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Premier SafetyShare™ February 2009

Premier SafetyShare Newsletter - Transforming Healthcare Together

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2006 Malcolm Baldrige National Quality Award Reipient

February 25, 2009 Premier SafetyShare

Dear Colleague:

Wrong site surgery and foreign objects left in after surgery are not rare events and surgery remains a high risk environment for adverse events. This issue features a number of new strategies to reduce surgical risk, including pre-op staff exercises and a structured checklist.

Gina Pugliese, editor
Vice President, Premier Safety Institute




Wrong site surgeries, foreign objects left in body comprise 32 percent of adverse events reported to MN health department

Wrong site surgeries and foreign objects left in place after surgeries comprise 32 percent of adverse events reported to Minnesota’s Department of Health (MDH). In 2003, Minnesota’s legislature required hospitals to disclose when any of the 27 (now 28) adverse events (AEs) occurred and required MDH to publish reports of the AE events by facility. Wrong site surgeries, foreign objects left in place after surgery, and stage 3 and 4 pressure ulcers account for more than half of the 800 AEs reported in the five-year period.

MDH’s annual public report summarizes the 800 adverse health events reported to MDH and include: Stage 3 and 4 pressure ulcers (182); foreign objects (161); wrong-site surgery (97); unstageable pressure ulcers (86); falls – serious disability (85); wrong procedure (44); other (40); falls – death (37); medication errors (30); criminal (13); suicide (12); and wrong patient (9).

The good news is that adoption of best practices has improved since 2003, particularly in the areas of sharing of adverse events data with boards of directors, staff and other facilities, disclosing adverse events to patients and family members, leadership engagement, and assessment of each organization’s safety culture.

Minnesota’s hospitals are implementing a number of proven strategies for preventing errors, including new ways to track objects used in surgical procedures, improving how patients are assessed for the risk of falling, regularly re-positioning patients at risk of pressure sores, and adding special labels to high-risk medications based on detailed analyses of why an event occurred. The full report includes summaries of these corrective actions that individual hospitals have implemented, along with some collaborative initiatives designed for broad implementation. The most common steps in response to these events were implementing process changes. Other responses were to provide additional education to staff, share data across the facility, and create topic-specific teams, such as organization-wide skin safety or falls teams.

The MDH also evaluated their adverse events system to determine the extent to which it has been successful as a catalyst for improvement and learning. The evaluation found that:

  • 72 percent of facilities responded the reporting law has made them safer than in 2003;
  • Most reporting facilities indicated that patient safety is a higher priority now than it was in 2003; and
  • Adoption of best practices has improved since 2003 (as noted above).

Diane Rydrych, assistant director of MDH’s Division of Health Policy, stated the evaluation helped pinpoint areas for improvement. Recommendations included in the report include:

  • Developing new methods to regularly share key lessons from individual events and information about overall trends;
  • Monitoring the process for reporting and reviewing events and implementing changes to ensure that the reporting system is easy to use, provides meaningful feedback, and is timely;
  • Working with professional organizations and practicing physicians to ensure that physicians and surgeons are fully engaged in patient safety initiatives; and
  • Cultivating additional physician champions or leaders on specific clinical issues, such as wrong-site surgery, retained foreign objects and pressure ulcers.

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Preoperative psychomotor warm-up exercises reduce surgical errors

Performing a 15- to 20-minute simple psychomotor surgical warm-up exercise preoperatively led to a 33 percent overall reduction in errors in simulated surgical skills. The recent
study (Journal of the American College of Surgeons, February 2009) measured tasks such as picking up rings and placing them on randomly highlighted pegs on a pegboard for both a warm-up session and a follow-up session. Study results showed all outcomes measures demonstrated statistically significant improvements after all post-warm-up exercises (p <0.01), and were seen in all groups with differing experience levels. This fits the model of many professionals who use substantial psychomotor skills and use short-term practice or warm-ups to enhance their abilities, but such practice has never been evaluated for surgical tasks.

To assess the impact of performing warm-up surgical exercises, researchers recruited 46 surgeons and asked them to perform several variations of a virtual task such as picking up rings and placing them on randomly highlighted pegs on a board. Specially designed gloves were worn to capture data on hand movements. The time required for completion of tasks and number of cognitive errors decreased, as the gesture-level proficiency, hand-movement smoothness, and tool-movement smoothness
increased. The amount of time needed to complete the tasks and the number of cognitive errors was reduced.

Researchers also found that warm-up sessions significantly improved surgical proficiency (p <0.05) even among fatigued surgeons following night call, though not to the level of optimal performance.

To evaluate whether the warm-up exercises would translate into improved surgical techniques, 12 surgical residents from the original study population were similarly evaluated. Six performed a warm-up session before completing a surgical task on a simulated gallbladder surgery; the other six performed the same task without the warm-up. The six performing the warm-up exercises had highly significantly differences (p <0.0001), i.e., better gesture proficiency and smoothness of hand and tool movements compared with the control group, but time elapsed was similar in the two groups.

Researchers stated that while the trial was limited, it demonstrated that simple preoperative warm-up exercises can be generalized for more than one type of procedure. They concluded by stating that the findings need to be validated in future studies before any clinical changes can be implemented.

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80 percent of patients can’t understand prescription drug labels; need for specific times cited

Four out of five patients misinterpreted one or more of 10 common prescription label instructions according to a recent study. Use of precise wording on prescription drug label instructions such as “take two pills in the morning and two pills in the evening,” as opposed to “take two tablets by mouth twice daily,” can improve patient comprehension and result in more effective treatment.

In this cross-sectional study (January 2009,
Journal of General Internal Medicine) researchers interviewed 359 patients in three clinics about their understanding of each of 10 label instructions. The objective of the researchers was to test whether the use of more explicit language to describe dose and frequency of use for prescribed drugs could improve comprehension, especially among patients with limited literacy. The study sites were two hospital-based primary care clinics and one federally qualified health center.

Of the total 3,590 responses for the three drugs, 23 percent (839) were completely incorrect and 78 percent of patients misunderstood one or more of the instructions. Patients’ understanding of prescription label instructions ranged from a low of 53 percent for the least understood to 89 percent for the most commonly understood label.

Patients were significantly more likely to understand instructions with explicit time periods. For example, the results were highest (89 percent) for instructions such as: “take two pills in the morning and two pills in the evening” or “take one pill by mouth every day. Take in the morning.” The least understood instructions were frequency in hourly intervals or the number of times of day, such as “take one pill by mouth every 12 hours with a meal” (53 percent) or “take two tablets by mouth twice daily” (61 percent). That is, patients did best with
precise times of day compared to instructions stating
times per day or hourly intervals. Authors believe that using time periods of day allows patients to tailor their prescription implementation to their daily schedule.

Even with the use of more precise instructions, patients with low literacy skills had significantly lower comprehension than patients with marginal or adequate literacy skills. The authors concluded that the use of precise wording on prescription drug label instructions can improve patient comprehension. The goal of the healthcare provider should be the delivery of simple, clear, explicit directions.

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FDA joins national efforts to educate consumers on proper use of antibiotics; advises not to skip or share doses

Tips from the FDA regarding proper antibiotic use include the importance of completing the full course of an antibiotic treatment, not skipping doses, not saving antibiotics for the next time you feel ill, and not taking antibiotics prescribed for someone else. The FDA’s latest newsletter to health educators and the public emphasizes that antibiotics are not meant for the treatment of viral infections such as colds, most coughs, many types of sore throat and influenza.

Once infected with an antibiotic resistant organism, treatment becomes more challenging and an equally great danger of spreading the resistant bacteria is possible. In the FDA’s Winter/Spring 2009 edition of
FDA and You, the article “Antibiotic Resistance: How Misuse of Antibiotics Could Threaten Your Health” explains many of the bacteria that have become resistant are the types that cause skin infections, meningitis, sexually transmitted diseases and respiratory tract infections, including pneumonia. The FDA, in concert with other government agencies, provides and updates information about the increasing public health concern of antibiotic resistance, and plays an important role in informing the public and health professionals through educational outreach and by assuring useful and accurate product labeling and appropriate marketing.

Antibiotic resistance would continue being an issue even if all antibiotic use were appropriate, and the need to continue the research and the development of new drugs, vaccines and improved diagnostics for infectious diseases would still be needed, the agency noted. In addressing these drug resistance concerns, the FDA is joining with other agencies to address the growing concern, and with CDC and NIH is co-chairing a U.S. multi-department
Task Force on Antimicrobial Resistance. This task force is developing a broader “Public Health Action Plan to Combat Antimicrobial Resistance,” issuing drug labeling regulations, emphasizing the prudent use of antibiotics and partnering with the
Centers for Disease Control and Prevention (CDC)’s campaign, “Get Smart: Know When Antibiotics Work,” which offers Web resources, brochures, fact sheets and other information aimed at helping the public learn about preventing antibiotic-resistant infections.

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Structured process with safety checks reduces surgical complications, mortality

Surgery-related complications and death were reduced by more than one-third when a structured process was implemented using a tool at three critical periods of operative care: before anesthesia begins, before the first incision is made, and before the patient is removed from the operating room. This surgical safety checklist was implemented at eight hospitals around the world, according to a new
study in the New England Journal of Medicine.

The checklist was developed by the World Health Organization’s (WHO) “Safe Surgery Saves Lives” initiative, led by Atul Gawande,
M.D., associate professor of Health Policy and Management at Harvard School of Public Health and a surgeon at Brigham and Women’s Hospital, Boston. The study period was from October 2007 to September 2008 and data was collected on 3,733 patients before using the checklist and on 3,955 patients after surgeons started using the checklist. Pilot sites included one hospital in each of the following cities: Seattle, Toronto, London, Auckland (New Zealand), Amman (Jordan), New Delhi, Manila and Ifakara (Tanzania). Hospitals in both high and lower income settings were included.

The one-page checklist takes only minutes to complete as it is read out loud in the operating room and is used at three critical periods of operative care as noted. The checklist is intended to ensure the safe delivery of anesthesia, appropriate prophylaxis against infection, effective teamwork by the operating room staff and other essential practices in perioperative care.

The rate of major complications in operating rooms dropped by more than a third when the checklist was used – from 11 percent to 7 percent. Once the checklist was introduced, inpatient deaths following surgery decreased by more than 40 percent – from 1.5 percent to 0.8 percent. Reductions in complications were of equal magnitude in high-income and lower income sites in the study. Researchers estimated that if the WHO Surgical Safety Checklist were implemented in all operating rooms across the United States, the annual cost-savings from the prevention of major complications would be $15 billion to $25 billion per year.

Gawande noted that hospital associations in five states, including Washington, North Carolina, South Carolina, Indiana and New York, are adopting the checklist. The Institute for Healthcare Improvement (IHI) recently announced a “sprint” to introduce the checklist in all 4,000 hospitals that took part in its recent “5 Million Lives Campaign.” In addition, four countries – the United Kingdom, Ireland, Jordan and the Philippines – have already established nationwide programs to implement the checklist in all operating rooms.

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Use of automated health records linked to reduced mortality

Use of a survey tool measuring the use of automated health records resulted in a 15 percent decrease in an adjusted odds ratio (OR) for mortality from all conditions studied. Hospitals using more automation were found to have fewer complications, lower mortality rates and lower costs, according to a recent study.

In the cross-sectional study, 41 hospitals in Texas responded to a
survey using the Clinical Information Technology Assessment Tool, which measures a hospital’s level of automation based on physician interactions with the information systems. The study sought to determine whether greater hospital automation of information was associated with reduced rates of impatient mortality, complications, costs and length of stay with four clinical conditions: myocardial infarction, congestive heart failure, coronary artery bypass grafting and pneumonia. The study examined 167,233 patients older than 50 years.

In addition to the overall mortality findings, higher scores in order-entry were associated with 9 percent and 55 percent decreases in the adjusted odds ratio of death for myocardial infarction and coronary artery bypass graft procedures, respectively. Higher decision support scores were associated with decreased mortality for patients with pneumonia. A 16 percent decrease in complications for all causes of hospitalizations was also noted in hospitals reporting higher scores in decision support.

No clear pattern was observed in the relationship between technology use and hospital length of stay, but the authors concluded that hospitals using automated test results, order-entry and decision support had lower hospital costs for nearly every clinical condition studied. Results also indicate the importance of adequately training clinicians to use the new technologies and designing information technology (IT) around clinical workflows.

While this study indicates the positive benefits of the use of IT, the journal Health Policy recently published a
report of a survey of 6,536 physicians in seven countries and found that adoption of health information technology remains highly variable, and the United States falls behind other countries. The article, funded by the Commonwealth Fund, also found that physicians with access to greater IT capacity were more likely to report feeling well prepared to manage patients with chronic illnesses.

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Focus group identifies majority of nurses are not included during error disclosure

A recent study, “Disclosing Errors to Patients: Perspectives of Registered Nurses,” (The Joint Commission
Journal on Quality and Patient Safety, January 2009) concludes that nurses often are not included when physicians tell patients about serious mistakes. Because of closeness to patients and families during care delivery and potential for involvement in the error, nurses should also receive training on how to tell patients and families that a mistake has occurred. Organizational culture plays a key role in error disclosure, and healthcare organizations that integrate the entire care team into the disclosure process will likely improve the quality of error disclosure.

Using a series of focus groups, information was developed from 96 registered nurses looking at the nurses’ perspectives on disclosure of errors to patients and the organizational factors that influence disclosure. For example, nurses talk with patients about errors that are within their control, such as late or missed medications or treatments, but are hesitant to independently disclose errors that involve serious harm or actions of other members of the care team. They see the responsibility of disclosure in these situations as that of the attending physicians.

Nurses were not involved in the error disclosure discussion among the care team members to plan for the disclosure or in the actual disclosure, which they felt led to their use of ethically questionable communication strategies with patients and families. They also say they would like a role in the disclosure process as a way to communicate directly with the patient about nursing’s role in an error event.

Nursing awareness of existing error disclosure policies in their facilities was low. “Improving the quality of error disclosure to patients is a top priority in healthcare,” said Sarah E. Shannon, Ph.D., R.N., lead author of the study. “Error disclosure needs to be a team sport.”

The authors concluded that organizations should adopt a team disclosure process and have policies in place that permit nurses and other caregivers to participate in and raise concerns about the disclosure process. Healthcare organizations that integrate the entire care team into the disclosure process can only improve the quality of error disclosure.

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Educating patients on teamwork skills increases their confidence in speaking up

Dana-Farber Cancer Institute implemented a successful patient-oriented
teamwork training initiative for their ambulatory oncology patients that boosted their confidence and participation in their care.

Researchers began a patient awareness campaign that was simple and accessible to patients with different levels of literacy, interest and attentiveness after other approaches were less successful. The teamwork training campaign was intended to encourage patients to use teamwork techniques to work more effectively with their healthcare providers. Researchers hoped patients could actively assist in addressing the three leading patient safety hazards in the ambulatory oncology environment: administration of the wrong chemotherapy drug, infections related to inadequate hand hygiene, and failure to communicate last-minute dose changes effectively.

Patients were surveyed at baseline and during the campaign and although no significant change was noted in the reported use of teamwork techniques, 39 percent of those exposed to the campaign said it changed their behavior. Many patients reported that the campaign provided an officially endorsed forum that allowed them to perform behaviors they found helpful, such as asking caregivers difficult questions.

For example, some patients found it easier to ask
caregiver questions because the caregivers are expecting
them to as a result of the campaign. For other patients, the
campaign provided an official endorsement of behaviors they
found helpful, if not always comfortable. "You sometimes
feel like you’re going to get a black checkmark next to your
name for asking questions," said one patient. "This
[program] will help because staff will know why I’m asking."
Of all the teamwork behaviors the campaign encouraged,
asking providers if they cleaned
their hands
posed the greatest challenge for patients and their companions. Yet both patients and volunteers agreed that the campaign made doing so a bit easier. One volunteer rounder said that patients were “receptive to the reminders about hand washing. …Somehow, [the campaign] seemed to legitimize things for them.” Even patients who already employed teamwork techniques appreciated the initiative. “I already do all this,” said one patient, “but it’s a great idea.”

Researchers acknowledged that teamwork training may not work in all patient care environments but felt there is potential in using the techniques.

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Frontline worker assessment provides true measure of an organization’s safety culture

Frontline workers’ perception of safety is the least positive when compared to that of managers and senior leadership, and likely reflects the true safety culture of an organization. Understanding this reality is important, according to a recent study, since a culture of safety is key to improving patient safety and reducing adverse events, and needs frontline workers willing to report errors, openly discuss mistakes and contribute to solutions.

Past research has shown that senior managers generally had better perceptions of safety than did lower-ranking managers. A new
study on the hospital patient safety climate was designed to determine whether frontline workers and supervisors perceived the patient safety climate in their hospitals differently than senior managers. The 2004 Patient Safety Climate in Healthcare Organizations (AHRQ) survey was administered to senior managers, physicians and other employees in 92 U.S. hospitals.

Results revealed differences in safety climate perception between management levels. Frontline workers were the least positive, supervisors were more positive, and senior managers the most positive. Possible explanations for this finding include the fact that many managers do not personally experience the safety hazards of frontline personnel, and because senior mangers rely on reported information, bad news may be filtered or not reported. Managers may not also be effectively communicating the importance they place on patient safety to the frontline workers.

Another significant finding was that differences by management level depended on discipline. The differences between frontline workers and senior managers were more pronounced for nurses and others than for physicians. The large variation in safety climate perception among nurses compared with physicians may stem from the many nurses who become managers and no longer actively participate in patient care. Meanwhile, many physicians in management positions do continue providing patient care.

Researchers drew several conclusions from their analysis, including senior management’s misperceptions of frontline workers. The perceptions of the frontline workers more accurately reflect the safety performance of the hospital. They also cite evidence that senior managers fail to allocate necessary resources when interventions are needed to improve organizational learning.

Senior managers need to encourage interventions that encourage communication and speaking up. They also need to listen to more accurately understand the perspective of the frontline workers. Activities that promote this understanding include safety culture-oriented simulation training and “Leadership WalkRounds.” Safety climate surveys should continue to include all management levels as well as frontline workers to assess the current climate and any achieved progress. The researchers concluded that continuing efforts to improve the patient safety climate should address perceptual differences, both among and within groups by management level.

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Safety Tools

HHS – New influenza pandemic guidelines

Healthcare workers likely to be exposed to influenza during a pandemic should receive preventive doses of antiviral medications, according to new guidance from the U.S. Department of Health and Human Services (HHS) titled “Guidance on Antiviral Drug Use during an Influenza Pandemic.” ( The document replaces the 2005 recommendations and provides guidance to planners on antiviral drug use strategies and the number of antiviral regimens that would be needed to support implementation.

Related guidance, “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic,” ( outlines considerations for antiviral medication stockpiling. This guidance does not establish the requirement or expectation that all employers stockpile antiviral drugs.

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RWJF toolkits – Improve cardiac care

Lessons learned from a 10-hospital, pilot program to improve cardiac care while reducing racial and ethnic disparities have been compiled into a
toolkit offering detailed guidance to other hospitals nationwide. All 10 chapters of “The Expecting Success: Excellence in Cardiac Care” toolkit, a program of the Robert Wood Johnson Foundation, can be accessed online. Participants in the “Expecting Success” collaborative increased the proportion of patients receiving all recommended care for heart failure by 37 percent over two years. Hospitals in the program also used a Web-based toolkit ( developed by AHA’s Health Research and Educational Trust affiliate to guide them through the process of systematically collecting race, ethnicity and primary language data from patients.

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ISMP – New drug safety consumer Web site

A new Web site designed to help consumers prevent adverse drug events is now available from the Institute for Safe Medication Practices (ISMP). ( provides information on the causes of medication errors and provides time-critical error-reduction strategies. Some of the learning methods include:

  • Blinded, memorable stories about actual errors that have happened and how to prevent them;
  • Peer-reviewed advice from safety experts, including health professional Web site readers and visitors;
  • A consumer error-reporting program that communicates issues to ISMP, FDA and medical product manufacturers to foster large-scale changes in healthcare;
  • Safety tools and resources, such as how to administer medications by various routes and which medications cannot be crushed;
  • E-mail safety alerts from ISMP, FDA and the ISMP safety partner,, personalized according to the list of medications the consumer provides to it via a secure database; and
  • E-mail notification of applicable drug recalls or drug class recalls that may affect consumers, based on the list of medications they provided.

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HHS – Consumer health history tool for electronic medical record

An updated version of a family health history tool from the Surgeon General is available from the U.S. Department of Health and Human Services (HHS). Consumers can create an electronic record of family health information to share with relatives and healthcare providers. The information can be used in electronic format and in personal health records. Using “My Family Health Portrait,” consumers can enter their family health history and create drawings of their family health history to share with family or healthcare workers. The tool is available at

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ASHP – New drug recall resource

A new link that provides timely information on the latest drug safety alerts and warnings has been added to the University of Utah Hospitals and Clinics Drug Information Service Web site The resource was spurred by member requests and a recommendation to the American Society of Health-System Pharmacists (ASHP) Council on Pharmacy Practice. The University of Utah Hospitals and Clinics Drug Information Service is ASHP’s long-standing collaborator for the Drug Shortages Practice Resource Center. Postings to the Drug Recall site include a summary of alert information, recommendations for management of the recall or alert, and links to relevant FDA documents. The ASHP Resource Center on Patient Safety Web site can be accessed at

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TMIT webcasts – updating safe practices

The Texas Medical Institute of Technology (TMIT) is providing a webcast of the “NQF Safe Practices for Better Healthcare – 2009 Update.” The webcast is designed to help healthcare facilities develop adoption plans for implementing National Quality Forum (NQF)-endorsed™ safe practices, and to optimize Leapfrog Survey submissions. The webcast is available at An additional webcast also includes updates to the Pharmacist Leadership Practice, which calls for pharmacists to assume a leadership role in their organizations with authority and accountability for medication management.

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Editorial team

  • Gina Pugliese, RN, MS editor
  • Judene Bartley, MS, MPH, CIC, associate editor
  • John Hall, BSJ, contributor
  • Judith Luca, RN, BSN, contributor
  • David Huntley, BA, Web master

About Premier Inc., 2006 Malcolm Baldrige National Quality Award recipient

Serving more than 2,100 U.S. hospitals and 53,000-plus other healthcare sites, the Premier healthcare alliance and its members are transforming healthcare together. Owned by not-for-profit hospitals, Premier operates one of the leading healthcare purchasing networks and the nation’s most comprehensive repository of hospital clinical and financial information. A subsidiary operates one of the nation’s largest policy-holder owned, hospital professional liability risk-retention groups. A world leader in helping healthcare providers deliver dramatic improvements in care, Premier is working with the United Kingdom’s National Health Service North West and the Centers for Medicare & Medicaid Services to improve hospital performance. Headquartered in San Diego, Premier has offices in Charlotte, N.C., Philadelphia and Washington. For more information, visit

SafetyShare © 2009 Premier, Inc.

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