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New 2009 Statewide Initiative - Standardizing Code Alerts
Wouldn’t it be nice to know that no matter what facility you work at, the same code alert for “fire” or “cardiac arrest” would be used? Well, soon that will be the case. In November 2006, Arizona lead the nation to standardize color coded wristbands, specifically, DNR, Allergy and Fall Risk. To date, 97% of Arizona's hospitals and 28 other states have adopted this standardization. Since that time, many of Arizona's hospitals have asked if the Arizona Hospital and Healthcare Association (AzHHA) could coordinate an effort that would standardize Code Alerts across the state. Team members representing hospitals across AZ convened during the summer of 2008 to work on the project. Analyzing Arizona and national data, reviewing recommendations and information from national stakeholder groups, the Team has developed recommendations for adoption for the following codes:
1. Fire 7. Infant Abduction
2. Abduction 8. Pediatric Abduction
3. Pediatric Cardiac Arrest 9. Internal Disaster
4. Bomb Threat 10. External Disaster
5. Combative Person 11. Hazardous
6. Combative Person with Weapon
In the past, AzHHA has had launch events to kick-off statewide initiatives. This time, to make the launch event convenient for more to attend and not as time consuming, we are hosting webinars that will review the initiative and present the toolkit (see following article). The launch webinars will be in January and February, 2009 with the goal for Arizona hospitals to implement the initiative by December 2009. If you have questions about this initiative, please contact Barb Averyt at baveryt@azhha.org.
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Webinar for Code Alert Standardization
To guide you through the Code Alert Standardization, webinars will be offered at four different dates/times. They are:
Tuesday, Jan. 20, 9:30a – 10:30a
Wednesday, Jan. 28, 11:00a – Noon
Tuesday, Feb. 4, 1:30p – 2:30p
Thursday, Feb 12, 1:30p-2:30p
During the webinar, participants will be introduced to the resources created for the initiative, such as:
• PowerPoint Presentation for Training
• Employee Education Brochure with FAQs (in English and Spanish)
• Reference chart showing new code alerts
• Pocket sized cut out of code alert chart
• ID badge cut out of code alert chart
• Three “cut and paste” newsletter articles for hospitals to use for their own employee newsletters about the initiative.
To register for the webinars, please send an email with your name, email and phone number to Karen Fallquist at kfallquist@azhha.org. Once registered, you will receive the call in number and instructions for the webinar. If you have questions about this initiative, please contact Barb Averyt at baveryt@azhha.org.
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Infections and Lawsuits: A Direct Correlation
A new type of med-mal lawsuit is on the rise — claims based on hospital infections. Don’t take my word for it, look at these recent verdicts and settlements:
- On Nov. 6, a jury awarded $13.5 million to the family of a Massachusetts woman who died of an infection caused by flesh-eating bacteria that she contracted during cancer treatment.
- On Nov. 14, a Utah woman reached a confidential settlement in a $16 million suit she filed, alleging that a hospital failed to detect necrotizing fasciitis before and after she gave birth, causing her to lose three limbs and several organs.
- In July, a Missouri couple was awarded $2.58 million after the husband contracted MRSA, when doctors inserted a pacemaker. As a result of the infection, the patient lost a kidney, and a leg and a foot had to be amputated.
Giles H. Manley, who was a practicing obstetrician /gynecologist for about 20 years before becoming a lawyer, offers some reasons for the recent legal verdicts. “The rate of patient infection is close to zero when health care personnel comply with strict protocols governing the washing of hands, instruments and hospital rooms.” Patient advocate Betsy McCaughy said hospitals, amid the recent wave of lawsuits, are on notice about the threat of hospital-acquired infections and must vigorously comply with the safety protocols to prevent infections — and litigation. “Now that the evidence is overwhelming that nearly all infections are preventable, hospitals that don’t follow the proven protocols are inviting lawsuits.” That position, coupled with CMS’ newly implemented “no payment for Never Events” which includes specific infections (such as surgical site infections and urinary tract infections), lends credence to the idea that infections are preventable and if they occur, may point to negligence.
This activity serves as a wakeup call to all and perhaps a warning that we need to take a serious look at the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) sponsored and authored the Compendium in partnership with and support from the Association for Professionals in Infection Control and Epidemiology (APIC), the Joint Commission, and the American Hospital Association (AHA) and the Centers for Disease Control and Prevention (CDC). Implementation tools such as this compendium will serve as a means to ensure that the best practices for infection prevention are successfully brought to the bedside. To access the Compendium, go to: http://www.shea-online.org/about/compendium.cfm
To view the original news article this was developed from, go to: http://wislawjournal.com/article.cfm/2008/12/01/Hospital-infections-spread-so-do-lawsuits
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Apology Accepted
When a medical error has occurred, a host of activities follow - chart reviews, patient and family discussions, staff interviews, a root cause analysis, and more. But does a full disclosure and an apology occur? Most of us would agree that disclosure and an apology is the humane thing to do. There is an obligation for physicians and hospitals to disclose adverse events. However, it is difficult to admit making an error, particularly one that harms a patient. This difficulty is compounded by lack of training on the subject. The SorryWorks Coalition, an organization that believes the medical malpractice crisis is a customer service crisis - not a legal problem, says the way an apology and disclosure occurs is a skill that must be learned. When done effectively, it can bring healing to the patient, their family members, and the providers involved. When an apology and / or disclosure is not done, or done ineffectively, it can be more damaging than the error itself.
Perhaps this is a good time for your organization to conduct an assessment on this topic. A good tool to facilitate a discussion about this topic is a recent video titled, “Physician, Say You’re Sorry”. Less than five minutes long, the video is being hosted on the New York Times website. It may be worth viewing at Board meetings, Medical Staff meetings, QI meetings, to help facilitate a discussion about this topic. As one man in the video says, “You have no idea how far a “sorry” will go.” Apology and disclosure also has a business case component. At the University of Illinois, for example, of 37 cases where the hospital acknowledged a preventable error and apologized, only one patient filed suit. At the University of Michigan Health System, existing claims and lawsuits dropped from 262 in August 2001 to 83 in August 2007, and legal costs fell by two-thirds. To start this conversation or to just ponder the issue, take a moment a view the video by clicking on the following:
http://video.nytimes.com/video/2008/11/24/opinion/1194833810295/op-ed-physician-say-you-re-sorry.html
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A Surgical Fire: A Lesson in Work-Arounds
A Surgical Fire: A Lesson in Work-Arounds
The following incident occurred in a hospital in Minnesota and involves a surgical fire. At first glance you think this story is about the fire. But the real error is not the fire. Read the following carefully and see if you can find the real errors. The errors of tolerating workarounds – and that occurs in every hospital.
The incident occurred while a patient was having a cardiac pacemaker installed. According to the investigation that was conducted by the state’s Department of Health, the fire most likely occurred because the surgeon was using a cauterizing tool near the patient's nose tube (a violation of safety protocols, a work-around #1), and because oxygen had pooled beneath improperly draped sterile sheets. The surgeon was in the process of cauterizing the area inside the patient's body that would hold the pacemaker when the left side of the sterile drape and the nasal prongs on the oxygen tube to the patient’s nose suddenly caught fire. Both were quickly removed, and the fire extinguished, but the patient was burned on her nose, shoulder and face. The surgeon and the nurse told investigators that a device normally used to properly drape sterile sheets around patients' faces is not available in that particular operating room (work-around #2). The surgeon said he has done many pacemaker procedures in that room without the draping device (tolerance for work-arounds).
This article should serve as a lesson in work-arounds, and not just a focal point for surgical fires. We all do work-arounds in many areas of life, but when it is on the job and involves patients, we need to stop. It is important to see where we are making similar errors in our practices and where we have a parallel issue. Just as the surgeon is saying, “I’ve done many pacemaker procedures in that room without the draping device”, we ought to realize it’s just a matter of time before a tolerated work-around catches up to us. How many times has someone used the medication bar coded scanner and not taken the scanner to the bedside, but scanned an extra patient ID label in the medication room? How many times have we had a “second check” on a high risk medication when the “check” was done by someone taking your word for it, and not really checking? How many times has a procedure been done without first conducting the surgical/procedural pause? A mistake may not have occurred yet, but that doesn’t mean it won’t occur. That’s the lesson we need to see in this incident.
Use this story as an opportunity at your next staff meeting. It’s easier to bring the topic up of work-arounds when you can use a story unrelated to your organization. Ask staff what work-arounds have they become de-sensitized to? Make a list and see which ones can be dealt with in the next 30 days. It may be a simple fix. I remember one organization I worked with had a work-around that was used for several years that involved labeling lab specimens. It was easily fixed within 14 days by purchasing a $200 printer for the unit. Maybe it is that simple for some of your work-arounds as well.
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MRSA Conference Call
As part of the ongoing support for Arizona’s Preventing MRSA: It’s In Our Hands campaign, conference calls occur quarterly with topic specific information. Because many organizations expressed an interest and started an Antibiotic Stewardship Committee, October’s call featured Scottsdale Healthcare’s journey and process for their Antibiotic Stewardship program. In January, we are taking the topic of Antibiotic Stewardship one step further and addressing how this can be done in Ambulatory Clinics. Featuring West Texas VA Healthcare Systems, we will hear one more application for Antibiotic Stewardship – a critical piece to preventing the spread of infections. There is no charge for the conference call, which is scheduled for Thursday, January 29, 2009 at 10am. The agenda is as follows:
Preventing MRSA: It’s In Our Hands Conference Call Thursday, January 29, 2009 at 10am. |
Agenda Item | Presenters | Time
|
1. Updates and Q&A opportunity – Scottsdale Healthcare's Antibiotic Stewardship Program in Acute Care | Patty Gray, RN, BA, CIC, Infection Control Preventionist and Bill Wightkin, Pharm D, R.Ph, Manager, Pharmacy Clinical Operations and Medical Safety /Quality Officer | 15 minutes |
2. Antibiotic Stewardship Program in an Ambulatory Clinic environment | Liz Moos, RN, Patient Safety Manager and Dawn McCright, MBA /HCM, BS, BA, MT(ASCP),ASSC(CVT) | 30 minutes |
3. Update regarding AZ's Infection Prevention and Control Advisory (Senate Bill 1356) | Patty Gray, RN, BA, CIC, Infection Control Preventionist and Barb Averyt, AzHHA Patient Safety Director | 15 minutes |
To register for this event, please contact Karen Fallquist at kfallquist@azhha.org. Please provide your name, email address, phone number and the organization you represent. Conference call information and pertinent materials will be sent to you once registered
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NPSGs Being Reviewed During 2009
Over the next year, the current National Patient Safety Goals will undergo an extensive review. As a result, there will be no new NPSGs developed for 2010. Responding to concerns about the challenge some Goals represent and the need for information about effective approaches to addressing these challenges, The Joint Commission and its Patient Safety Advisory Group (PSAG)which helps develop the NPSGs, are undertaking a thorough review of the goals and the process for their development. As NPSGs have evolved over time, some have become more specific and detailed, and therefore, require more time and resources to implement. The extensive review process includes a baseline survey, review of potential changes by the PSAG and the Standards and Survey Procedures (SSP) Committee, and final approval by the Board of Commissioners. Revisions to the current NPSGs based on recommendations will be effective in 2010. During December the Joint Commission conducted a baseline survey to gather input from the field on the 2009 NPSGs. The Joint Commission will continue to work with the PSAG and the SSP throughout 2009 to review and refine the process for future NPSG development. To access the current NPSGs, go to: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
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