NOVEMBER 20, 2012

Welcome to the Patient Safety Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by The Quality Colloquium

Safety Program Reduces Patient Errors at Wyoming Medical Center
Wyoming Medical Center (WMC) launched a patient safety program three years ago that has led to a 70% drop in errors that cause serious harm to patients. "It is worth every penny that we have spent to get our staff and our culture...aligned on safety," said Vicki Diamond, WMC's CEO. "They are all looking at how we take better care or our patients." She was inspired by a visit to NASA's Kennedy Space Center. That visit led to several changes at the Hospital, including daily safety briefings and badges that help nurses avoid distractions while handling medications. WMC's program was described during the Wyoming Patient Safety Summit in Casper, a first-time event organized by the Wyoming Medical Society and the Wyoming Hospital Association. (trib.com, November 3, 2012)

Baylor, UT Health Researchers Suggest Framework to Make Electronic Patient Records Safe
Researchers from Baylor College of Medicine and the University of Texas Health Science Center at Houston have devised a framework to improve patient safety through use of the electronic health record (EHR). In a New England Journal of Medicine article describing their recommendations the authors suggest those implementing an EHR should follow three phases:

  • Phase 1: Ensure the technology in question is safe to use. Make sure it's fast enough and that there is data backup in case the main database is corrupted or loses information.
  • Phase 2: Providers should make sure the records are used appropriately. Mixing paper and electronic records can result in wasted time and lost or confusing records. Authors of the study recommend using electronic records completely, not partially.
  • Phase 3: Organization should improve accuracy of measurements recorded. For example, systems might be used to alert someone if lab results come back abnormal or if old labs haven't been reviewed yet.
The authors, Hardeep Singh, MD, professor at Baylor College of Medicine, and Dean Sittig, PhD, professor at UT Health, are developing methods for providers to ensure accuracy and safety while using electronic records. Dr. Singh added, "We are also working on a self assessment checklist providers can use to ensure patient safety in the context of electronic health record-based health care system," (Houston Business Journal, November 12, 2012)

Aligning EHR Patient Safety with Meaningful Use
A New England Journal of Medicine article suggests that policies surrounding the implementation of the electronic health record (EHR) and meaningful use need to highlight the importance of patient safety. According to the authors, "[A]t a time when institutions are focused heavily on achieving 'meaningful use' requirements...clearer guidance must be provided so that these institutions can align activities related to patient safety with the activities required to support a safe EHR-enabled healthcare system. A set of EHR-specific safety goals, modeled after the Joint Commission's National Patient Safety Goals, may provide organizations with areas of focus for sustained improvements in organizational infrastructure, processes, and culture as they adapt to new technology." The authors propose a three-phase framework for the development of EHR-specific patient-safety goals (e-PSGs):
  • Phase 1: Address Safety Concerns Unique to EHR Technology
  • Phase 2: Mitigate Safety Concerns Arising from Failure to Use EHRs Appropriately
  • Phase 3: Use EHRs to Monitor and Improve Patient Safety

To view this image, go to the article and click on the imbedded image for Table 1.

The authors conclude that, "Creating unique EHR-related national patient-safety goals will provide new momentum for patient-safety initiatives in an EHR-enabled health system." (Government Health IT, November 13, 2012)

Medical Errors, Adverse Events, and Patient Safety
George Lundberg, MD. Editor-at-Large of MedPage Today, offers his perspective on ther fundamental truths of the patient safety movement. (MedPage Today, November 5, 2012)

Doctors Debate Value of 'Fringe' Heart Treatment
The results of 10-year , $30 million dollar tax-payer-funded study of chelation were called inconclusive at this month's American Heart Association conference in Los Angeles. The study tested chelation (pronounced "kee-LAY'shun") which involves the periodic intravenous infusions that proponents say may help remove calcium from hardened arteries around the heart. Chelation has long been used to treat lead poisoning but its safety and value for heart disease are unproven. More than 100,000 Americans use the treatment at a cost of up to $150 per treatment which are done weekly for 30 weeks and then lest frequently. While there was some benefit noted in the control group (researchers said that a chelation mixture they tested in a study of 1,708 heart attack survivors led to fewer complications - repeat heart attacks, strokes, deaths, hospitalization for chest pain or need for an artery-opening procedure), 17 percent of participants dropped out before the study ended, and only 65 percent had all 40 infusions they were supposed to get. Further, the results of the study have neither been published in a medical journal nor vetted by independent scientists. Dr. Clyde Yancy, MD, a Northwestern University cardiologist and a former Heart Association president, said, "I've never seen a study in which one in five people withdrew consent." (Fox News, November 5, 2012)

Texas' Oversight of Compounded Drugs for Patient Safety Reduced
Since 2010, the number of individual pharmacies providing compounded drugs (prescription medications mixed and prepared by individual pharmacies) subjected to tests has dropped from 65 to 21. Budget cuts have been cited as the reason for the reduction. State Sen. Leticia Van de Putte, a licensed pharmacist who sponsored the bill authorizing the testing program, said "Testing fewer than two dozen pharmacies is 'absolutely not' sufficient to protect patients. You hope to God nothing goes wrong." Paul Holder, the pharmacy board's assistant director of enforcement, said errors resulting from compounding are "extremely uncommon." While state's performing such tests are uncommon, it is noted that drugs mixed by a Dallas pharmacy a year before the testing program was implemented were linked to three deaths -- two in Oregon and one in Washington. The pharmacy, while not admitting guilt, agreed to pay a $125,000 fine and install better quality control procedures to settle with the board. (YourHoustonNews.com, November 5, 2012)

In Hurricane's Wake, Decisions Not to Evacuate Hospitals Raise Questions
The experiences from Hurricane Sandy are raising policy questions around both preparedness for such events and the decision to evacuate patient care facilities or not. This commentary by Sheri Fink, a reporter experienced in covering disaster responses, examines the experience and response of several hospitals and reports her conversations and observations recorded during the storm. While no conclusions were reached, the article relates important events that provide valuable insights for those responsible for disaster preparedness. A related ProPublica story entitled "Why Do Hospital Generators Keep Failing?" is also an important report. (ProPublica, November 1, 2012)

Going Virtual to Improve Patient Safety
The Food and Drug Administration (FDA) has created a family of "virtual patients" to improve the safety of devices and drugs before they are released to the public. These virtual patients were created using computer-aided design. They are high-resolution, magnetic-resonance images of healthy volunteers, complete with organs, bones and other tissue. Michelle McMurry-Heath, associate director for science in FDA's Center for Devices and Radiological Health, said, "These models will eventually play an important role in replacing, in some instances, the need for clinical trials to prove that a device fails or succeeds...without necessarily subjecting live patients to it." (iHealthBeat, October 29, 2012)

Now Wash Your Hands

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Physician Training and the Culture of Quality

David Nash, MD, MBA, FACP
Thomas Jefferson University, Philadelphia, PA