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July – August 2010

Premier Safety Institute - Safety Share Newsletter

Medical ErrorsStaff empowerment, communication and standardization
are keys to safer care.

Gina Pugliese, editor


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Staff empowerment to “stop the line” reduces patient identification errors

Identification band errors, a persistent safety
issue, were reduced in one hospital from a rate of
20.4 percent to an average mean rate of 2.6 percent
with a combination of strategies suggested by
leadership and frontline staff, including data
display using control charts and the clear
expectation to "stop the line" if patient
identification error was suspected.

Patient misidentification
continues to be a quality and safety issue, with
minimal data describing interventions to reduce
identification band error rates. The Monroe Carell
Jr. Children’s Hospital at Vanderbilt recently

its experience in reducing and
sustaining near zero error rates after

Study process Web-based
surveys were sent to hospital personnel, asking them
to anonymously identify perceived barriers to
reaching zero defects with identification bands.
Corrective action plans were created and implemented
with ideas from leadership, frontline staff and the
online survey. Data from unannounced audits of
patient identification bands were plotted on
statistical process control charts and shared
monthly with staff. All hospital personnel were
expected to “stop the line” if there were any
patient identification questions.
Staff ideas led to
other interventions, including “luggage-tag” style
bands for NICU patients to ensure a better fit.
Sample unit corrective action plans included
education, and plans for ensuring all staff were
reached with weekly communications.

Data from audits using process
control charts and shared with frontline staff on a
weekly basis, along with a series of audits
measuring defective bands per bands checked,
established initial upper and lower rate limits of
10 and 1.5 percent, respectively, and an average
mean rate of 6.5 percent. After three months of
interventions and measurements, the limits dropped
to five and 0 percent, respectively, with a 2.5-fold
drop in the mean error rate from 6.5 to 2.6 percent.

Lessons learned

  • The initial rate of patient identification band errors in the hospital was higher than expected.
  • Most significant improvement was staff awareness of the problem, with clear expectations to immediately
    “stop the line” if a patient identification error had occurred or was about to occur
  • Staff surveys were a key source of suggestions for combating patient identification issues.
  • Continued audits and data are necessary for sustained focus and continuous improvement.
  • Statistical process control charts are effective for tracking and sharing data with staff.

Medication errors more frequent and severe with interruptions

A recent study showed that the
frequency and severity of medication administrative
errors by nurses was associated with the frequency
of interruptions they face on the job.

Controlled laboratory studies
have clearly demonstrated that interruptions of
tasks contribute to inefficiency and errors.
Although one study by

Rivera-Rodriguez and Karsh
notes that
although some interruptions may be positive, such as
stopping an immediate danger, experimental studies
have shown that interruptions produce negative
impacts on memory by requiring individuals to switch
attention from one task to another. Returning to a
disrupted task requires completion of the
interrupting task and then regaining the context of
the original task. Clinical environments are highly
interruptive, with studies of emergency departments
reporting rates of six to 15 interruptions per
physician per hour.

To determine the impact of
interruptions on medication error rates,

Westbrook et al.
conducted an observation
study of nurses preparing and administering 4,271
medications to 720 patients, finding that the risk
of medication errors during administration without
interruptions was 2.3 percent; with four
interruptions, this risk doubled to 4.7 percent.

A combination of observation
and chart review was done to assess (1) procedural
failures (e.g., failure to read medication label,
check patient identification, or record medication
administration on medication chart to use aseptic
technique) and (2) clinical errors (e.g., wrong dose,
drug, route, patient or infusion rate).

Each interruption was
associated with a 12.1 percent increase in
procedural failures and a 12.7 percent increase in
clinical errors. Interruptions occurred in 53.1
percent of all administrations. Nurse experience
provided no protection against making a clinical
error. Error severity was also found to increase
with interruption frequency, with major errors
defined as those likely to lead to permanent
reduction in bodily functioning, subsequently
leading to major permanent loss of function or

Compliance with aseptic
The rate of compliance with aseptic
technique during medication administration was found
to be only 82 percent, an alarming finding given the
recent outbreaks related to administration of
parenteral medications from lack of aseptic
technique and unsafe injection practices.

Strategies to reduce
interruptions and medication administration errors

Although some interruptions are central to providing
safe care, the authors point out that there is a
need to better understand the reasons for such high
interruption rates. They noted a study of over 5,325
interruptions to nurses in a Canadian pediatric
hospital revealed that the most frequent sources
came from the external environment (e.g., monitor
alarms), accounting for 37 percent of interruptions,
followed (in percentages) by other nurses (25),
patients (9) family members (8) and physicians (5).
Only 11 percent of interruptions were judged to have
a positive outcome.

The authors do offer some
simple strategies such use of “white boards” or
wearing “interruption vests” that say “Do not
interrupt – medication rounds in progress,” as well
as redesign of physical spaces and work practices.
Other error reduction strategies include
well-designed electronic medication management
systems such as bar coding, and other features
identifying errors being made so they can be
corrected and support memory of recall of
interrupted tasks.



New CDC guidance for healthcare facilities combines seasonal and H1N1 flu

Updated guidance proposed by the Centers for
Disease Control and Prevention (CDC) recommends a
consolidated approach for preventing pandemic H1N1
and seasonal influenza in healthcare settings. The
guidance was published in the

June 22 Federal Register

This guidance supersedes prior guidance issued
throughout 2009 and is based on the knowledge that a
safe and effective H1N1 vaccine is available for the
coming flu season.

One of the top CDC
recommendations is to encourage and administer
seasonal flu vaccine to healthcare personnel (HCP).
Acknowledging the controversy surrounding mandatory
vaccination of healthcare workers, the CDC said
healthcare facilities can boost uptake through
incentives, free vaccines, better access to
vaccines, and required declination forms that spell
out the risks and benefits of immunization.

As stakeholders prepared
responses to CDC’s proposal, organizations noted the
improved emphasis on influenza as a community-based
infection transmitted in households and community
settings. Many recommendations address how to
instruct patients before arrival (e.g., when making
appointments), at entry and during visits (face
masks to patients with flu-like systems to wear in
triage areas, instructions on hand and respiratory
hygiene and cough etiquette).

Other CDC guidance spells out
when HCP ill with the flu should return to their
jobs and encourages the use of face masks instead of
N-95 respirators when HCP enter the rooms of flu
patients. N-95 respirators are recommended only for
the same short range aerosol producing procedures
listed in prior guidance, e.g., bronchoscopy.
Addressing both seasonal and pandemic H1N1 influenza
in one document resolves the challenges of
respiratory protection equipment faced during the
2009 H1N1 pandemic. 


Post-op infection risk reduced with adherence to all SCIP infection process measures

An analysis of the Premier
healthcare alliance comparative database confirmed
that post-operative infection risk may
be reduced when adherence to at least two of six
SCIP infection prevention process of care measures
are implemented and measured as a composite. The
association between the six SCIP performance and
clinical outcomes was not demonstrated unless
measured as a whole.

The SCIP involves measuring and
reporting six infection prevention process-of-care
measures and was launched to reduce infection
complication rates associated with surgery.

Stulberg and colleagues
conducted a
retrospective cohort study of more than 405,000
patients to examine the relationship between SCIP
infection-prevention process-of-care measures and
postoperative infection rates.

The study involved the Premier
healthcare alliance’s Perspective database for
discharges between July 1, 2006, and March 31, 2008,
from 398 U.S. hospitals. 

Findings A total of
3,996 postoperative infections were documented and
results showed that among hospitals reporting SCIP
performance, adherence measured through a global
all-or-none composite
infection-prevention score was associated with a
lower likelihood of postoperative infection.
Adherence reported on individual SCIP measures,
however, was not associated with a significantly
lower infection probability. A significant decrease
was also not associated with the three core measures
of SCIP INF-1 (administration of prophylactic
antibiotics within an hour), INF-2 (use of the
appropriate antibiotic) and INF-3 (discontinuance of
antibiotic within 24 or 48 hrs. as appropriate for
the surgery). 

Conclusions and comments The
authors concluded that to truly drive improvements
in patient outcomes, improved individual
process-of-care measures and use of aggregation
techniques in addition to improved data collection
methods may be necessary. A number of explanations
for these results were noted in a related
commentary, including the maximization of
achievement for some of the measures. However, it
should also be noted that this study demonstrates
the limitations of administrative data to capture
elements of variability. Another limitation is the
under- or over-reporting of infection during a stay
or post-discharge. Data on infections that are
collected by prospective surveillance incorporating
a severity of illness index such as defined by CDC
are far more sensitive in determining true outcomes
and rates of infections. However, these findings do
resonate with current experience in measuring
infection reduction risks, demonstrating the
importance of “bundling” or combining a group of
evidence based interventions and measuring the
impact as a whole, compared to any one single
intervention measure.


Lapses in infection control at surgery centers lead to expanded federal oversight

Outbreaks of hepatitis and
lapses in infection control practices identified in
a recent federal study has prompted the Health and
Human Services department to expand its HAI Action
Plan to cover the more than 5,000 ambulatory care
centers and dialysis centers.

Prompted by numerous outbreaks
of hepatitis in ambulatory surgical centers (ASCs),
a recent
federal study in three states identified
many lapses in infection control, including unsafe
injection practices. As a result, the Health and
Human Services department is expanding its HAI
Action Plan to include ambulatory surgical centers
(ASC) and dialysis centers out of concern these
lapses may be widespread in the 5,000 ASCs the
Centers for Medicare & Medicaid Services has
surveyed using an infection control tool developed
in conjunction with CDC.

According to lead study author
Dr. Melissa Schaefer of the CDC, a surprising lack
of compliance occurred with practices considered
fundamentals of infection control, such as hand
hygiene and cleaning surfaces in patient care areas.
Assessments focused on five areas of infection
control: hand hygiene, injection safety and
medication handling, equipment reprocessing,
environmental cleaning, and handling of blood
glucose monitoring equipment such as meters.

Overall, 67.6 percent of ACS
had at least one lapse in infection control and 7.6
percent had lapses identified in three or more of
the five infection control categories. Common lapses

  • Using single-dose
    medication vials for more than one patient (28
  • Failing to adhere to
    recommendation regarding equipment reprocessing (28
    percent); and
  • Handling blood glucose
    monitoring equipment improperly (46.3 percent).

In the study, state inspectors
visited 68 centers in Maryland, North Carolina, and
Oklahoma using a new audit tool focusing on
infection control. At each site, inspectors followed
at least one patient through an entire stay.


FDA, NIH launch new safety reporting portal

The FDA and the National
Institutes of Health (NIH) launched a new website
for reporting safety data to the federal government.

The “Safety
Reporting Portal
” (SRP) streamlines the process
of reporting product safety issues to the FDA and
the NIH. This site can be used by manufacturers,
healthcare professionals, researchers, public health
officials or concerned citizens. Initially it will
be used to report safety concerns related to food
and human gene transfer trials, and eventually to
report safety concerns related to medical products
and other clinical trials and products. The agencies
called the portal “a first step toward a common
electronic reporting system that will offer one-stop
shopping, allowing an individual to file a single
report to multiple agencies that may have an
interest in the event.”

The SRP website permits easy
reporting of certain safety issues to the FDA; one
feature is a convenient menu, listing all types of
reporting with a direct link to the appropriate site
(e.g., “For other issues,

find out where to submit your report
.”). The
site also provides an extensive list of FAQs that
address many issues, including mandatory versus
voluntary reporting.


Tips for communicating abnormal test results to achieve a National Patient Safety Goal

Failures of communication and
follow-up of abnormal diagnostic test results can
lead to errors, adverse events and liability claims.
The Joint Commission prioritized safe and timely
communication of critical test results as a National
Patient Safety Goal (NPSG.02.03.01): “Report
critical results of tests and diagnostic procedures
on a timely basis.” However, this goal remains one
of the most commonly cited areas of noncompliance in
routine surveys, although communication breakdowns
are deemed largely preventable.

The rationale of eight
recommendations for effective policies on
communication of abnormal diagnostic test results
was developed from
policy refinements at the Houston-based Michael E. DeBakey Veterans Affairs Medical Center on the basis
of previous work, other literature, and sound
clinical practice for updating similar policies at
other institutions. The proposed recommendations for
ensuring safe test-result communication may be
potentially useful to a wide variety of institutions
and healthcare settings. The eight recommendations
focus on policies that:

  1. Should be introduced with
    clear definitions of key terms;
  2. Should clearly outline provider responsibilities;
  3. Should specify procedures for fail-safe communication of abnormal test results;
  4. Must define verbal and/or electronic reporting procedures for both critical and significantly abnormal laboratory, imaging and other test values;
  5. Should specify “critical tests” and acceptable length of time between their ordering and reporting;
  6. Should define time lines between the availability of test results and patient notification, and institutions should
    specify preferred mechanisms for patient notification;
  7. Must be of “real world” value and written with feedback from key stakeholders; and
  8. Should establish responsibilities for monitoring and evaluating communication procedures.

These practical suggestions may
be a useful guide for designing or amending policies
for safe test-result communication in both inpatient
and outpatient settings.




AHRQ – New, updated communication tools

  • TalkingQuality –
    Producing effective reports 

    This site is an opportunity to learn how to
    communicate quality information that’s
    understandable and useful, and is intended to
    help healthcare consumers choose high-quality
    health plans, hospitals, doctors or other
    providers of care.   

    The Agency for Healthcare Research and Quality’s
    (AHRQ) TalkingQuality site was first released in
    2001 as a comprehensive guide for the many
    organizations developing reports on the quality
    of health plans. Now, AHRQ has

    updated TalkingQuality
    to meet the needs of
    a new generation of quality reporters with
    up-to-date guidance from technical experts and
    experienced reporters, as well as examples drawn
    from reports on hospitals, physician groups,
    health plans and nursing homes.

  •  AHRQ – Health literacy

    The Agency for Healthcare Research and Quality
    (AHRQ) commissioned the University of North
    Carolina at Chapel Hill to develop and test the
    Literacy Universal Precautions Toolkit

    The free toolkit provides step-by-step guidance
    and tools for assessing your practice and making
    changes so you connect with patients of all
    literacy levels. This toolkit is designed to be
    used by all levels of staff in a practice
    providing primary care for adults and/or
    pediatric patients. Please note that references
    to patients also include caregivers and parents.
    This toolkit is divided into manageable
    components so that its implementation can fit
    into the busy day of a practice. It contains at
    least 20 tools and another set of 20 forms in
    its appendix.

TMIT Discovery – Free patient safety documentaries: medical errors

A new patient safety

“Chasing Zero: Winning the War on Healthcare Harm,”

recently premiered on the Discovery Channel. The
program is hosted and narrated by Dennis Quaid.
Following the near-death experience of his infant
twins resulting from a medication error, Quaid has
made a "call to action" for healthcare leaders to
invest in patient safety.

“TMIT Patient Safety
Documentaries” are inspirational programs
highlighting “extraordinary impact through ordinary
things.” A series of short “arc to action” stories
are included in each program. Each story opens with
a challenge, and later shows how caregivers overcome
such challenges with practices that everyone can
adopt. The target demographics are consumers and
hospital leaders. The series’ objective is to
inspire the audience to act in their own communities
or at their own hospitals. The messages reinforce
supporting adoption of the