Amid hospital 'chaos,' stick to standards to improve quality

Every time a mistake is made in a healthcare setting, there can be serious repercussions. Patients may suffer lifetime injuries or even pay the ultimate price for someone else's mistake. Hospitals may wind up paying the price literally — financially and legally — and suffer costly public reputation troubles in the aftermath. 

Increased patient loads combined with the workforce shortage and often decreasing financial resources have created "chaos" in hospitals, said Doug Salvador MD, chief quality officer at Baystate Health in Springfield, Mass. 

Safety watchdog organizations, including The Joint Commission and The Leapfrog Group, have reported the result of that chaos: soaring cases of preventable medical errors. 

The solution, he and several other sources who spoke with Becker's said, is to create standard operating procedures in every department, at every step of the patient journey. These SOPs are more than lists of guidelines; they require strict adherence and limited room for error thanks to built-in cross-check points. And, when instituted properly, they highlight system flaws in real time by creating what Dr. Salvador called "situational awareness." 

Situational awareness, he added, keeps front-line healthcare professionals on top of their safety game. 

SOPs can employ simple, no-cost solutions based on creativity and common sense as well as high-tech systems that require funding but come with significant return on investment. 

In fact, the World Health Organization reported that "investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes."

Either way, experts say, safety must be standardized if hospitals want to move the needle on quality. 

"We all make mistakes. You can get it right 99 percent of the time, but it's that 1 percent that's the problem," said Barbara Fain, executive director of the Betsy Lehman Center, a Massachusetts state agency focused on improving patient safety. 

She said putting safety protocols in place has to be more than just talk. "We can't just say, 'Here's the information. Just go do it.' We know that doesn't work. The idea is to minimize mistakes that hurt people by building backup systems."

Heidi Raines, past board president of the American College of Healthcare Executives’ Women Healthcare Executive Network, said "it's simply unrealistic" to expect "flawless performances from people who work in high-stress complex healthcare environments."

"Most medical errors occur because of flawed systems, not reckless practitioners, and systems should aim to proactively identify these factors — and learn from them," Ms. Raines added.

A look at the extent of the challenge

From the patient standpoint, medical mistakes are often life-altering. From the moment a patient enters a hospital, they can be misidentified, accidentally be given drugs they are allergic to or not immediately be recognized as a fall risk. Add to that the myriad things that can cause a hospital-acquired infection, as well as wrong-site surgery mistakes and delayed treatment, and recently reported harrowing statistics make sense.

According to a study published in 2023 in the New England Journal of Medicine, nearly 1 in 4 admitted patients suffers a preventable medical error.

The Joint Commission said April 4 that of all reported sentinel events (an inadvertent action that causes significant patient harm or death) reported in 2022, 44 percent resulted in severe temporary harm and 20 percent resulted in a patient death.

Additionally, it found that voluntary reporting of adverse events in hospitals rose 19 percent in 2022.

In its spring 2023 safety grades report, The Leapfrog Group said incidents of hospital-acquired infections are at a five-year-high — a statistic that "should stop hospitals in their tracks," according to Leah Binder, president and CEO of The Leapfrog Group.

Further, some states reported triple-digit increases in cases of methicillin-resistant Staphylococcus aureus, central line-associated bloodstream infections and catheter-associated urinary tract infections. 

The WHO estimates that up to 80 percent of medical errors that cause patient harm are preventable.

"Which is why healthcare organizations must prioritize taking a systems-focused, proactive approach to patient and healthcare worker safety. And that starts with fostering a culture of safety," Ms. Raines said. "Humans are best guarded against errors when placed in an error-resistant environment where the systems, tasks, and processes they work within are well-designed and the materials they need are readily available."

The most recent Leapfrog report showed that HAIs, which were in decline in 2019, have been on the rise since the start of the pandemic. Connie Steed, MSN, RN, infection prevention consultant, told Becker's, this is because some basic best safety practices — including hand hygiene and social distancing — fell by the wayside.

There are also notable gaps in education about best practices to prevent HAIs and adverse events due to large staff turnover and shortages across the healthcare sector, she explained.

What can be done?

It comes back to SOPs because creating the "culture of safety" includes checks, double checks and triple checks for any necessary failsafes. And hospitals don't have to reinvent the wheel to put these procedures in place.

Consider wrong-site surgeries, which The Joint Commission said in a May 2023 issue of its Journal on Quality and Patient Safety, "cause serious medical and emotional harm, as well as significant financial and legal consequences for patients and healthcare providers." 

The Joint Commission offers a three-step strategy to help reduce surgical errors: a pre-procedure verification process, marking the surgical site before the procedure is performed and taking a time out. During the time out, all surgical team members follow a standardized protocol before an incision is made to confirm the patient and procedure and to answer any questions from any member of the team before the surgery begins.

This protocol doesn't require a capital expenditure and, when followed before each and every surgery, it works.

Dr. Salvador described another no-cost example of creative problem-solving. 

When Baystate decided to focus on reducing catheter-associated urinary tract infections, departments went old school by each putting up a rack — conspicuously placed near huddle boards — for every patient who had a catheter. The cards are turned showing a different color when the patient's Foley is checked by a nurse. If the card isn't turned, the nurse can see the patient needs to be checked. It's right there in front of them as a live reminder. 

"That's situational awareness," Dr. Salvador said. "The entire team is aware of what's going on,  whereas before we put this simple system in place, there was not a collective knowledge about how many people had catheters, so the info was siloed."

How technology can help

At the same time, Dr. Salvador added, "If you have access to technology, use it."

"In order for us to achieve the quality and safety that we aspire to deliver, we have to introduce technology to help us standardize care delivered in the same way across regions and institutions," Dr. Salvador said. "Humans are not able to standardize things the way technology can, so we need to let technology help us."

The four-hospital Baystate system decided to focus first on patient fall statistics, which Dr. Salvador said became worse during the pandemic "because nurses were unable to keep eyes on every patient at every moment."

The healthcare system installed a camera-based monitoring system. Patients at risk of falling are placed in rooms with cameras that are monitored from a central location. If a monitor, who is able to watch 12 rooms at a time, sees any problem arising, they can speak directly to the patient, Dr. Salvador said. 

"The monitor can say, 'Do you need something?' They can remind the patient, 'Remember you're not supposed to get out of bed without help,'" he said, noting the monitor can simultaneously alert department staff about patients who need immediate assistance.

Michael Richardson, BSN, RN, chief quality and patient safety officer at Chicago's St. Bernard Hospital, said technology can be a hospital's best friend.

When you consider that safety organizations, including The Joint Commission and The Leapfrog Group, set industry standards for safety, it shouldn't be difficult to figure out which challenges a hospital needs to address first, he said. "Hand hygiene, infections, falls with fractures — all hospitals need to look at these types of issues and do something about them."

St. Bernard scored a Leapfrog "A" this spring, after getting "F" after "F" only a couple of years ago. The hospital's safety team focused on specific issues such as hand hygiene and installed a tech platform that visually reminds employees to sanitize their hands before entering a patient's room. Every employee wears a badge, C-suite leaders included, that they have to swipe at hand hygiene stations. 

"Green means clean," he said, noting since putting in the hand hygiene check technology, St. Bernard has recorded more than 1 million pairs of hands sanitized. That's far higher than the benchmark set by Leapfrog.

Ms. Raines said transparent communication, between colleagues and employees and leaders, is also important.

"While there are several resources that can be employed to lower the number of patient and employee safety events, programs focused on reporting near misses and conducting employee rounding are particularly important," she said. "By identifying potential safety hazards and gathering feedback from front-line staff, healthcare organizations can take proactive steps to address safety issues before they lead to harm."

Knowledge is power

It's been said a million times: You don't know what you don't know. To that end, find out where cracks in your hospital's safety protocols exist and repair them.

"Every healthcare organization should examine its own safety risk profile and prioritize what to tackle accordingly," said Haytham Kaafarani, MD, chief patient safety officer and medical director of The Joint Commission. "Decreasing these serious adverse events is not only important to safeguard patients and provide them with the quality care they deserve, but can also [offer] cost savings to the healthcare organization." 

He added that The Joint Commission Office of Quality and Patient Safety provides hospitals with access to a large team of patient safety specialists who are "one phone call away to help healthcare organizations examine their risks and to determine root causes of these sentinel events."

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