Weekly Must Reads in Patient Safety (May 29, 2015)

This week’s must reads demonstrate that improving patient safety and health outcomes can be accomplished.

As a recent article by Healthcare Financial Management Association (HFMA), “Patient Harm: Attaining & Sustaining Dramatic Improvements”, says, “prevention-oriented leaders are scrapping outdated ideas and finding new approaches and technologies that are making a big difference.”

Hospitals Leading by Example

Hospitals making patient safety “pay off” are cited in the HFMA article:

Eliminating Pressure Ulcers

  • One study found that 4.5percent of newly admitted Medicare patients developed a pressure ulcer while hospitalized.
  • Chris Tarver, RN (nursing director of medical/surgical services, El Camino Hospital) says that they have achieved zero reportable pressure ulcers by implementing a range of interventions, like using silicone dressings and a new technology that helps ensure patients get turned on the appropriate schedule, which helps prevent pressure ulcers from forming.
El Camino Hospital eliminates pressure ulcers #ptsafety Click To Tweet

Preventing Falls

  • According to CMS data, In 2012, 11.3 percent of nursing home residents fell, with 5.3 percent suffering an injury.
  • By implementing simple fixes – eliminating fall alarms and spreading the responsibility – Jean Jorlett (quality assurance and fall risk coordinator, Minnesota Masonic Home) says the 214-bed facility currently averages five falls per 1,000 resident days, down from seven in late 2008.
Minnesota Masonic Home prevents falls #ptsafety Click To Tweet

Reducing Hospital-Acquired Infections

  • Although hand hygiene has reduced healthcare-acquired infections, the rates of two dangerous infections—Clostridium difficile (C. diff) and methicillin-resistant Staphylococcus aureus (MRSA)—did not decrease.
  • Anne Arundel Medical Center is using probiotics and UV-emitting robots to significantly reduce C. diff. “The use of probiotics has generated a measurable cost savings of $225,000 per year,” says Mary R. Clance, MD, MPH (hospital epidemiologist and president of the medical staff). ”Prevention of only six cases of hospital-acquired C. diff covers the cost of the probiotic program.”
  • Anna Noonan, RN (vice president, UVMC’s Jeffords Institute for Quality, credits executive leadership support for a culture of safety behind UVMC’s success at dramatically reducing infection rates and sustaining them for years.
  • Among its accomplishments:
  • No surgical site infections in knee replacements in the past four years
  • A three-year run of zero CLABSIs in the neonatal intensive care unit (NICU) and near-zero rates in other ICUs
  • Only 0.8 bloodstream infections associated with dialysis access per 100 patient months in its six outpatient dialysis clinics, down from 4.8 infections per 100 patient months in 2008
Anne Arundel Medical Center reduces hospital-acquired infections #ptsafety Click To Tweet UVMC's Jeffords Institute for Quality reduces hospital-acquired infections #ptsafety Click To Tweet

Mining Patients’ Wisdom for Safer Care

Can clinicians learn from their patients?

Insights from the Armstrong Institute confirms that mining patients’ wisdom can indeed lead to safer and better care. The following example of a COPD patient is used:

Consider, for a moment, that you are a new physician. A patient, who is a lifelong smoker, comes to your clinic complaining of shortness of breath, and after conducting several tests you diagnose him with chronic obstructive pulmonary disease (COPD). Relying on your training, you prescribe medications, arrange for follow-up visits and describe activities that can help him better manage his breathing problem. You understand that even light activities — taking a shower, making breakfast, taking the dogs outside — can be challenging, making it difficult for him to breathe. These episodes can lead to great anxiety and possibly an ambulance ride to the hospital, with all its risks, stress and costs.

Despite all your efforts, the patient ends up in the emergency department two weeks later. Could you have prevented it?

Perhaps he had been overwhelmed by his new diagnosis and had trouble following medication instructions. He may have had difficulty taking his inhaler medicine properly, and the drugs never made it to his lungs. Maybe he did not have transportation to his follow-up visit and so did not receive the necessary medical care. Maybe he’s struggling to stop smoking and has not found a program to support him in doing so.

Such scenarios, presented by patients with a recent COPD diagnosis, are real examples of what you learn when you engage patients in their care. At the Armstrong Institute, one of our research teams is partnering with COPD patients and their loved ones to design better ways to treat those who have the disease, help them manage their symptoms at home and avoid rehospitalizations.

Armstrong Institute: mining patients’ wisdom leads to safer & better care #ptsafety Click To Tweet

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