analyzed available reports from the top 50 EHR vendors, as measured by the number of meaningful use attestations made to the ONC between April 1, 2013, and Nov. 30, 2014. The researchers found that a significant percentage of vendors did not even follow basic federal requirements for certifying the usability of their products, yet these products were certified under the meaningful-use incentive program.
Effective usability is critical to patient safety and physician satisfaction. A study conducted by the AMA and RAND Corporation in 2013 found that EHR usability “represents a unique and vexing challenge to physician professional satisfaction” and that the current state of technology raises “concerns about effects on patient care.” The AMA-RAND report urged improved usability among federal certification criteria.
The AMA will continue to move aggressively to advance the goal of more usable EHR products based on eight usability priorities created last year by the AMA to lead EHR design improvements that would ultimately improve the health of the nation.
Sources: American Medical Association and MedStar Health’s National Center for Human Factors in Healthcare
On September 25, 2015, the Centers for Medicare & Medicaid Services (CMS) awarded $110 million to 17 national, regional, or state hospital associations and health system organizations to fund a second round of Hospital Engagement Networks (HEN), which will extend through September 2016. The contracts are part of the Partnership for Patients, a nationwide public-private collaboration designed to protect patients from being harmed while in the hospital and suffering complications after discharge.
Launched in April 2011, the Partnership for Patients strives to engage short-stay acute care hospitals across the nation in improving the quality of care delivered to patients. Along with the HENs, partnerships with physician, nursing, and pharmacy organizations, consumers and consumer groups, and employers have emerged to align their efforts. In addition, private health plans, local agencies on aging, and state and federal government officials have pledged to work together to meet the initiative’s goals.
The Partnership for Patients and the HENs operate within a framework established by the Affordable Care Act to deliver better care to individuals and the population, and to spend dollars more wisely. The Department of Health and Human Services has estimated that 50,000 fewer patients died in hospitals and that approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. Nationally, in that same time period, patient safety has improved, resulting in 1.3 million adverse events and infections avoided in hospitals. This translates to a 17% decline in hospital-acquired conditions during that time frame. In addition, 30-day hospital readmissions in Medicare decreased by nearly 8% between January 2012 and December 2013—translating to 150,000 fewer readmissions.
Partnership for Patients
The focus of the Partnership for Patients’ work going forward will be to sustain national progress on its existing goals:
- Keep patients from getting injured or sicker. Decrease preventable hospital-acquired conditions by 40% compared to 2010.
- Help patients heal without complication. Decrease preventable complications during a transition from one care setting to another so that 30-day hospital readmissions are reduced by 20%compared to 2010.
Concurrently, the Partnership will conduct evaluations to more assess its contribution to national improvements in patient safety.
Hospital Engagement Networks
The HENs will continue to identify solutions that already succeed at reducing healthcare-acquired conditions, and work to spread them to other hospitals and healthcare providers.
HENs work at the national, regional, state, or hospital system level to develop learning collaboratives for hospitals so that they can implement the changes and innovations necessary to achieve the Partnership for Patients’ safety and care-transition goals. HENs engage in a wide array of initiatives and activities to spread established, evidence-based interventions to rapidly improve patient safety in hospitals.
The Partnership for Patients will continue to evaluate the capacity of large improvement networks to bring about improvement in patient safety. HENs are required to focus on the following 10 core areas of harm:
- Adverse drug events.
- Catheter-associated urinary tract infections in all hospital settings, including avoiding placement of catheters, both in the emergency room and in the hospital.
- Central line–associated bloodstream infections in all hospital settings, not just intensive care units.
- Injuries from falls and immobility.
- Obstetrical adverse events, including early elective delivery reduction. Obstetrical adverse events are to include, at a minimum, obstetrical hemorrhage, and preeclampsia treatment and management to prevent morbidity and mortality.
- Pressure ulcers.
- Surgical site infections (SSI), including measurement and improvement of SSI for multiple classes of surgeries.
- Venous thromboembolism, including, at a minimum, all surgical settings.
- Ventilator-associated events, including infection-related ventilator-associated complications and ventilator-associated conditions.
In addition to these topics, HENs are expected to address all other forms of preventable patient harm in pursuit of safety. HENs are expected to detail their plans to address these other forms of harm, including at a minimum the aims, measures, and evidence-based best practices they propose to put in place. The Partnership for Patients recognizes that the pediatric population has unique needs related to these other forms of preventable harm. Therefore, HENs supporting pediatric hospitals and pediatric wards within general hospitals may choose to augment and delineate an alternative program of work to address highest-risk harms specific to the pediatric population, including readmissions.
Additionally, the following are some topics HENs may consider in addressing other harms:
- Severe sepsis and septic shock
- Hospital culture of safety that fully integrates patient safety with worker safety
- Iatrogenic delirium
- Clostridium difficile, including antibiotic stewardship
- Undue exposure to radiation
- Airway safety
- Failure to rescue
Data Tracking and Reporting
Each HEN, in consultation with the Partnership for Patients, will identify and use appropriate process and outcome measures for each area of focus to track hospital progress on quality improvement. A new requirement in this second round of HENs will mandate that they submit data on a standard list of measures. HENs will also be strongly encouraged to use any additional measures that align with existing measurement activity already underway within their community, or that they feel would be most impactful to the populations they serve.
The HENs will also submit monthly reports to CMS describing their activities and the progress of their quality improvement efforts, including hospital progress on improvement measures for each core area. HENs will submit final reports to CMS at the conclusion of the 12-month period of performance detailing the successes, failures, lessons learned, and areas of improvement in each focus area.
To support hospital submission of measurement data, the HENs will be required to establish a secure, Web-based data collection and management portal. Through this portal, the HENs will have access to hospitals’ measurement data, and will use that information to evaluate progress and focus attention on efforts or hospitals that have yet to see improvement. Data collected by the Partnership for Patients will not be used to evaluate hospital performance for existing quality programs such as the Hospital Value-Based Purchasing Program and the Hospital Readmissions Reduction Program.
The HENs will support approximately 3,400 hospitals during this upcoming 12-month period of performance. The competitive procurement process enabled support for a diverse group of acute care hospitals across the nation in an effort to recruit the active participation of as many of the short-stay acute care hospitals in the country as possible.
Selected Hospital Engagement Network Organizations
The 17 HENs (listed in alphabetical order) for round two are:
- American Hospital Association
- Ascension Health
- Carolinas HealthCare System
- Dignity Health
- Healthcare Association of New York State
- Health Research and Educational Trust of New Jersey
- Hospital & Healthsystem Association of Pennsylvania
- Iowa Healthcare Collaborative
- LifePoint Health
- Michigan Health & Hospital Association Health Foundation
- Minnesota Hospital Association
- Ohio Children’s Hospital Solutions for Patient Safety
- Ohio Hospital Association
- Premier, Inc.
- Tennessee Hospital Association
- VHA-UHC Alliance NewCo Inc.
- Washington State Hospital Association
Database features quality information for approximately 104 million insured lives.
The National Committee for Quality Assurance (NCQA) has released its latest version of Quality Compass 2015: Commercial. This comprehensive database of health plan performance compiles data from 400 publicly reporting commercial plan products, offering information on clinical performance and patient experience for approximately 104 million covered lives.
The updated Quality Compass tool features performance data on active commercial health plans pulled from both the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®).
Quality Compass is a valuable tool for health plans, employers, and consumers. Itprovides state, regional, and national benchmarks, as well as individual plan performance. Benchmarks, or national averages for certain measures, are calculated from a total pool of 420 publicly and non-publicly reporting health plan products. Health plans use this information to help compare their performance to others in their area and across the country. Employers and purchasers use the information to choose the best-performing plans to offer their enrollees.
Quality Compass 2015: Commercial includes the following new and updated measures from the HEDIS Effectiveness of Care domain:
- Cervical Cancer Screening
- Non-Recommended Cervical Cancer Screening in Adolescent Females
“Health plans, employers and other consumers look to Quality Compass to pinpoint areas where plans are performing well, or that need improvement,” said NCQA’s Chief Information Officer, Rick Moore. “Offering the most comprehensive data set available lets consumers make sound decisions when choosing their plan.”
NCQA will release the Medicaid and Medicare editions of Quality Compass later this fall.
All Quality Compass editions can be ordered online through NCQA’s website, www.ncqa.org/qualitycompass.aspx, or by calling NCQA Customer Support at 888-275-7585.
While much emphasis has been placed on the improvement of IV infusion safety, standardized safe practices associated with IV push injection safety remain limited. The Institute for Safe Medication Practices (ISMP) recently released new guidelines to help healthcare practitioners identify risks associated with adult IV push medications.
The guidelines were developed as part of a national summit held by ISMP in 2014 to address safety concerns reported through ISMP’s National Medication Errors Reporting Program and uncovered by several ISMP surveys, as well as unsafe practices and at-risk behaviors observed during onsite consultations at acute care and outpatient locations across the U.S.
Funded by a grant from BD, the summit brought together expert stakeholders, including frontline practitioners, professional organizations, regulatory agencies, and product vendors, to gain consensus on strategies for safe IV push administration of parenteral medications to adults. Participants also identified a number of unresolved issues that deserve additional study. A draft of the document was shared on ISMP’s website for public comment before being finalized.
The guidelines discuss the risks associated with IV push therapy, and present recommendations that address the following areas:
- Acquisition and distribution
- Aseptic technique
- Clinician preparation
- Clinician administration
- Drug information resources
- Competency assessment
- Error reporting
- Future inquiry
The guidelines also call on manufacturers to provide IV products in the most ready-to-administer form possible and to design devices and technology that promote safe IV push drug administration. Researchers are asked to take on the unanswered questions expressed by participants, leading the healthcare community to a better understanding of what places patients at risk and the corresponding evidence-based risk-reduction strategies that have proven to be the most successful.
"A number of latent system issues have contributed to the variable state of IV push injection practices—they can differ significantly not only between healthcare organizations, but even within a single organization’s individual clinical units," says Michael Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, president of ISMP. "Through dedicated commitment to standardization, we can significantly improve patient outcomes and prevent errors."
“BD shares ISMP’s goal of reducing the risks associated with IV push medication errors,” said William A. Tozzi, worldwide president, BD Medical – Medication and Procedural Solutions. “One of BD’s top priorities is to provide solutions that help improve medication safety, and our grant to ISMP will help support development of standardized safe practices associated with IV push medication use.”
For a copy of ISMP's Safe Practice Guidelines for Adult IV Push Medications, visit the Institute’s website at: http://www.ismp.org/Tools/guidelines/ivsummitpush/ivpushmedguidelines.pdf
In a report released in July, the American Hospital Association’s (AHA) Interoperability Advisory Group (IAG) calls on health systems and hospitals, developers and vendors of electronic devices and information systems, and government and regulatory agencies to work together to improve the interoperability of healthcare data.
In Achieving Interoperability that Supports Care Transformation, the group observes that the United States will gain full advantage of its recent investment in electronic health records (EHR) only when information can be shared easily and securely among all who need to use it. Acknowledging that initiatives such as meaningful use and EHR certification provide starting points, the report faults the Office of the National Coordinator (ONC) for not doing enough to support interoperability. EHR certification includes standards that support data sharing, but the IAG reports that organizations need more practical help for implementation and better oversight of vendor offerings before they will be able to achieve the goal of interoperability:
…ONC generally did not provide implementation guidance for the use of the standards, allowed flexibility in how the standards are used by vendors and adopted relatively lax testing of EHRs for certification. As a result, AHA members report very limited actual interoperability today.
Members of the IAG include administrative and clinical leaders, as well as experts in information technology, and represent the range of AHA member organizations from large academic medical centers to standalone hospitals.
In addition to wanting ONC and the federal government in general to focus more effectively on standards, certification, and testing, the IAG’s report describes things the private sector must do to advance interoperability. The private sector includes providers, vendors, health information exchanges, and organizations that represent the interests of other stakeholders. Among the ways they can support interoperability, the IAG highlights demanding that vendors adhere to accepted standards, contributing use cases that accurately represent the need for sharing information, and sharing lessons learned and best practices.
In addition to a long to-do list for the private and public sectors, the IAG suggests that a new multi-stakeholder organization may be necessary to “drive progress on interoperability.” Citing the success of CAQH—a non-profit alliance that promotes standardized sharing of financial and business data for healthcare organizations— the IAG proposes that a similar group might help navigate the competing stakeholder interests and accelerate what so far has been slow progress on interoperability.
On Wednesday, June 24, 2015, the American Board of Magnetic Resonance Safety (ABMRS) administered the first examination to certify individuals with the credentials MR Medical Director/Physician (MRMD) and MR Safety Officer (MRSO). More than 100 radiologists, technologists, and medical physicists took the exam for either the MRMD or MRSO. Only licensed physicians may sit for the MRMD exam. The ABMRS will also offer an MR Safety Expert (MRSE) credential, for which the inaugural exam will be administered on October 21, 2015, in Orlando, Florida. Exams for the MRMD and MRSO credentials will also be offered at that time.
The MRMD and MRSO examinations cover distinct aspects of the same MR safety knowledge domains (e.g., static magnetic fields, gradient magnetic fields, radio frequency energies, contrast agents, bioeffects, etc.). The exams focus directly on the candidates’ knowledge of the underlying MR safety concepts as well as their ability to apply that knowledge to real-world clinical and research situations.
The ABMRS was formed in 2014 to certify healthcare professionals who oversee safety in all magnetic resonance environments. For more information visit the ABMRS website.
Having residents—physicians in training—participate in surgery does not in itself increase a patient’s risk of postoperative complications or of dying within 30 days of the surgery, according to a recent study of more than 16,000 brain and spine surgeries. A report on the study appears in the April issue of the Journal of Neurosurgery.
“Patients often ask whether a resident is going to be involved in their case, and they’re usually not looking to have more residents involved,” says Mohamad Bydon, MD, himself a resident in neurosurgery at The Johns Hopkins Hospital. “Some people have a fear of being treated in a hospital that trains doctors.”
To see whether that fear is borne out by real-world outcomes, Bydon worked with Judy Huang, MD, a professor of neurosurgery and director of the neurosurgery residency program at the Johns Hopkins University School of Medicine, and other collaborators to analyze data from the American College of Surgeons National Surgical Quality Improvement Program database. Specifically, they examined outcomes for all patients who had brain and spine surgeries between 2006 and 2012—16,098 in total.
The initial analysis appeared to affirm the fear, showing that patients operated on by a fully trained physician—known as an attending—plus a resident had a complication rate of 20.12 percent, while patients with only an attending had a complication rate of 11.7 percent. The patients operated on by attendings plus residents also had a slightly higher risk of death within 30 days after the surgery.
But, the research team suspected, that might not be a difference caused by the participation of the residents. Residents are most often found in teaching hospitals associated with academic medical centers, and such hospitals are also the most likely to treat higher risk, more complicated cases. So the team did a deeper analysis of the data, one that took into account patients’ conditions and severity of illness prior to surgery. That analysis showed that having a resident present in the surgery was not an independent risk factor for postsurgical complications or death.
The authors say the study’s results may help physicians reassure nervous patients about the prospect of having a trainee assist with a surgery.
The U.S. Senate has confirmed David J. Shulkin, MD, as the Under Secretary of Health for Veterans Affairs. As the chief executive of the Veterans Health Administration (VHA), Shulkin will lead the nation’s largest integrated healthcare system with more than 1,700 sites of care, serving 8.76 million veterans each year. VHA is also the nation’s largest provider of graduate medical education and a major contributor of medical research. Shulkin will oversee the 300,000 people who work at the VHA.
Shulkin was nominated by President Obama on March 19, 2015, to serve as under secretary and confirmed by the U.S. Senate on June 23, 2015. The vote to confirm Shulkin comes as Congress has shown concern over issues at the VA over the past year related to access and quality of care.
Shulkin, 55, of Pennsylvania, will replace interim Under Secretary Carolyn Clancy, MD, who took over shortly after Dr. Robert Petzel resigned in 2014.
At his Senate confirmation hearing, Shulkin pledged to improve the largest healthcare organization in the U.S. by using his private sector experience to help guide the VA beyond patient access problems that led to waiting lists and falsified records in Phoenix and elsewhere around the country. Dr. Shulkin told senators at his hearing on May 5, 2015, that “VA needs change” and that the time had come to create a “new VA” with “superior access and the highest standards for quality of care.”
Shulkin said that taking care of veterans is a personal mission. His father served as a captain in the Army and his grandfather was chief pharmacist at the Madison Wisconsin Veterans Medical Center. Both Shulkin and his wife, Dr. Merle Bari, worked in a number of VA facilities during their medical training.
Prior to becoming under secretary, Shulkin led a number of healthcare organizations. He most recently served as president of Morristown Medical Center and vice president of Atlantic Health System in Morristown, New Jersey, where he led the hospital during a period of significant growth and transformation. Prior to that, Shulkin was president and CEO of Beth Israel Medical Center in New York City. Shulkin has also served as the chief medical officer of the University of Pennsylvania Health System, Temple University Hospital, and the Medical College of Pennsylvania Hospital.
Shulkin’s expertise includes management in healthcare organizations and integrated delivery systems, medical education, health services research, and health technology. He has been an entrepreneur, author, researcher, and academic leader in the areas of health administration, quality, and patient safety. Dr. Shulkin founded DoctorQuality, Inc., one of the first companies in the country to help consumers choose better quality healthcare.
Shulkin, a general internist, is a graduate of Drexel University School of Medicine and did his medical training at Yale University and the University of Pittsburgh. Shulkin was a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania. Most recently he has been Professor of Medicine at Mt. Sinai School of Medicine.
Safe use of health information technology (health IT) is the focus of a new Sentinel Event Alert recently released by The Joint Commission.