Hospital Transparency in Reporting Medical Errors (What’s New at AHRQ PSNet, July 7, 2010)
This issue features successful patient safety innovations pertaining to disclosure, multidisciplinary patient safety conferences, and proactive reporting. For more information, go to: http://www.innovations.ahrq.gov/whatsnewArchive_issue.aspx?id=84
[
TOP ]
HIPAA Q&A: Notifying Patients About Changes to NPP (HIPAA Weekly Advisor, July 5, 2010)
Q. If a Notice of Privacy Practices (NPP) is updated, is it necessary to redistribute it to existing patients who are receiving direct care? Must patients sign another Acknowledgement of Receipt form?
A. When covered entities significantly change their NPP, they must notify patients and health plan members that they have done so. They may communicate this information via a newsletter announcement or a notice posted in the waiting area. In a direct care setting, providers are not required to ask patients to sign another Acknowledgement of Receipt form. Notification of the update is sufficient.
[
TOP ]
FCC Order Allows Hospital to Use Amateur Radios During Disaster Drills (CHA News, July 23, 2010)
Consistent with a blanket waiver request submitted by the American Hospital Association (AHA), the Federal Communications Commission (FCC) has adopted an order that permits the use of HAM radios during hospital disaster drills. FCC determined that amateur radio operators play a critical role during disasters, and they should be permitted to participate in disaster drills regardless of whether they are employed by the entity conducting the drill. The blanket waiver request was filed by AHA in response to The Joint Commission's requirement that hospitals prepare an emergency operations plan specifying alternative forms of communication during emergencies and establishing back-up communications links, including amateur radio stations, if primary communications systems fail. Due to the adoption of the FCC order, AHA's blanket waiver request is not needed. For more information, visit http://www.calhospitalprepare.org/FCC.HAM.
Contact: Cheri Hummel, (916) 552-7681, chummel@calhospital.org.
[
TOP ]
AHRQ Guides Help Hospitals with Emergency Evacuation Plans (ASHRM eNews, July 2, 2010)
The Agency for Healthcare Research and Quality has released two resources to help hospital administrators and facility planners decide when to evacuate a hospital during an emergency situation and when it is safe to return. The "Hospital Evacuation Decision Guide" walks users through the process of deciding when to evacuate, shelter in place, or defer and reassess as the situation evolves. The guidance draws on expert panel experiences as well as lessons learned from past events, including the Northridge, CA, earthquake of 1994; the Three Mile Island nuclear reactor incident of 1979; and hurricanes Katrina and Rita in 2005. The companion "Hospital Assessment and Recovery Guide" helps administrators and planners assess a facility's infrastructure after an emergency to determine when it is safe to reoccupy the area. Both guides are available at http://www.ahrq.gov/prep
[
TOP ]
August 2010
Optima's next webinar will be held on Thursday, August 26, 2010 at 10:00 - 11:30 a.m. on "Psychiatric Patients in the Emergency Department". Faculty for this program will be Monica Cooke of Quality Plus Solutions. Program details and registration information have been sent to CHI insureds. Contact: Millie Mastromattei, Education Specialist, at 916/772-5109, or at mmastromattei@optimahealthcare.com.
[
TOP ]
September 2010
Optima's next Risk Forum will be on "The Reality of Risk in Electronic Health Records" on Tuesday, September 14 in Sacramento, and Wednesday, September 15 in Arcadia. Faculty for this program will be Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, FHIMSS, of Dak Systems Consulting. Program details and registration information will be sent to CHI insureds in the near future. Contact: Millie Mastromattei, Education Specialist, at 916/772-5109, or at mmastromattei@optimahealthcare.com.
[
TOP ]
Ask the Expert: What Does the Phrase "Just Culture" Mean? (Medical Staff Leader Connection, July 1, 2010)
The goal of the just culture is to assign the consequences for an unsafe act in a fair way based on an understanding of an individual's accountability and responsibilities within the context of the systems and circumstances that the individual was operating. The just culture is not a blame-free culture. It merely tries to provide a consistent guide to determine 1) when a person is truly at fault for a specific act and 2) reasonable consequences that will best serve the individual's and the organization's interests in the long run. The four key categories of fault in a just culture are:
• Human error: Unintended slips, lapses, and mistakes
• Negligent conduct: Failure to exercise care expected of a prudent worker
• Reckless conduct: Conscious disregard for a known risk
• Knowing violations: conscious disregard for known rules
To guide managers and organizations when making fair decisions, decision algorithms have been developed. These algorithms typically ask a series of questions:
1. Were the actions intended?
2. Was the person under the influence of unauthorized substances?
3. Did the person knowingly violate existing policies, procedures, or expectations?
4. Would another person in the same situation perform in the same manner?
5. Does this person have a history of unsafe acts?
Based on the answers those questions, the medical staff may offer the physician consoling, coaching, counseling, or progressive discipline, or it may terminate the physician or implement system changes.
[
TOP ]
Incident Report Versus Educational Opportunity (Medical Staff Leader Bog, July 15, 2010)
As the medical affairs office at Children's Medical Center in Dallas reviewed incident reports from across the hospital, we felt the need to clearly define what actions warrant an incident report (which requires the medical staff to track and trend subsequent actions) versus an event that represents an educational opportunity. Incident reports are filed electronically through our organization's intranet. All incidents involving physicians are routed to the medical affairs office for review and then presented to the appropriate medical staff leaders. Primarily, an incident report is classified as either a behavior concern, a rule or compliance violation, or a quality of care issue. Although an incident falls under one of these categories, it may not be significant enough to warrant an incident report, which becomes part of the physician's quality file. However, these events still need to be documented in a manner that shows the issue was appropriately addressed. For example, if Nurse Jones feels that an attending physician is not playing an active role in the time-out procedure, she may express her concerns to her supervisor, who brings the concern to the medical affairs office. After review, Nurse Jones determines that she did not feel that the physician's behavior was disruptive (rude, yelling, etc.). She was simply concerned that the attending was not participating as needed in the time-out procedure. She fills out an event form and submits it to the appropriate department chief. The chief discusses with the physician his role in the time out procedure and the expectations of the medical staff as it relates to the universal protocol policy. The chief outlines in the event form the educational plan for the physician and the issue is soon thereafter closed. While an official incident report requires action by the appropriate department chief and review, approval, and closure by either the department chair or the vice president of medical staff affairs, an event that is identified as an educational opportunity is addressed and closed at the department level. They can also be handled by a member of the administrative team. Medical staff leaders appreciate the less punitive approach while still having a mechanism to address these minor events.
[
TOP ]
What is Required for Fair Hearings Focused on Advanced Practice Professionals? (Medical Staff Leader Connection, July 8, 2010)
In my travels as a consultant, I get asked a lot of questions regarding the status and rights of advanced practice professionals (APP). Some medical staffs include APPs on the medical staff and others don't, and there are pros and cons to both approaches, depending on your perspective. For example, if APPs are members of the medical staff, they are afforded the right to the same fair hearing as physicians, and some medical staffs feel that this is only fair. Other medical staffs, however, would rather reserve that sometimes herculean effort for physicians. However, the water gets muddied because APPs must be credentialed and privileged through the medical staff or an equivalent process, even if they are not technically medical staff members.
Below are three questions that medical staff should ask themselves when faced with the possibility of having a fair hearing for an APP. To continue reading this article, go to: http://xrl.us/bhu4vn
[
TOP ]
Leapfrog Report Shows CPOEs Can Miss 30% of Potentially Fatal Medication Orders (Patient Safety Monitor Alert, July 7, 2010)
The Leapfrog Group released the results of a study that shows through web-based simulation that computer physician order entry (CPOE) systems can miss as many as one in three potentially fatal medication orders when unchecked, reports HealthLeaders Media. The report urged the government to include specifications about CPOE monitoring in its meaningful use guidelines, which are expected to be released within the coming weeks. Meaningful use refers to a set of requirements regarding health information technology that hospitals and physicians must meet to receive incentive payments through Medicare and Medicaid. The simulation tool was used to see how often CPOE caught common medication errors. Adult hospitals involved in the study received ten sample patients and 50 medication orders and pediatric facilities received 10 sample patients and 51 medication orders. Most of the hospitals that adjusted their protocols and CPOE systems after using the tool improved their performance. For more information, go to: http://xrl.us/bhu4wj
[
TOP ]
Joint Commission On-Site Surveys to Focus on Safe Injection Practices (HRC Alerts ECRI Institute, July 21, 2010)
During upcoming on-site surveys of Joint Commission accredited facilities, the agency will be observing injection practices to ensure that care providers are following standard precautions for disease-free injections, according to an article in the July 14, 2010, Joint Commission Online. The article notes that, although most providers believe that they follow safe injection practices, some myths and misunderstandings exist that have led to major outbreaks over the past few years. Joint Commission's infection control (IC) standards require accredited organizations to follow relevant scientific guidelines for infection prevention per IC.01.05.01 element of performance (EP) 1; safe injection practices are a key component of standard precautions required per IC.02.01.01 EP 2. To address injection safety, the agency recommends the U.S. Centers for Disease Control and Prevention's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings at:
http://www.cdc.gov/injectionsafety/IP07_standardPrecaution.html and resources from the One and Only Campaign at:
http://www.oneandonlycampaign.org/default.aspx
[
TOP ]
ISMP: Loose Labels on Lovenox Syringes Can Cause Potential Needlestick Injuries (HRC Alerts ECRI Institute, July 28, 2010)
The Institute for Safe Medication Practices (ISMP) warns healthcare providers about the potential for needlestick injury created by loose labels that have been found on prefilled syringes of Lovenox, in a July 23, 2010, ISMP Medication Safety Alert. According to the alert, ISMP received a report about a nurse who received a needlestick injury when her latex glove became stuck to the adhesive of a loose label on a commercially prepared, prefilled syringe of Lovenox after administering an injection. The hospital involved states that the loose label problem was found to be affecting syringes in at least two 30 mg lots and two 40 mg lots that were shipped to the facility. ISMP notes that the manufacturer, sanofi-aventis, acknowledged that it was aware of the report and is currently conducting an investigation. For hospitals and other facilities that use unit-dose syringes of Lovenox, ISMP recommends making pharmacy and nursing staff aware of the situation so that any loose labels can be identified before the syringes are removed from the packaging. To read the Alert, go to: http://xrl.us/bhu44y
[
TOP ]
Center to Advance Palliative Care Launches New Initiative to Improve Palliative Care in the ICU (IPAL-ICU Project Patient Safety & Quality Healthcare eNews Alert, July 14, 2010)
New York, June 16, 2010 - In a major national effort to integrate and improve palliative care in the ICU, the Center to Advance Palliative Care (CAPC) has launched The IPAL-ICU Project.
Supported by the National Institute on Aging of the National Institutes of Health and developed by experts in both critical care and palliative care, The IPAL-ICU Project will be the central U.S. hub for shared expertise, evidence, tools and resources. The goal is to promote a paradigm shift in the way that critically ill patients, and their families, are cared for in the ICU. Approximately six million people in the U.S. end up in the ICU each year. For many, ICU treatment may be accompanied by distressing symptoms. Families often fail to receive information to address their concerns and help them make treatment decisions. Palliative care has proven effective in meeting these needs but is often unavailable in the ICU. The IPAL-ICU Project seeks to close this gap, assisting with implementation of palliative care in all types of ICUs and for all critically ill patients, regardless of prognosis. To continue reading this article, go to: http://xrl.us/bhu43n
[
TOP ]
Teamwork and Communication (What’s New at AHRQ PSNet, July 7, 2010)
Articles in this special supplement (from Patient Safety Authority Pennsylvania) outline tactics to improve communication including crew resource management, chain-of-command policies, and teamwork training. To access the information, go to: http://xrl.us/bhu4dy
[
TOP ]
FDA Warns of Dangers with Luer Lock Connectors (ASHRM eNews, July 16, 2010)
Standard luer lock connectors are found on various tubing sets, solution bags, and other medical products. Unfortunately, the ease of connection between these connectors has led to misconnections that have inadvertently linked unrelated systems, and at times have resulted in serious adverse events. Luer lock misconnections are often under-recognized; therefore, adverse events resulting from such misconnections are likely to be under-reported. Additional information and the current Joint Commission and USP Medication Safety Forum recommendations are available at: http://www.fda.gov/MedicalDevices/Safety/default.htm
[
TOP ]
Universal Protocol Question of the Week (MCN Healthcare, July 30, 2010)
Is a second time-out required if a patient is having two procedures or can the OR team confirm all of the procedures at one time? For the answer, go to: http://xrl.us/bhu4zt
[
TOP ]
Contact Us