Capnography, Patient Safety, Patient-Controlled Analgesics, PCA

Improving Patient Safety in Hospitals: Can Hospitals Afford to Give Away Money? So Why Do Preventable Adverse Events Still Occur in Hospitals?

by Michael Wong

This is the question that I posed to lawyers, insurers, and healthcare professionals attending a major healthcare conference, the Crittenden Medical Conference.

According to the Institute of Medicine, each preventable adverse event costs about $8,750 — and this excludes potential litigation costs.

Can hospitals afford to give away money? So, why do preventable adverse events still occur in hospitals?

I was honored to be invited to speak at this conference. Held this April 16-17 in Scottsdale, Arizona, the conference featured healthcare experts who spoke on some of the most pressing matters facing the healthcare industry, including the implications of healthcare reform, rising malpractice claims and awards, and decreasing provider reimbursements.

Barbara Rebold (Director of Operations at ECRI Institute) and I were the only representatives for patient safety organizations at the conference. For those who don’t know ECRI, it is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care. ECRI has previously been referred to on this blog on technology hazards and how the FDA may have acted hastily earlier this year.

Barbara emphasized the need for the preservation of peer review and quality assurance, which provides critical information and data on medical events. In short, data provides solutions, as described in this slide:

The third member of our panel, Andrew Bolin (an attorney with Beytin, McLaughlin, McLaughlin, Bolin & Willers), spoke about the legal requirements and consequences of peer review and quality assurance.

In urging providers, insurers, and lawyers to not be scared of peer review and quality assurance, I spoke of how data produced by peer review and quality assurance can be used to help lower healthcare costs, while improving patient safety and outcomes.

Pointing to the tragedies of Amanda Abbiehl, Leah Coufal, Justin Micalizzi, and Louise Batz, I underscored the commonality of these unfortunate patient tragedies — healthy patients who were put on PCA without monitoring shared a common result — sadly, none of them came out of the hospital alive.

These patients demonstrate that respiratory depression can happen with any patient who is on PCA, regardless of how healthy they be or how low a “risk” they might seem to be. I presented this data showing the prevalence of incidents arising from the use of PCA pumps:

  • Pennsylvania Patient Safety Authority:
    • about 4,500 reports associated with PCA pumps
    • 6-yr period (June 2004 to May 2010)
  • Medmarx (national voluntary medication error-reporting database):
    • 9,571 (1%)  of 919,241 voluntary medication errors reported were associated with PCA (only 801 facilities reporting)
    • 5-yr period (July 1, 2000, to June 30, 2005)
  • Veterans Health Administration (root cause analyses since 1999):
    • 13% involved two types of pumps
    • about 50% general-purpose and 50% PCA (because there are 10 times more general pumps in use at VHA than PCA pumps, this means errors with PCA pumps are 10 times more likely than with general pumps)

I provided the solutions of the Veterans Affairs Administration. Bryanne Patail (biomedical engineer at the US Department of Veterans Affairs, National Center for Patient Safety). As he told me in our recent discussion:

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate, or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.

As Bryanne told me, this strong fix will reduce adverse events:

A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60% of adverse events related to PCA pumps.

Although a human life should never be measured in terms of dollars and cents, does capnography monitoring of PCA pumps produce a return on investment?

The best example of the long term benefits of PCA with capnography is St Joseph/Candler Hospitals (see pages 47-50) in Savannah, Georgia. Not only have they been event free for eight years since implementing the “strong fix” of using capnography and have averted almost 500 preventable adverse drug events, they calculated that they:

  • prevented estimated potential expenses of almost $4 million
  • 5 year ROI of $2.5 million

Next week, I will post my interview with Carolyn Williams from St. Joseph/Candler, which describes in detail the St Joseph/Candler story (click here to read that post). In the meantime, for a pdf of my conference presentation, please click here.

My presentation prompted attendees to discuss the issues raised in the following questions:

  • If any patient receiving narcotics can suffer respiratory depression, does a hospital knowingly jeopardize the safety of a patient using PCA if the hospital does not monitor with capnography?
  • Have Veterans Affairs Administration and St Francis/Candler Hospitals established a new legal standard of care that all patients using PCA must be monitored with capnography?
  • Are hospitals missing an opportunity to reduce adverse events and costs if they do not monitor patients using PCA with capnography?

What do you think?

4 thoughts on “Improving Patient Safety in Hospitals: Can Hospitals Afford to Give Away Money? So Why Do Preventable Adverse Events Still Occur in Hospitals?

  1. Dr. Emanuel Kanal and I looked at two years of MRI accident data from the FDA. Much to our horror, more than 92% of the reviewed accidents fell into only three categories of preventable errors! Our analysis suggested that there are thousands of these types of accidents every year, and yet these accidents that jeopardize the safety of patients *and* providers continue, and have grown year-over-year for most of the last decade at alarming rates.

    If there are existing best-practice standards that can reduce injury, improve efficiency, and save a facility money, why aren’t they put into practice? For relatively low-frequency events, there’s always the thought that ‘it won’t happen to me’, a condition made worse by the low reporting rates (thought to be due largely to embarrassment of reporting an error that a provider could have readily prevented).

    We hope that license authorities, accreditation organizations, and regulatory bodies help providers conform with best practices. Not only would it be good for patients, but these efforts would also reduce the alarming costs associated with accidents in what is a very expensive service to operate.

  2. Great points Toby.

    As an expert in Root Cause Analysis (RCA) who has investigated hundreds of undesirable outcomes across most every industry over the past 27 years, I have found the healthcare industry to be the most resistant to accept what ‘true’ RCA is all about. Much of this is NOT due to mal-intent by any stretch, but driven by regulations that 1) encourage reaction and 2) lack comprehensiveness and depth in order to be compliant.

    First of all RCA is ill-defined in the industry as a whole and people can find or create a definition that matches their need. Whatever they are doing to solve problems, they will call it RCA. This is a big part of the problem, lack of a universal standard for what RCA is, versus should be.

    There are over 6000 hospitals in the U.S. and most all are accredited. If all are accredited and meeting regulatory RCA minimum standards, why aren’t patient safety numbers improving (especially since the 1999 IOM report) nationally? It doesn’t make sense on the surface.

    Let’s get back to your question, “So Why Do Preventable Adverse Events Still Occur in Hospitals?”

    It has been my experience the primary goal of healthcare (in general) related to RCA, is to pass their regulatory audits to ensure they continue to receive their CMS funds. The problem here is there is no direct, bottom-line correlation to an improvement in patient safety. This demonstrates a direct disconnect between compliance and patient safety. RCA should be focused on patient safety metrics first and then compliance would be a by-product. I see it the other way around today.

    How can this happen with such well-intended people involved? RCA regulations need to be more comprehensive and prevent ‘shallow cause analysis’ from being compliant. Secondly, regulations should use risk assessment technologies to focus on preventing sentinel/never events instead of reacting to them.

    Part of the image problem with RCA is it is seen only as a reactive tool. Something really bad has to happen before a hospital will commission a full blown RCA. What if….we used RCA proactively? What if…we conducted more FMEA’s and applied RCA to the identified unacceptable risks? Why shouldn’t we first focus on reducing the risks instead of becoming better responders after-the-fact?

    Preventable adverse events are permitted because we don’t analyze them deep enough and uncover all the systemic root causes that impact decision making, and because we can get away with a shallow cause analysis to be compliant. Think about it, RCA is seen as another task on my already full plate. I did not go to school to learn how to be a professional RCA analyst, yet I am expected to be proficient at it in my job responsibilities. This is a paradox for sure.

    When we start measuring the effectiveness of our RCA efforts by direct improvements in patient safety we will start to make greater strides in protecting our patients and lowering our costs of care. How many hospitals measure the effectiveness of their RCA efforts by how may times they analyze the same event over and over again? RCA is about uncovering the truth and the sad fact is the truth is hard to accept. However, denying the truth only opens the door for a repeat of the undesirable outcome.

    We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again.

    Bob Latino
    CEO
    Reliability Center, Inc.
    http://www.reliability.com

  3. Two interesting comments posted on National Patient Safety Foundation in answer to question “Why do preventable adverse events still occur in hospitals?”:
    (1) Cost of Doing Business – “Presumably because the necessary costs for prevention procedures/systems will be more expensive than the costs of the few litigation cases in each hospital that go to trial.”
    (2) Lack of Training – “In part due to our lack of specialty training after graduation with performance as an end point vs. X number of weeks. Our students have limited experience due to too many schools of nursing who need clinical sites.”

  4. Pingback: A Promise to Amanda » Calling All Patient Safety Advocates: Make a #Promise Today

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