Top 10 Patient Safety Issues for 2014

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Patient safety is a serious issue. While sentinel events continue to happen in healthcare, the bottom line is no one wants patients getting hurt. Linda Butler, MD, chief medical officer at Rex Hospital in Raleigh, N.C., says the key to reducing harm is taking on responsibility to change: "As healthcare providers, we track many [sentinel] events and strive to have rates that approach zero. The use of technology and safety systems have lowered some of our rates and improved our outcomes. However, much of the burden for safe care lies with the clinical providers who interact with these patients while they are hospitalized," she says.

In no particular order, the following is a list of the 10 most pressing patient safety considerations for 2014. The following list has been compiled from material from the Patient Safety Movement Foundation in partnership with The Joint Commission Center for Transforming Healthcare as well as from comments from Dr. Butler, Susan Moffatt-Bruce, MD, PhD, chief quality and patient safety officer at Columbus-based Ohio State University Wexner Medical Center, and Linda Efferen, MD, chief medical officer and senior vice president at Oceanside, N.Y.-based South Nassau Communities Hospital.

1. Healthcare-associated infections. HAIs are both prevalent and costly. According to the Centers for Disease Control and Prevention, 5 percent of all inpatients will develop an HAI. The Association for Healthcare Research and Quality puts the cost of an average HAI in the tens of thousands of dollars. Dr. Moffatt-Bruce of Wexner Medical Center notes an additional difficulty in reducing HAIs: climbing rates of multidrug-resistant infections. "We must improve the use of antibiotics and partner to understand where the tension is around prescribing priorities," she says. The CDC's 2013 report on antibiotic resistance confirms the problem and the need to find long-term solutions based around HAI prevention, antibiotic prescription and antibiotic use as soon as possible.

2. Surgical complications. While surgical complications such as retained foreign objects, mistaken identity and wrong-site surgery don't happen often, potential consequences are severe when they do. Dr. Butler of Rex Hospital says retained foreign objects pose a particularly severe risk: "They should be a concern for any surgical team," she says. "At Rex, all instruments and sponges are counted pre-operatively and again at the end of the procedure. If there is a discrepancy, the surgeon does not close the patient and an X-ray is ordered." According to Dr. Butler, the University of North Carolina Medical Center in Chapel Hill is experimenting with an application of RFID technology to track objects used during surgery. However, this technique does not guarantee the ability to track objects, especially in patients with high body mass indexes, which can also complicate other aspects of surgery. At the moment, good planning and attention to detail from all members of the surgical team seem to be the only reliable solutions to improving surgical complications.

3. Handoff communications. Poor handoff communication results in errors, both minor and major, which may result in increased lengths of stay and increased costs. According to The Joint Commission, handoff communication has often been the leading root cause of malpractice lawsuits since the organization began collecting the data in the mid 1990s. Improving communication may require better structures for information transfer, according to several recent studies. Good communication has been linked to strong safety cultures and good workplace relationships, so investing in a safety culture in addition to standardizing ways and means of transferring all medically necessary information between relevant clinicians is a vital step to making sure clinicians can clearly say what a patient needs for his or her treatment.

4. Diagnosis. An incorrect diagnosis means any treatment, no matter how well executed, has the potential to cause patient harm. According to the Patient Safety Movement Foundation, failure to rescue, and failure to detect congenital heart diseases and sepsis are particularly problematic in this regard. Failure to rescue occurs when a patient dies as a result of an undetected or unrecognized complication. Both congenital heart disease and sepsis patients are at a high risk of failure to rescue. While true of most conditions, sepsis is particularly dangerous if not diagnosed early and may be fatal within a matter of a few days if undiagnosed or treated too late. While improving diagnostic techniques may seem daunting, earlier this year at the conference for the Society to Improve Diagnosis, National Quality Foundation, President and CEO of the National Quality Forum Christine Cassel, MD, said it's important to plan improvements that can be adjusted, rather than waiting around for the perfect solution. "Don't let the perfect be the end of the good," she said.

5. Medication errors. As the rate of comorbidities rise, the average patient today tends to be on more medications at one time than in the last decade, according to Dr. Moffatt-Bruce. This leads to worse potential side effects and more potential challenges for patients once they leave the hospital. Dr. Butler, who sees the same problem at her healthcare system, recommends implementing a comprehensive medication history and reconciliation process during care transitions as well as increased patient education to reduce associated risks.

6. Failure to implement a culture of safety. Strong safety cultures allow patient safety events to be identified and analyzed and their root causes to be eliminated. While in a perfect world all clinicians would speak up about every error (or potential error) they see, human nature means this is often not the case. Allowing clinicians to stop fearing retribution for error reporting is in large part the responsibility of leadership, which must invest in systems for successful change management, according to The Joint Commission and the Patient Safety Movement Foundation. The Joint Commission model for moving to a safety culture includes four steps: planning the change, inspiring people to change, launching the framework and supporting the change both to completion and afterward. These steps facilitate buy-in from employees and increase the odds of success in safety culture implementation.

7. Lack of interoperability. While electronic medical records represent one of the incredible advances medicine has made in recent years, they are far from perfect. "We can all appreciate the theoretical benefit," says Dr. Efferen of South Nassau Communities Hospital, "but it's still a burgeoning industry. We don't yet have the experience or advanced technology to readily achieve the full potential of the technology. There's a learning curve, and there's a need to have more regulation around vendors providing us with these tools to make sure they're interconnected," she says. Indeed, interoperability is a major sticking point with these electronic tools. An analysis from the West Health Institute estimated complete interoperability has the potential to save the healthcare system $30 billion a year. As the need for cooperation through data-sharing in healthcare becomes apparent, vendors are beginning to invest in platforms with more sharing capabilities. The progress on interoperability, however, may be largely out of the hands of clinicians.

8. Falls (and other geriatric considerations). By one reckoning, baby boomers are joining the ranks of the senior citizens at the rate of 10,000 per day. In addition to causing a care shortage some time in the not-too-distant future, a larger number of older patients necessitates preparation for the complications with which they are associated, including falls. Dr. Butler indicates screening for patients at risk for falls may reduce the issue. These patients include those with reduced mobility, low blood pressure and dementia. Dr. Moffatt-Bruce says hospitals attempting to be fiscally responsible by reducing staffing on the front lines are also at a greater risk for falls. "We're asking nurses to care for acutely ill patients with a multitude of issues, yet we're not able to staff to the level to which we need," she says. "We should carefully re-evaluate how we spend our healthcare dollars."

9. Better treatment choices. Assuming a correct diagnosis and flawless execution of a given treatment, choosing which treatments to give to patients also creates a patient safety issue. "Unnecessary tests and/or therapy are at the crux of patient safety," says Dr. Efferen. "The challenge is how to realign patient-consumer expectations of treatment as well of supporting providers in terms of changing practice patterns," she says. One such example championed by the Patient Safety Foundation is blood transfusion, which has been documented as a much-overused practice in recent years. Championed by the Patient Protection and Affordable Care Act, better treatment choices have the potential to reduce patient harm and improve spending and utilization of care.

10. Alarm fatigue. According to The Joint Commission, between 85 and 99 percent of alarm signals don't require clinical intervention. Yet, between January 2009 and June 2012, the organization recorded 98 sentinel events related to alarm fatigue, 80 of which resulted in death. Alarm fatigue earned a spot on the ECRI Institute's "Top 10 Health Technology Hazards" list, where it has made frequent appearances since the list's inception in 2007. Creating guidelines to customize alarm settings to individual patients, rather than keeping strict alarm settings has the potential to alleviate some of the problem, according to The Joint Commission.

"By nature, hospitals have always been focused on patient safety," says Joe Kiani, founder of the Patient Safety Movement Foundation. "Unfortunately, the fact remains that preventable patient deaths in hospitals around the world continue to rise. What we are finding is that clinicians and others in the healthcare community are no longer willing to accept the fact that medical errors are part of practicing medicine. [Improvement] is about creating a culture of safety within the organization, making measurable commitments, creating solutions and sharing success," he says.

Note: The Patient Safety Movement will be holding its Patient Safety, Science and Technology Summit Jan. 11-13, 2014. Visit the organization's website to learn more.

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