patient safety quality healthcare

C.diff Infection Raises Hospital Costs by 40% per Case

By Alexandra Pecci, for HealthLeaders Media

Treating Clostridium difficile adds about $7,285 in hospital costs per patient, not including readmissions, research finds.

It can be difficult to quantify the exact economic burden of C. diff on hospitals and the health system as a whole. But a recent study puts a dollar amount on the cost of C. diff, that number is not only big, but also likely underestimated.

Published in the November issue of the American Journal of Infection Control, the study found that C. diff-associated diarrhea (CDAD) increases hospital costs by 40% per case and puts those infected at high risk for longer hospital stays and readmissions.

Read more...

FDA validates revised reprocessing instructions for Model ED-530XT duodenoscopes

FUJIFILM Medical Systems issued revised reprocessing instructions late last month for Model ED-530XT duodenoscopes, according to a safety communication issued by the FDA. The instructions require exacting pre-cleaning, manual cleaning, and high-level disinfection procedures.

While these revised reprocessing instructions are for Model ED-530XT duodenoscopes, the FDA is encouraging healthcare facilities that use Fuji’s 250 and 450 duodenoscope models, to use the revised reprocessing instructions until the revised instructions for those models are final.

Key changes to the reprocessing procedure for Fuji’s ED-530EXT duodenoscope:

  • Pre-cleaning
    • During immersion of the scope tip in detergent solution, move the forceps elevator back and forth and aspirate detergent solution while the forceps is raised and while lowered.
  • Manual cleaning
    • Additional brushing of the distal tip, forceps elevator and elevator recess first using the existing Fujifilm valve cylinder cleaning brush (Model WB11002FW2) and then using the new disposable (Model WB1318DE) cleaning brush.
    • Additional flushing of detergent and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered.
    • Additional flushing steps and increased channel flushing volumes of detergent and rinse water
  • Manual high-level disinfection
    • Additional flushing of disinfectant and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered. Additional raising and lowering of the elevator while immersed in disinfectant solution and rinse water.
    • Additional flushing steps and increased flushing volumes of disinfectant and rinse water through the duodenoscope’s internal channels.


    In October, the FDA ordered the top three manufacturers of duodenoscopes, Olympus America, Inc., Fujifilm Medical Systems, USA, Inc., and Hoya Corp. to submit plans outlining how they were going to conduct studies to understand how the duodenoscopes are being reprocessed in healthcare settings.

    For more information visit the FDA website.

Study: Discharge notes are often written grades above patient reading levels

A study published in The American Journal of Surgery found that low literacy rates can drive up the number of hospital readmissions. Of the 497 patients studied, researchers found that only 24% had the reading skills necessary to understand their discharge instructions, with 65% reading a lower grade level than what their notes were written in.

“Even if patients believe they understand what occurred during their hospitalization and the instructions they are to follow upon dismissal, they can become confused after they leave the hospital environment as their memory can be clouded by medications they were administered, the stress of hospitalization, and, particularly, within our patient population, traumatic brain injuries such as concussions,” senior study author Martin Zielinski, MD, told Reuters.

The study also found that 65% of 30-day readmissions were for patients who didn’t have the literacy skills to understand their discharge notes. Researchers recommend writing dismissal notes at a sixth-grade level to ensure patient comprehension.

Massachusetts medical board proposes rules on simultaneous surgeries

Surgeons in the state of Massachusetts will have to document each time they enter and leave the operating room according to a new regulation approved by the Massachusetts Board of Registration in Medicine, according to a recent report in The Boston Globe.

Patients rarely know if they are sharing their surgeon with another patient, and the lack of documentation about the surgeon’s whereabouts during a procedure leaves some wondering if their doctor actually performed the entire procedure, according to the report.

Additionally, the primary surgeon will need to identify the backup doctor in the event the primary surgeon needs to leave the operating room during the procedure.

Other rules approved by the board last week include:

  • Doctors will be required to report other physicians who are impaired by alcohol or drugs while on duty
  • Online physician profiles have been expanded to include out-of-state malpractice judgments and settlements involving Massachusetts doctors

The approved rules need approval by various state agencies by the end of March before they can go into effect.

The Hidden Patient Experience

Alexandra  Wilson Pecci, for HealthLeaders Media

How well-meaning and clinically important actions can make or break the patient experience, and how leaders at Cleveland Clinic and Mount Sinai Health System are refocusing efforts.

During her hospital's monthly executive leadership rounds, Cleveland Clinic's executive chief nursing officer, K. Kelly Hancock, MSN, RN, NE-BC, met a patient who didn't seem quite happy, despite his insistence that everything was OK.

"We could just tell that he was a bit hesitant in his answers," Hancock says. So before she and her fellow executives left him, they probed a little more, asking "Are you sure there's nothing else we could to make your experience better?"

Actually, something was bothering him. Someone had come in to change his gown, and instead of addressing him by name, such as Mr. Smith, they called him "honey" and "sweetie."

"For him, he was offended," Hancock says.

It may have seemed like a small thing, but it really rubbed him the wrong way, and totally colored his experience as a patient. It was clear that it had been bothering him for quite some time.

"You've really got to dig when you're with the patients and families," Hancock says. "What's important to that patient [is something] you may miss."

Clinicians might check off all of the important clinical boxes when caring for a patient, but it's often the small--perhaps nearly imperceptible--nonclinical elements of a hospital stay that most affect whether a patient has a good experience.

"I think that patients come to us expecting to get really good clinical care," agrees Sandra Myerson, MBA, MS, BSN, RN, senior vice president and chief patient experience officer at New York's Mount Sinai Health System.

With all the effort, money, and attention that's currently being paid to the patient experience, it's important for clinicians to understand how to get to the real heart of how a patient is feeling, and to do it in real-time.

Digging In

Beginning this year, Cleveland Clinic will be starting a program in which providers, such as nurses and physicians, will actually shadow patients during their inpatient stay or outpatient visit to better understand "what their experience is through their lens." Hancock says she's "really excited" about the program and can't wait to start it, adding that they think that "it's important enough that it's clearly worth the investment to take those caregivers offline."

Shadowing could also help clinicians develop the empathy they need to really understand what patients are going through, and therefore, what they care about. Hancock says compassionate care is about being present, empathetic, and listening for key words that a patient uses that might clue clinicians into their emotions, and ultimately, their experience.

Use the right language

Hancock says it's important to meet patients where they are, and the shadowing project will very literally do that. By asking something as simple as "What's important to you during this stay?" clinicians might find out that the patient really wants his hair washed or face to be shaved. They're small things that can go a long way in providing dignity and comfort, but that may not be "important" clinically.

"We have to pay attention to those things that are concerning to the patient that we might not even think they should be concerned about," Myerson says. "We tend to be really task oriented."

Hancock says providing a template for talking about these nonclinical topics can help staff drill down into what's really important or worrying to the patient. In addition, engaging in role-playing exercises can help staff ensure that such conversations with patients happen naturally and without sounding scripted.

Myerson adds that training managers and other clinicians to ask certain open-ended questions, rather than yes-or-no questions, can elicit better responses. For instance, clinicians might ask "How did you sleep?" or "What got in the way of you sleeping well?" instead of "Did you sleep well?"

Another question that could be useful, especially if a patient is suffering, is "What's the worst part of this for you?" according to a new essay in JAMA. Asking such a question and "turning toward" suffering, the authors write, helps not only with the patient experience in the moment, but with overall, long-term healing in a way that straightforward diagnosis and treatment may not. It acknowledges that patients are whole human beings. It's also important to remember that clinicians are whole humans, too, and that these non-clinically focused interactions doesn't always come naturally. That's why they need training.

"We're spending a lot of time and effort around coaching people to be really effective communicators because it's not something that we learned in school," Myerson echoes. "It's about the human experience."

Be visible and open

Myerson says patients aren't always comfortable expressing their concerns during their hospital stay, especially if they're unhappy with a particular clinician. Patients may also not know who to complain to in the first place. That's why nurse managers have to be visible and available to patients.

"What we like to do is have the nurse manger round on every patient every day. It is a really great way for the patient know who's in charge of the unit," she says. "At the end of the day the nurse manager is really the CEO for their unit."

Nurse managers at Mt. Sinai also hand out postcards with their name, photo, and contact information—in English on one side, and Spanish on the other—so patients have it handy if they need to get in touch. Nurse managers at Cleveland Clinic also round on new patients and distribute business cards.

"If I know who's in charge I can go right to the boss," Myerson says.

But it's not only the boss who has a role to play in listening to the patient. For instance, Myerson says some of their housekeepers have a great, natural ability to interact and connect with patients, and sometimes patients will confide things in them. When that happens, they're instructed to tell either the charge nurse, nurse manager, or their own supervisor.

In fact, everyone on the nonclinical teams receive education about making eye contact with patients, smiling, and introducing themselves. Myerson adds that building services team members have huddles before each shift, and "they talk about patient experience almost every single huddle."

"Everybody has a role in the patient experience," Myerson says.

Editor's Note: This article initially appeared in HealthLeaders on January 6, 2016.



Process Improvements in the ED increase sepsis bundle compliance, reduce mortality

By improving compliance with the sepsis three-hour bundle, Dartmouth-Hitchcock Medical Center reduced patient mortality by 50% in just 90 days

Effectively treating any infection requires a certain measure of early identification and rapid response. Infections, by their nature, worsen over time, so hospitals with successful care processes that rapidly identify and treat infections often see the most success.

Identifying and appropriately treating a patient with sepsis, however, takes that response to a whole new level. Research shows that early identification and treatment of sepsis significantly reduces mortality. In a 2011 presentation at the Society of Critical Care Medicine 40th Critical Care Congress, researchers showed an 88% increase in mortality in patients who received antibiotics six hours after arrival, compared with those who received antibiotics within two hours.

Furthermore, sepsis has become more prevalent in healthcare over the past decade. According to statistics released by the National Center for Health Statistics in 2011, hospitalization rates for septicemia or sepsis more than doubled from 2000 to 2008. Seventeen percent of hospitalizations related to sepsis ended in death, compared to 2% of all other hospitalizations. In 2011, sepsis was identified as the most expensive condition treated in hospitals.

Despite the severity of the infection, hospitals still struggle with management and prevention, particularly in the ED where patients are often admitted with symptoms that aren't particularly unique, including fever, rapid breathing and heart rate, chills, and disorientation. This makes sepsis difficult to identify in the early stages.

The reason sepsis is still so prevalent and dangerous is not a lack of best practices; the Surviving Sepsis Campaign was created in 2002 and guidelines have been in place for a decade. But sepsis continues to plague healthcare because of an inability to manage the process of applying those best practices consistently and in a timely manner, says Megan Zweig, senior consultant on research and insights at The Advisory Board Company, headquartered in Washington D.C.

"The issue with sepsis isn't that clinicians and physicians don't know how to treat it," she says. "They know how to treat it. The Surviving Sepsis Campaign guidelines have a lot of underlying literature proving that if followed correctly, they reduce mortality, and yet we still see tremendous figures on the number of people that are dying in this country from sepsis."

But some hospitals are finding that focusing on the lean principles of process improvement offer the most effective way to quickly implement sepsis treatment. In December, Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire announced that it has reduced patient mortality by more than 50% by achieving 80% compliance with the three-hour sepsis bundle, and they did it within 90 days.

The hospital achieved these impressive reductions by taking a very "granular look at every step of the process," according to Andreas H. Taenzer, MS, MD, an anesthesiologist at Dartmouth-Hitchcock who led the intervention.

Taenzer says even when they looked around at other high-performing hospitals, their compliance rates with the bundle hovered around 25% to 30%. The trick was to bring together a variety of clinicians from all parts of the hospital to coordinate processes necessary to improve the response time to sepsis patients.

"The three-hour bundle doesn't sound very difficult, but the actual compliance is very low," he says. "The big picture was we know what to do, it just wasn't clear on how to do it."

Corralling all the moving parts

One of the primary reasons that hospitals struggle to adhere with sepsis identification and treatment best practices is because the guidelines involve many different units working in unison. Nurses screen patients in the ED, physicians order tests from the lab, which dictates if and when antibiotics are ordered from the pharmacy.

"I think it's the complexity of the execution and how many people are involved that make it incredibly difficult to translate what we know works into consistent practice," Zweig says.

Starting in January 2014, Taenzer says his team brought in representatives from all sectors of the hospital?ED nurses and physicians, laboratory technicians, and pharmacists?and dissected the entire three-hour bundle from top to bottom.

During each step of the way the multidisciplinary group discussed problems and obstacles that would impact any one of those departments during any stage of the process.

For example, one of the keys to identifying sepsis in an admitting patient is drawing lactate. Dartmouth-Hitchcock found its turnaround time was 60 minutes. After implementing process improvements, that time was reduced to six minutes, Taenzer says.

"That sounds like something simple to do, but we brought everyone in a room for at least 20 hours total time, and just walked through the ED, [looking at] what is the patient flow? Where does one need to go to get the antibiotics? Where are they stored? Who replenishes them when they are being used? What are the optimal dosages? How can we simplify all that?" he says.

The team also adjusted the process to empower nurses to better identify potential sepsis patients that arrived in the ED. From there, it installed an accelerated pathway that would start the process of notifying the physician, drawing labs, ordering IVs, and alerting the rest of the ED staff that this was a high-priority case.

Timing is imperative in treating sepsis patients, but Taenzer says that nearly every delay they encountered with the three-hour bundle was process-oriented. The process improvements allowed clinicians to quickly identify sepsis patients and then get them started on antibiotics as soon as possible.

Zweig says the early detection of sepsis in the ED relies heavily on a fluid process.

"I think education can be helpful, but I think it's about having a hardwired and defined process for who should be doing that screening, and during the screening, what they should be looking for," she says. "Depending on what they are looking for, if they see potential signs of sepsis, who should they tell and what are the follow-up steps?"

Setting an aggressive goal

Dartmouth-Hitchcock president and CEO James N. Weinstein, MD, set an aggressive goal of hitting 80% compliance within 90 days. Initially, Taenzer admits he thought the goal was "a little lofty or ambitious," but it ultimately drove the team toward high standards of improvement.

"It's something that has to be learned from leaders in healthcare, that sometimes you have to set the goal as high as he did and go for it," Taenzer says.

The hospital was able to achieve such a rapid improvement for two reasons, Taenzer adds. First, they reached out to 16 other member hospitals in the High Value Healthcare Collaborative (HVHC).

North Shore-Long Island Jewish Hospital offered a sepsis identification tool and Intermountain Healthcare provided some suggestions for implementation improvements.

Second, Dartmouth-Hitchcock utilized professionals from its Value Institute, an initiative created in 2012 that utilizes "Lean Six Sigma" methodology to improve healthcare processes. Sam Shields, MBA, a performance improvement expert with the Value Institute, was imperative to the success of the intervention in the ED, and then later in transitioning to the ICU, Taenzer says.

"His background is chemical engineering," he says. "The same methodology that they use there to keep production safe and efficient can be used in healthcare. That was a key component to getting this done right."

Start in the ED

Statistics show that the identification of sepsis patients begins in the ED, which is why many healthcare organizations start by adjusting ED procedures and then move to other units, like the ICU.

According to The Advisory Board's Crimson program, which tracks data analytics from more than 1,000 hospitals, there is an 80-20 split that identifies where sepsis patients are coming into the hospital.

"When I'm talking to an organization who wants to improve sepsis outcomes, one of my first recommendations is you need to look at the ED because you're going to catch 80% [of] your patients based on this data set if you're more deliberate about screening for sepsis in ED triage," Zweig says.

She also notes that most hospitals have had success when screening tools or checklists are made available to ED nurses, who can use them to catch symptoms that may have otherwise gone unnoticed.

From there, the process can be tweaked to fit into other units. Dartmouth-Hitchcock has implemented a process in the ICU and rolled out an inpatient detection tool for the early identification of sepsis. Now clinicians are required to take an annual sepsis class, just as they would for CPR.

The hospital is also making efforts to attack sepsis at a community level, Taenzer says. Because patients are often transferred to Dartmouth-Hitchcock from surrounding areas, a delay in sepsis treatment can negatively impact those patients. Research shows that for each hour that the patient goes without antibiotics, the risk of mortality increases 8%.

Unlike other time-sensitive illnesses like stroke or heart attack, where small hospitals don't have the means to perform complicated interventions, sepsis prevention merely relies on administering fluids and antibiotics.

"Because that three-hour bundle is relatively easy to do, we really want the community hospitals to start that bundle and get it going and then send us the patient," Taenzer says.

Editor’s Note: This article originally appeared in HCPro’s Patient Safety Monitor Journal.

DebMed Announces Results of 2015 Survey on Hand Hygiene

DebMed® has announced the results of its 4th annual survey on the state of healthcare hand hygiene compliance. Results from more than 850 healthcare professionals throughout North America show that while improved methods for gathering reliable data with electronic hand hygiene compliance monitoring are known to contribute to increased hand hygiene compliance, competing healthcare priorities and budgets still hinder the widespread adoption of these technologies.


According to data gathered from more than 650 infection preventionists, nurses, and other healthcare leaders in the U.S., and more than 200 in Canada, the state of healthcare hand hygiene compliance and compliance reporting has remained consistent over the past year. Direct observation (DO) and secret shoppers still remain the primary methods used to measure and report hand hygiene compliance, while approximately 90% of respondents believe that the Hawthorne Effect over-inflates compliance rates.  Further contradictions reveal that more than 80% of respondents are not extremely satisfied with their data, yet only a very small percentage (1.6% in the U.S. and 4% in Canada) are using electronic monitoring for hand hygiene compliance. Taking that a step further, the contradictions are compounded by the fact that 76% of respondents in the U.S. and  67% in Canada believe electronic monitoring of hand hygiene compliance to be more accurate (Table 1).


Table 1.

Respondents who:



Use manual methods of direct observation or secret shoppers as the primary method to measure and report hand hygiene compliance at their facility.



Believe the Hawthorne Effect overinflates compliance rates



Are not extremely satisfied with the data they report



Use electronic monitoring as the primary method to measure and report hand hygiene compliance at their facility.



Believe electronic hand hygiene compliance monitoring to be a more accurate option than direct observation





“Healthcare professionals working in infection prevention, nursing and patient safety are an informed and highly educated audience, looking to make positive change in a highly regulated, budget-intense healthcare environment,” said Didier Bouton, president of DebMed. “Step one is awareness; knowledge of better options in hand hygiene to help healthcare facilities reduce costly and unnecessary hospital-acquired infections. And we believe we are on the brink of step two—a real movement for a significant shift in healthcare around hand hygiene measurement.”


Change on the horizon

Looking ahead, feedback from the survey shows that change is underfoot. With reports citing that hospital-acquired infections cost healthcare $10 billion each year, hospital leadership is acknowledging a need for focus and change. Additionally, new penalties are in place in the U.S. and increasing through 2018; all four CMS programs include HAI-related measures. These factors likely contributed to the increase in C-suite awareness and action indicated by survey respondents (Table 2).


Table 2.

Respondents who:



Say their CEO would mention increased hand hygiene compliance as one of the top five priorities on which their organization is focused.



Have or are currently considering an electronic hand hygiene compliance monitoring system



Of those currently considering a purchase, have a budget—or are planning to include a budget—allocated to the purchase of an electronic hand hygiene monitoring system




“Healthcare is a business focused on prevention and positive patient outcomes, and from a business perspective and a patient safety and wellness issue, a focus on improved hand hygiene compliance monitoring and reporting is a necessity,” said Carrie L. Howard-Canning, associate vice president of patient care operations at Champlain Valley Physicians Hospital. “At CVPH, electronic hand hygiene compliance monitoring is a foundational element of our infection prevention program. Having real time, accurate, 24/7 data from the DebMed® GMS™ allows us to improve our quality of care. All of our leaders understand and support this philosophy.”


Source: DebMed®

ECRI Institute Issues Technology Hazards List for 2016

Reprocessing of flexible endoscopes rises to #1 hazard; failure to recognize clinical alarms, health IT errors and other issues remain perennial hazards.

Every year hospitals are blindsided and patients are harmed by unexpected health technology hazards. Medical technology is intended to improve patient care, but even the best technology—if configured, used, or maintained improperly—can lead to problems. 

"With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked," says Anthony Montagnolo, chief operating officer, ECRI Institute. "Based on our experience with independent medical device testing in our laboratory, accident investigations, and reported events, we're very aware of serious safety problems that occur."

To help hospitals prioritize technology safety efforts that warrant their attention and to reduce risks to patients, ECRI Institute publishes an annual list of top 10 health technology hazards. The 2016 Top 10 Health Technology Hazards list, released in November, includes both high-profile and unexpected issues, as well as ones that are emerging, such as hazards related to electronic health records.

A series of fatal Carbapenem-resistant Enterobacteriaceae (CRE) infections that attracted national media attention in 2014 and 2015—combined with ECRI Institute's own studies into endoscope cleaning and disinfection practices—prompted ECRI safety engineers to elevate flexible endoscope reprocessing to the top of the 2016 list. This year's top hazard specifically addresses the need to adequately clean flexible endoscopes before disinfection to help prevent the spread of deadly pathogens.

Safety risks from clinical alarms, a perennial No. 1 hazard, moved down to the No. 2 spot. Failure to recognize and respond to actionable clinical alarm conditions in a timely manner can result in serious patient injury or death, according to ECRI's report. It remains an important issue for hospitals as non-compliance with the Joint Commission's January 1, 2016, deadline for its National Patient Safety Goal on clinical alarms can put patients at risk of harm.

Other topics on the 2016 list include failure to effectively monitor post-op patients for opioid-induced respiratory depression, inadequate surveillance of telemetry-monitored patients, insufficient physician training on new OR technologies, health IT errors, gamma camera mechanical failures, and more.

To develop the annual list, ECRI Institute's multidisciplinary staff of engineers, scientists, nurses, physicians, and safety analysts draw on the resources of the Institute's nearly 50-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. Topics on the list take into account factors such severity, frequency, breadth, insidiousness, profile, and preventability.

To download the 2016 Top 10 Health Technology Hazards Brief  for free, visit For questions about the technology hazards or to purchase the comprehensive 2016 Top 10 Health Technology Hazards Solutions Kit, contact ECRI Institute by telephone at (610) 825-6000, ext. 5891, or by e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Spectra 900 UVC Overhead Light Disinfection System for Labs, Operating Rooms, and Telemedicine

Spectra254, a provider of UVC light disinfection solutions, has released the Spectra 900 Series Overhead Cleaning System, a fixed decontamination system similar to a ceiling light fixture that kills MRSA, Clostridium difficile (C. difficile), and other pathogens.

Using three custom-built germicidal bulbs with protective FEP sleeves, the Spectra 900 Series Overhead Cleaning System is appropriate for laboratories, surgical suites, operating rooms, self-service kiosk medical stations, patient dressing rooms, patient exam rooms, and mobile medical stations used for telemedicine. The Spectra 900 Series is designed to kill pathogens in enclosed spaces with typical dimensions of 8 x 8 x 8 feet and is controlled remotely.

The overhead cleaning system employs motion detection sensors and an audio annunciator to ensure safe and proper operation for daily use. The software interface for the Spectra 900 Series features a countdown in minutes and seconds of the time remaining for treatments. It also features a digital monitor for the device’s UVC bulbs that can indicate if one or more need to be replaced. The cleaning system sends error signals to the remote computer to notify operators of events such as a shutoff initiated by motion detectors.

Independent laboratory tests find that the Spectra 900 Series Overhead Cleaning System is 99.9% effective in killing C. difficile spores, MRSA, and an Ebola surrogate pathogen in as little as five minutes. The Spectra 900 Series is one part of Spectra254’s decontamination solutions portfolio, which also includes disinfection systems for inpatient and outpatient care, emergency vehicles, and shared tools and devices.

Spectra254’s systems are assembled by an ISO 9001:2008 + AS9100C certified company located in Connecticut. Full product line details are available at, or by calling 203-796-5315 or emailing This email address is being protected from spambots. You need JavaScript enabled to view it. .



New Sentinel Event Alert Focuses on Preventing Patient Falls

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

Study Finds Higher Rates of Perioperative Medication Errors than Previous Research

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.

The study and a related editorial were published online (for free) to coincide with the 2015 annual meeting of the American Society of Anesthesiologists, held in San Diego in October.

Study Shows Positive Effects From UVC Robot

A new study on use of UV light in the short C-wavelength (UVC) for disinfection was presented at IDWeek 2015. The study showed that Tru-D SmartUVC significantly reduced healthcare-associated infections (HAI) caused by common multidrug-resistant organisms (MDRO) in hospitals. Tru-D SmartUVC was the UVC device selected for this study and proved its ability to reduce environmental pathogens by measuring the required reflective dose to thoroughly disinfect a hospital room.

            Results of the study, Benefits of Enhanced Terminal Room Disinfection, indicated that three enhanced terminal room disinfection strategies decreased the cumulative incidence of MDROs by 10% to 30%, and the largest decreases were seen when a UVC-emitting device was added to the standard cleaning protocol. Such reduction rates, validated through a randomized clinical trial, differentiate Tru-D technology.

            The study’s primary outcome showed the clinical incidence of an MDRO in the next patient to occupy the room for at least 24 hours after disinfection. Adding a cycle of measured-dose UVC light added approximately 10 minutes to the total room turnover time.

In honor of this landmark study and to further the company’s mission of eradicating HAIs and making hospitals a safer place for patients and staff, Tru-D is donating one Tru-D robot to a hospital in the United States. Hospitals may register to win at The drawing for the robot will be held December 7.  

Source: Tru-D

Medication Management Training Improves CMS Quality Metrics, New Study Finds

Scores improve in hospitalization, readmission and high-risk disease states

A new study shows that medication management educational tools can improve key Centers for Medicare & Medicaid Services (CMS) quality measures. Following a seven-month program developed by Prescriber’s Letter drug advisory service, Quality Independent Physicians (QIP) successfully decreased patient hospitalization across all disease states by 26%. It also saw a 24% relative drop in discharges and a 7% relative decrease in 30-day hospital readmissions.

QIP, a 50-physician accountable care organization (ACO), conducted the study. The organization treats 12,000 Medicare patients annually across Kentucky and Indiana.  As a Medicare provider, QIP is required by CMS to report on a variety of strictly defined quality measures. Traditionally a fee-for-service industry, healthcare has shifted towards a quality-driven, pay-for-performance model as a result of the Affordable Care Act (ACA).

“As an ACO, our organization is addressing these new challenges and opportunities head on by participating in the Medicare Shared Savings Program (MSSP),” said QIP medical director Gregory A. Hood, MD, MACP. “Because key Medicare reimbursements are directly tied to quality metrics and related performance ratings, it is in everyone’s best interest to focus on creating optimal patient outcomes across the entire continuum. As a result, better care as defined by CMS benefits both our patients’ personal health and our practice’s financial health.”

Effective medication management is a major determinant of quality scores. QIP’s partnership with Prescriber’s Letter strengthened its quality metrics through an integrated program of current medication management recommendations delivered at the point of care. It accomplished this by leveraging tools to align medication management enterprise-wide and brought about changes in prescriber behavior, when needed, as well as supported patient education. 

“There was a strong belief that a focus on medication management would have the greatest impact on our ability to meet CMS metrics,” said Dr. Hood. “By delivering the latest drug information to the point of care, we were able to align medication management practices and related process throughout the ACO.”

The effort focused on high-risk disease states specifically targeted for CMS reporting or directly related to key quality measures. These included COPD, heart failure, bacterial pneumonia, hypertension, anticoagulation, diabetes and acute coronary syndrome.

Reaching across the continuum, Prescriber’s Letter provided customized, actionable educational resources. These included coverage of target diseases, online searchable medication management recommendations, drug comparison charts, physician training materials, and patient education handouts. All materials were incorporated into QIP standard policies, procedures and organizational culture.

After seven months, metrics during the intervention were compared with a baseline prior to program implementation. “As we hoped, medication management, specifically the Prescriber’s Letter solution, played a pivotal role in changing metrics and patient outcomes,” said Dr. Hood. “We found a statistically significant improvement on all data reported to CMS on MSSP Utilization reports required for an ACO, which yields overall cost savings and higher reimbursements for the organization.”

 “The success of the QIP study and the role Prescriber’s Letter in those results underlines our focus on providing unbiased evidence-based information to the healthcare community,” said Wes Crews, chief executive officer of Therapeutic Research Center. “Straightforward, concise information enables health systems and physician groups to streamline distribution across the entire organization, blending our information into clinician workflow. This allows providers, like QIP, to see a change in performance and a change in outcomes.”

Source: Therapeutic Research Center

AMA and MedStar Health Partner to Improve EHR Usability

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

Medfusion Launches Mobile App to Simplify Healthcare Records

To provide patients with a single destination for all of their medical records, Medfusion—a patient engagement platform dedicated to facilitating the relationship between doctors and patients—has developed a consumer mobile application called Medfusion Plus. 

For decades, if patients wanted access to their medical records, they had to request and pay for a paper copy, which could take several days if not weeks. With the advent of portals, patients gained electronic access to portions of their medical records created by individual providers.

Via a download on the App Store and Google Play, iOS and Android device users can now aggregate and access their healthcare records on their mobile devices. The information is pulled via Continuity of Care documents from patient portals and includes laboratory results, immunizations, medication lists, allergies, as well as appointments.

“Patients should have a complete view of the care provided to them across multiple provider settings—hospitals, physician practices, and from their wearables,” said Chris Fierer, director of innovation and Medfusion Plus solution manager. “We believe patients should play a more significant role in their care, and the only way they can optimize the quality and efficiency of that care is to have a total, accurate view of their medical records.”

“I regularly see patients who have recently been hospitalized who have seen multiple specialists who ran diagnostic tests on them and may have changed their medications without sending me notification or medical records pertaining to these encounters,” said internist and pediatrician John Meier, MD, MBA. “As their primary care physician, I am void of critical information that would allow me to better manage and optimize their care, which is frustrating to both me and my patients.

“Until we get to full interoperability within and among EHRs,” Meier added, “we need a solution like Medfusion Plus that allows my patients to show me their latest lab tests and current medications on their smartphones. This will enable me to create a much better care management plan based on higher quality, lower cost and most importantly better outcomes.”

Medfusion Plus, which also provides an application programming interface and is available on the Apple Watch, will continue to evolve with a significant roadmap ahead for the developers. The app is available at no cost to consumers, and a branded version will be made available to provider organizations.

Source: Medfusion



ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine