by Michael Wong
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
More than 10 years ago, the Institute of Medicine in its landmark report, “To Err is Human” pointed out that at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented. IOM therefore called for the building of a safer healthcare delivery system.
In 2009, ten years after the original IOM report, Consumers Union, the non-profit publisher of Consumer Reports, concluded in its report “To Err is Human – To Delay is Deadly”:
“Despite a decade of work, we have no reliable evidence that we are better off today. More than 100,000 patients still needlessly die every year in U.S hospitals and health-care settings …”
Implementing change to decrease adverse events and to increase patient safety can be difficult for hospitals and healthcare facilities to implement. But, improvements are possible. Here are five tips to get you started.
1. Focus on what is right for the patient.
This leads to better patient care and outcomes and, often, lower costs.
For example, at Riley Hospital for Children in Indiana, Courtney Rowan, MD, a pediatric critical care fellow, and her colleagues looked at how to decrease the number of blood gas measurements required from patients. Their study found that, after continuously monitoring with capnography all mechanically ventilated patients in pediatric ICU, they were able to save almost $1 million over a 6-month period.
As Dr. Rowan explains, “Every time we draw blood to measure blood gases, we risk putting an infection in the central line. They can be expensive to treat, and add time to the patient’s hospital stay.”
Concludes Dr. Rowan:
“The money you save is a nice bonus, but we use capnography mainly because it’s the right thing to do for patients.”
2. Don’t be mired in the way things “have always been done.” Let technology help you in caring for patients.
For example, Anne Miller, RN, an assistant professor at Center for Research and Innovation in Systems Safety at Vanderbilt University Medical Center (Nashville, Tennessee) and her colleagues looked at continuous patient monitoring in acute post-surgical units. As Ms. Miller observes:
“One of the things we became very aware of was that, in most post-surgical units, monitoring hasn’t really changed since the 1970-80’s. A nurse still typically checks on a patient 15-30 minutes immediately post-op, and then again about 2-4 hours after and then 8 hours throughout the day. This involves checking the patient’s heart rate, blood pressure, temperature and respiratory rate.
At the same time, our patients have changed: They are older on average, have more complex co-morbidities and undergo more complex procedures that previously.
The problem is that changes in patients’ conditions are invisible to nurses still using last century methods and measures. Without oximetry, you can’t easily ‘see’ patients with sleep apnea. Without capnography, you may not be alerted to a patient beginning to experience respiratory depression.”
The use of technologies, such as oximetry and capnography, allows patients to be more accurately monitored.
3. Realize that any new technology or technique may have unintended changes to daily routine.
But remember that this is better than having an adverse event.
Ms. Miller describes some unintended consequences related to implementing new technology:
“Implementing new technology inevitably changes the way people work (after all that’s what it’s intended to do) but can introduce new and unanticipated problems. For example, in general surgical units, one RN may have 4 to 6 patients all with different needs. One of the consequences of continuous monitoring is frequent alarms. Attending to one alarm means that an RN has to stop attending to one patient in order to attend to another. This causes disruptions and discontinuities in care. In this case while solving one problem the monitor has introduced a raft of other problems. So we need to think about this before the technology is implemented. “
However, as Tammy Haslar, RN, an oncology advanced practice nurse at St Francis Hospital (Indianapolis, Indiana), says, caregivers need to make the necessary adjustments and keep in mind the adjustment is preferable to an adverse event.
A few years ago, St Francis was in the process of replacing its IV pumps with “smart” IV PCA pumps. Research into best practice literature and guidelines led them to purchase “smart” pumps with integrated capnography, explained Ms. Haslar. She added:
“Although monitoring all patients using PCA can be seen as ‘extra-work,’ our facility decided that we could not make the ethical decision of saying which patients should or should not be monitored, and our facility made the decision that all patients with PCA would be monitored with capnography.”
4. Ensure changes help caregivers better manage their own daily work days.
At St. Francis, the hospital sought to make the implementation of “smart” pumps into nurses’ workflow as seamless as possible.
As Ms. Haslar explains further about the PCA monitoring initiative:
“Capnography monitoring for PCA is a nursing intervention and does not require a physician order. We have an educational brochure which is dispensed with each PCA initiation along with the PCA unit and capnography monitor and nasal sampling cannula to provide education for the patient and the families about PCA safety and capnography monitoring.”
5. Get closer to the patient.
Doing so provides answers and this affects the practice habits of healthcare professionals. As Ms. Miller observes:
“In my opinion, the solutions lie closer to the bedside. For example, real-time monitoring has benefits beyond simple patient monitoring. For the nurses in our study, the major revelation was that their patients had changed and that they needed to be doing things differently. Continuous electronic monitoring gave them feedback about the effectiveness of their actions on these patients.
We need to better understand nurses work – what do nurses do, how do they work, and what pressures lead them to act in certain ways; what problems in their work should the technology solve for nurses (and patients); what are nurses’ priorities and how do they make trade-offs when priorities compete.”
These are just five tips, and there are undoubtedly many more. However, as Dr. Rowan reminds us, it all starts with what is best for the patient.