FDA and Joint Commission to Address Alarm Fatigue
The Joint Commission, a national organization that accredits hospitals, has announced that addressing alarm fatigue is one of its highest priorities this year. The Joint Commission is planning to meet with the Food and Drug Administration over the next few months to develop a strategy for effectively addressing alarm fatigue.
The announcement comes just months after a Boston Globe investigation revealed that over 200 alarm-related patient deaths occurred between 2005 and 2010. In many of these cases, medical personnel either didn’t notice the alarms or failed to react with the urgency required—both typical signs of alarm fatigue.
“There is uniform agreement that this is a major problem,” said Dr. Paul Schyve, a senior vice president at the Joint Commission, in a recent telephone interview. And that problem may be even worse than reported. The health care industry often fails to report these types of incidents, leading some researchers to believe the number of alarm-related deaths is much higher.
Having Too Many Alarms Reduces Usefulness
Schyve said the issue is much more complex now than it was just 10 years ago, because medical device manufacturers have “put a lot more alarms’’ on their devices. He cited devices in intensive care units as an example, explaining that these devices now sound alarms not only when a patient’s heart rate has gone above or below a predetermined level, but also whenever the patient’s heart rate appears to be headed in the wrong direction, no matter if it is a life-threatening situation or not.
Not only are there more alarms on devices than there were in the past, there are more devices with alarms in patients’ rooms than ever before. Studies show that the vast majority of alarms are false, triggered by something as insignificant as the patient turning in bed or coughing. “If you have that many alarms going off all the time, they lose their ability to work as an alarm,’’ Schyve said.
Health care professionals and device manufacturers all agree that alarm hazards, particularly alarm fatigue, need to be addressed. However, no panacea has yet been found. Some industry experts say that device manufacturers need to redesign their devices so that they produce fewer false alarms. Others say that hospitals should hire extra caregivers to improve alarm response statistics.
“Sooner or later, there is going to have to be a meeting with the users of alarms and people who put the alarms on their equipment,’’ Schyve said. “Neither side alone is going to be able to figure out how to address this problem.’’
Alarm Integration As a Possible Solution
Often hospitals will provide extra training for nurses to try to reduce alarm-related incidents but “telling nurses and doctors to be more careful and reeducating them isn’t the solution,’’ says Dr. Peter Pronovost, director of the Quality & Safety Research Group at Johns Hopkins Hospital in Baltimore.
“In the ICU there is somewhere between 50 and 100 electronic pieces of equipment, and each of them has alarms. Each individual device maker makes its alarms the most annoying. It’s an arms race of alarms. No one has worked on integrating them. The FDA could require that all these monitors link into a common platform,’’ Pronovost said.
In a recent statement to the Boston Globe, the FDA said it is collaborating with the Association for the Advancement of Medical Instrumentation, a nonprofit education organization run by the health care industry and the ECRI Institute, a nonprofit health care research organization “on raising the awareness of these issues and challenging the industry and the Joint Commission to work with us on a strategic approach moving forward.’’
HHS Announces $1 Billion Patient Safety Initiative
HHS has announced the launch of Partnership for Patients, a $1 billion collaborative initiative focused on improving patient safety by reducing preventable harm and improving care transitions.
More than 500 hospitals have committed to participate in the partnership, as well as numerous clinicians, employers, and patient-safety advocates, HHS said. Government estimates claim the program could help save 60,000 lives over the next three years and save up to $50 billion in Medicare costs during the next decade.
Initial funding of $500 million was made available recently as part of the Community-based Care Transitions Program, a provision of the healthcare reform law focused on improving readmission rates and transitions of care. According to HHS, the remaining sum of $500 million will be available through the CMS Innovation Center, supporting local projects that reduce hospital-acquired conditions (HACs).
“With new tools provided by the Affordable Care Act, we can aggressively implement programs that will help hospitals reduce preventable errors,” said CMS Administrator Dr. Donald Berwick, in the press release. “We will provide hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals and hospitals to support their efforts to reduce harm.”
Pushing for Widespread Involvement
Discussing how this initiative differs from previous ones focused on patient safety, Sister Carol Keehan, president and CEO of the Catholic Health Association, said HHS “is going after everyone,” rather than singling out a particular health system.
“The second thing that stands out is there are going to be consistent measurements and transparency about those measurements,” Keehan said. “And they’re going to share best practices—share tools—because people have done some really wonderful work around the country on various things.” She added that stakeholders haven’t spent sufficient time documenting the methods and tools they’ve used to make changes and improvements.
When asked about the $500 million from the CMS Innovation Center to test different models of care, the center’s director, Dr. Richard Gilfillan, said official announcements regarding specific contracts will be made in the upcoming months.
Gilfillan said that demonstration projects will support a variety of network types and other activities to promote this effort among participating hospitals. He was optimistic, saying, “We’re going to find our way to engagement with every hospital in America.”
HHS said the partnership’s two highest goals are reducing the number of preventable HACs by 40% and reducing preventable complications occurring during care transitions by 20% by the end of 2013.
Dalcon Featured in Patient Safety and Quality Healthcare Magazine
Dalcon was featured in the March/April issue of Patient Safety and Quality Healthcare, a clinical leader magazine.
The featured topic of the March/April issue was Alarm Notification systems, which is a perfect fit for the Dalcon Alert Patient Care Notification System. The cover article discussed the strengths of alarm notification systems in increasing patient safety and the quality of patient care, as well as overcoming the challenges presented by alarm fatigue via alarm management.
Read more at Patient Safety and Quality Healthcare’s website:
PSQH: Alarm Management Showcase
Adverse Events in Hospitals are Largely Undetected
Adverse events errors that are serious enough to harm patients occur in hospitals at least ten times more frequently than previously recorded, according to a report recently released by the journal Health Affairs.
Researchers visited three large hospitals in the U.S., all of which have well-established patient safety systems. The research team then tested a newer, more expensive, and more thorough system from the Institute for Healthcare Improvement called the “Global Trigger Tool (GTT),” against two common but less sensitive systems: the voluntary reporting method and the Agency for Healthcare Research and Quality’s Patient Safety Indicator.
Currently, most hospitals use these two adverse event detection systems:
- The voluntary system used by nearly all hospitals. When a nurse or other provider notices a problem and notifies the appropriate person, an investigation is launched to determine whether the incident should be reported to higher authorities.
- The Agency for Healthcare Research and Quality’s Patient Safety Indicators review, which encompasses more than the voluntary reporting system but less than the GTT. The AHRQ PSI only searches for certain codes in medical records.
With the GTT, hospital employees closely review closed charts for codes, summaries, medications problems, lab results, operation reports, and nursing notes to detect any signs that a mistake may have occurred.
“A trigger could be a notation indicating, for example, a medication stop order, an abnormal lab result, or use of an antidote medication,” the authors wrote. An investigation would then ensue.
Commonly Used Systems are Inefficient
In the study, the GTT detected 354 adverse events, compared to the AHRQ system which detected 35 events and the voluntary method which found detected four. All detected errors were serious enough to require intervention, says lead author of the report, David Classen, associate professor of medicine at the University of Utah in Salt Lake City.
Classen says, “The point of all this is that we need to develop better tools to measure the safety of care that we deliver.” He adds that many hospitals are just not as aware of patient safety pitfalls in existing systems as they need to be. “It’s a learning curve that a lot of places have to go through,” he says.
The GTT recorded a wide variety of events ranging from extremely serious events to events that could be resolved quickly. These events included infections, venous thromboembolisms, pressure ulcers, device failures, and falls. Among less serious events, medication was required to fix a problem provoked by the incident; however, among the most serious events, a patient actually died because of the adverse event.
The GTT did not distinguish between preventable and unavoidable errors in this study, but Classen says that other studies suggest that 40-60% of the errors captured by patient safety system tools are considered preventable.
According to the study, for extreme events, the GTT and the AHRQ systems each detected four events that the voluntary system missed entirely. For less serious events, the GTT caught 204 errors, AHRQ captured 23, and the hospital voluntary reporting system caught none.
GTT’s Use Limited By Cost and Time
Classen says that only 2% of the country’s hospitals currently use the GTT. That’s mostly because the method is expensive and time consuming, especially if hospitals lack a well-developed electronic medical record system.
He explains that the AHRQ method often fails because hospital staff who are tasked with inserting codes “are not necessarily highly trained clinical individuals.” This results in poor documentation of the adverse event, effectively preventing the AHRQ system from find it. “If it’s not obvious and apparent, they won’t see it and even if it is, they may miss it,” he says.
Classen offers the example, “If a patient has a side effect from a drug that requires an antidote to be ordered, the AHRQ system would miss it, but under the GTT, our reviewers would have picked it up.”
The study’s results don’t surprise him. He says, “I do work in hospitals all the time, and I see the use of these other approaches – which are much cheaper and easier to do – often seem to miss these problems.”
New Consumer Reports Poll Finds High Levels of Public Concern about Patient Safety
A new poll from the Consumer Reports National Research Center reveals high levels of public concern about hospital-acquired infections and other medical errors as well as support for making information about hospitals’ rankings in patient safety more easily accessible to the public.
The Consumer Reports National Research Center conducted the survey by phone, using a nationally representative probability sample of houses with phones. Interviewing occurred January 28-31, 2011. In total, 1,026 interviews were completed by adult respondents aged 18+. The poll’s results grant the healthcare community valuable insight into the public’s opinion on how patients are treated:
- 6 out of 10 respondents said that it was common for patients to be harmed by a medical errors, and nearly half (48 percent) said that it is very or somewhat common for patients to be seriously harmed during their stay in the hospital.
- Interestingly, 78 percent of those polled thought that hospitals were effective at medical error prevention, yet only 21 percent thought error prevention was very effective.
- Only 17 percent thought doctors or other hospital staff would inform them of a medical error occuring during treatment, even though 97 percent always wanted to be informed. 47 percent said that they rarely or never anticipated being fully informed when medical errors occurred.
- Only 1 out of 4 respondents said they would know where to file a complaint about a medical error.
According to the poll, 77 percent of those who responded were highly or moderately concerned that they or their loved ones might be harmed by a hospital infection during their stay. Similarly, 71 percent were highly or moderately concerned about being harmed by medication errors, and 65 percent were highly or moderately concerned about being harmed by surgical errors.
Nearly all respondents (96 percent) felt that hospitals should be required to report medical errors to state health departments, and 82 percent wanted medical error records for individual hospitals to be publicly available.
Lisa McGiffert, director of Consumers Union’s Safe Patient Project, says “It’s not surprising to find such high levels of public concern about hospital-acquired infections and medical errors given that one in four patients is harmed during treatment. Our poll found that the vast majority of the public wants to know more about their local hospital’s record for keeping patients safe and supports efforts to require disclosure of this critical patient safety information.”
Increased Frequency of Medical Errors
Recent studies have found that hospital infections and other medical errors are even more common than previously thought. A study from November 2010 by the U.S. Department of Health and Human Services’ Office of the Inspector General found that 1 in 7 Medicare patients, or 13.5 percent, experienced serious or long-term medical harm (including infections) or death while they underwent treatment in the hospital. An additional 13 percent experienced short-term harm. Researchers now estimate that hospital infections and medical errors involving Medicare patients contribute to approximately 180,000 deaths and $4.4 billion in additional hospital care costs each year.
Similarly, the New England Journal of Medicine published its November 2010 study which found that one in four patients are harmed by the care they receive. This harm includes hospital acquired infections, surgical errors, medication mistakes, bed sores, patient falls, and diagnostic mistakes. The study found no significant improvement in patient safety during its 6-year timeframe.
Improvements Needed in Error Reporting
“Most Americans have no way of finding out whether their hospital does a good job or not at preventing medical errors,” says McGiffert. “We need to hold hospitals accountable for the harm done to millions of patients each year through mandatory, public reporting of medical errors and of health care-acquired infections.”
26 states in the U.S. require hospitals to report certain medical errors; however, only 10 of those states require public reporting of information from individual hospitals. The remaining 16 only publicly report summarized statewide data.
Tips on Avoiding Common Nursing Errors
Of all healthcare professionals, nurses play the greatest role in coordinating care. They are tasked with providing patient care, communicating with physicians, and administering medication. Unfortunately, this strenuous workload sometimes results in nursing errors. Some of the most common errors are also some of the most preventable. In regards to patient safety, these preventable errors include patient falls, infections, and medication administration. Hospitals working to improve patient safety have implemented some interesting techniques that have helped nurses address these three preventable events.
Patient Falls
Patient falls often occur because patients attempt tasks that they believe do not require nurse assistance, such as going to the bathroom or moving to pick up something out of reach. To help prevent unattended movements in the patient’s room, several practices have been introduced in hospitals. Hourly rounding has become a near industry-wide practice that has proven to help reduce patient falls and improve patient satisfaction.
A more recent falls prevention technique involves the use of communications technology to alert nurses via text message to their wireless phones. In such a setup, bed exit pads or bed fall pads are connected to the alarm system in the patient’s room, which creates and sends alerts to the nurse’s phone when the patient triggers an alarm. This allows nurses to stay mobile while still receiving patient updates in real time. In some hospitals, these systems are modified to allow patients to call their nurses’ phones directly if they need assistance.
Preventing Infections
As a basic rule of thumb, hand hygiene is incredibly important for controlling and preventing infections. Additionally, nurses must disinfect equipment and other items in the environment, and they must wear protective equipment.
Clinicians have historically considered infection an accepted risk, but modern medical care is now evolving so that nurses know they can prevent patients’ infections. The Institute for Healthcare Improvement at Johns Hopkins University packages collections of best-practice interventions into checklists that have been shown to reduce infection rates. For example, to prevent central line bloodstream infections, nurses should use appropriate hand hygiene, use chlorhexidine for skin preparation, ensure full barrier precautions are taken, and maintain a sterile field during insertion, and ask if the line can be removed each day. To prevent ventilator-associated pneumonia, nurses need to keep the head of the bed elevated and perform daily oral care with chlorexidine.
While such checklists can prove effective, clinicians may achieve even greater success when combining the checklists with a comprehensive unit-based safety program (CUSP), which is a team-based approach to learning more about safety, identifying unit hazards and addressing the associated risks. This open style of learning encourages communication between physicians, nurses, and other unit staff, which promotes positive interaction and can actually increase unit efficiency.
Preventing Medication Errors in the Hospital
Interruptions are a primary cause of medication errors. Nurses deal with multiple questions and other interruptions from coworkers and physicians while collecting, measuring, and administering medications. These distractions create an unnecessary risk for patients receiving medication. Understanding this risk, some hospitals are adopting a standardized medication administration process, which includes a quiet zone for nurses preparing medication, and having those nurses wear a sash to signal to others not to disturb them.
Vague or overly similar labeling can also contribute to errors. Nurses must take extra precautions when administering medications that come in easily confused bottles. Bar-coding medication and confirming the correct dose, route, time and rate for an administered drug can help prevent mistakes.
Healthleader’s Media 2011 Industry Survey Nurse Leader Overview
Healthleader’s Media has released its 2011 Industry Survey. Broken down into various sections, the survey includes reports from senior healthcare leaders, community leaders, finance leaders, marketing leaders, technology leaders, quality leaders, physician leaders, health plan leaders, and nurse leaders.
The nurse leaders survey is of particular interest because it reveals the opinions of workers at the point of care. The survey shows that nurse leaders are focusing more on improving patient satisfaction and patient safety than ever before. For example, in the survey nurse leaders ranked their top three priorities as:
- Patient experience/patient satisfaction
- Quality/patient safety
- Cost reduction
Furthermore, 75% of nurse leaders say that low nurse-to-patient ratios are effective or very effective in improving the quality of care given to patients. Additionally, when asked how patient experience and overall patient-centered care will impact their organizations over the next 3 years, 88% of nurse leaders said that the impact would be positive or strongly positive.
This focus on improved patient care reflects the changes put in place by 2010’s healthcare reform law. As Eileen L. Dohmann, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA, points out, “Issues such as the drive for accountable care organizations are important issues, but the more burning issues are patient satisfaction and quality, because we know that that’s how we’re going to start getting paid next year.”
Indeed, healthcare reform places a great amount of financial concern on hospitals, with 64% of those surveyed claiming that healthcare reform has weakened their organization’s financial position and 57% claiming that it has weakened their organization’s morale.
However, this added stress doesn’t imply that nurse leaders have negative feelings about healthcare reform. In fact, only 19% on those surveyed had a negative assessment of the Patient Protection Act.
Regarding nurses’ feelings toward their job, the results were typically positive, with 69% saying they feel like their organization is on the right track for improving healthcare. Also, 78% of both nurses and physicians felt like nurse-physician relations had improved over the past 3 years. 60% of those surveyed stated that workplace hostility had been effectively addressed by their organization, and 74% said that physician disrespect of nurses was uncommon. Overall, only 3% of those surveyed felt dissatisfied with their jobs.
See the full Healthleader’s Media 2011 Industry survey here.
Dalcon at AONE Conference 2011
Dalcon will be exhibiting at the 2011 American Organization of Nurse Executives (AONE) annual meeting and exposition April 13-16, in booth 1036. This will be the third year that Dalcon has exhibited its solutions at AONE, and the second year where the focus will be on Dalcon’s flagship product, Dalcon Alert.
Dalcon Alert is Dalcon’s Patient Care Notification and Alarm Management solution that allows clinicians to receive notifications on wireless phones. Notifications can be either patient care related, such as bed turn reminders for pressure ulcer prevention, or alarm related, such as a bed fall alarm notification for use with a fall prevention policy.
Attendees who visit the Dalcon booth (Booth 1036) can register with Dalcon to win 2 free round trip tickets to any Southwest Airlines destination.
For more information about Dalcon at AONE 2011, or Dalcon Alert, call 877-WE-UNIFY (938-6439) or click here to send us a message.
CMS Proposing to Prohibit Medicaid Payments for “Provider Preventable Conditions”
The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule, published in the Federal Register on February 17, 2011, setting forth policies for prohibiting Medicaid payments to states for expenses related to “Provider-Preventable Conditions” (PPCs), thus broadening the range of Medicaid nonpayment policies.
The proposed rule actually requires Medicaid nonpayment policies to adopt, at a minimum, Medicare’s current list of Hospital-Acquired Condition (HAC) guidelines, which include hospital acquired fall injuries and pressure ulcers, but also authorizes states to recognize unique PPCs under their applicable state plans, pending CMS approval through the state plan approval process. PPC is an umbrella term CMS created to signify conditions (inpatient and otherwise) states will not pay for.
The Reason for the Provider Preventable Conditions Rule
Prior to the proposed rule, since the Medicare HAC rule did not require state Medicaid programs to implement nonpayment policies for HACs, CMS had contacted Medicaid directors in 2008, encouraging them to modify nonpayment policies to reflect the Medicare HAC rule; however, subsequent review data showed great variation between nonpayment policies, with at least half of the policies exceeding Medicare’s HAC requirements. For this reason, the proposed rule seeks to provide a level of uniformity among Medicaid nonpayment policies.
The Rule’s HAC Reporting Guidelines
Under the proposed rule, states would also be able to identify the specific portion of a provider’s payment that arose from HAC treatment. CMS has stated that providers have no incentive to report conditions or events for nonpayment without clear and explicit reporting requirements. Therefore, the proposed rule would require provider self-reporting measures as well as systems within Medicaid programs that identify claims for nonpayment. CMS plans to utilize existing Medicaid claim systems as the platform for collecting and reporting the required data.
The rule was mandated by section 2702 of the Patient Protection and Affordable Care Act of 2010 (PPACA) and will go into effect on July 1, 2011. CMS is accepting public comments on the rule until March 18, 2011.
Click here to read the proposed ruling.
12 Ways to Reduce Hospital Readmissions (Part 2 of 2)
This post continues an article on methods of lowering patient readmission rates in hospitals. Click here for the first part of this article.
Stephen F. Jencks, M.D., M.P.H., and Amy Boutwell, M.D., internist at Newton-Wellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement are experts on the subject of patient readmissions. They have developed a list of 12 preventative strategies suggested to help hospitals reduce readmission rates. Strategies 1-6 were discussed in the first part of this article, here are the remaining 7-12 methods.
7. Understand What’s Happening After Discharge
Kaiser Permanente now uses video cameras to monitor home settings as well as the entire care process to determine what happens to the patient after discharge to provoke readmission. The team also video documents the care team (including the pharmacist, home care providers, nurses, and physicians) about the care provided to the patient to uncover flaws in the system that contributed to the patient’s readmission.
Kaiser officials are pleased with the results of the project thus far, citing a readmission rate reduction from 15.7% to 9% at Kaiser’s South Bay Medical Center.
8. Provide Preschedulable Home Care
Case management, housekeeping services, transportation to and from pharmacies and physicians’ offices can all be scheduled in advance. Boutwell says that at Piedmont Hospital in Atlanta, patients who undergo elective knee surgery receive coupons and prescheduling “so that by the time you get out of the hospital, it’s waiting there for you,” She adds that although this kind of a prearrangement for post-transition care is mainly being tried with elective patients, it is “spreading like wildfire” among hospitals.
9. Consider Physician Medication Reconciliation
A recent essay in the New England Journal of Medicine by Yuting Zhang, from the University of Pittsburgh, noted the wide variation among physicians’ prescribing practices with medications that should typically be avoided in patients older than 65. She also noted the variation in prescribing practices for drugs that carry a high risk for negative drug-disease interaction.
Jencks says that Zhang is “pointing us to a rather important gap in the most common thinking about transitions—that we are to make sure that patients are able to get and take medications, get recommended follow-up, and generally do as they are told. But we know that medication plans can be in life-threatening error, that physicians often recommend a time-to-follow-up that is too long, that discharge plans are often written in ignorance of the patient’s pre-admission history and experience. In general, we need to be much more critical of the plans patients get.”
10. Prove that the Patients Understand
Patients need to be engaged in “teach back,” in which they (or their caregivers) repeat the instructions they’ve been given. Jencks tells caregivers that they need to understand that patients are often heavily medicated, stressed, tired, or confused. Their state of illness often impairs their ability to fully comprehend and remember what they are being told.
11. Focus on Highest-risk Patients
Hospitals need to examine their readmission rates and see which patients, with which conditions, have the most readmissions. Limited resources should be pushed toward these select groups of patients in a more focused way to see if the expanded effort improves the rates.
For example, Jencks has documented depending upon the disease or condition, and depending upon the part of the country, readmission rates can be even higher than the national average of 21%. For example, the readmission rate for heart failure patients is 27%; for those with psychoses, 24.6%; chronic obstructive pulmonary disease, 22.6%. Patients with pneumonia are readmitted at a rate of 21%, and those with gastrointestinal problems are readmitted at 19.2%.
12. Listen to the Patient
Emergency rooms, hospice, and home health providers need to be involved in the effort as well, in order to ensure that patients only come to the emergency room for true emergent care issues. If patients and their families are provided with informed options, opportunities for advance directives, and counseling in the emergency room, unnecessary admissions can be reduced.
Jencks says, “There really needs to be a care plan that reflects the patient’s wishes. This is quite different from either a medical power of attorney or what is often called a living will because it lays out the goals of treatment.”
Jencks continues, “This kind of plan has little relevance to persons without substantial chronic conditions, but it is totally relevant to a patient with one or more chronic conditions that have required hospitalization. With such a plan, one can often avoid readmissions that really do not serve the patient’s needs or values. What is, after all, worse than a readmission? Readmission of a patient who does not want to be readmitted.”
