Improving Patient Safety in Hospitals; a Resource List

The Agency for Health and Quality Research (AHRQ) has developed a resource list to provide easy access to patient safety resources.    This web document provides organized access to the many patient safety resources developed by AHRQ.

After alphabetically listing some general resources including the major patient safety organizations,  this document presents resources organized by the 12 dimensions of the AHRQ Hospital Survey on Patient Safety Culture.  Many of the resources are tool kits that help hospitals implement changes.

Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/patientsafetyculture/hospimpptsaf.htm

 

Making Inpatient Medication Reconciliating Patient Centered, Clinically Relevant and Implementable

Medication reconciliation has been a National Patient Safety Goal since 2005 but “the meaningful and systematic implementation of medication reconciliation … proved to be extraordinarily difficult for healthcare institutions around the country.”

The Society of Hospital Medicine held a stakeholders conference in 2009 to identify key principles and necessary first steps:

• Achieve consensus on the definition “medication” and “reconciliation”
• Clarify roles and responsibilities
• Develop measurement tools
• Phased implementation
• Develop risk stratification systems
• Study interventions and processes
• Disseminate success
• Promote the personal health record
• Promote partnerships
• Align financial incentives with newly developed regulatory and accreditation requirements

The stakeholders main message is this: “Patient safety and patient/family-centered care must be the principal drivers in the development and implementation of medical reconciliation systems.”

Greenwald JL and others.  Making inpatient medical reconciliation patient centered, clinically relevant and implementable:  a consensus statement on key principles and necessary first steps.  Journal of Hospital Medicine 2010 Oct;5(8): 477-485.

Managing Patient Access and Flow in the Emergency Department

Patient flow and delays in the Emergency Department are   problems that various quality improvement teams have been tackling for a long time.    However,  the fact that ED metrics such as median time from ED arrival to ED departure for admitted patients are being considered for public reporting in 2012 will provide more impetus to address these issues.

The Pennsylvania Patient Safety Authority published the article “Managing Patient Access and Flow in the Emergency Department to Improve Patient Safety” in the December 2010 issue of the Pennsylvania Patient Safety Advisory.  ED crowding and wait times contribute to poor quality care.

This article covers:

• Care Along the ED Continuum of Quality Metrics
• Patient Arrival in the ED to Diagnostic Evaluation
• Front-End Patient Flow Processes and Patient Safety Concerns
• Alternative Triage Strategies
• Patient Flow Managers
• Environmental Design of ED Waiting Rooms
• Fast-Track Service Lines
• Information Technology
• Customer Service Culture and Communication
• Risk Reduction strategies for Front-End ED Processes.

Top 10 Technology Hazards for 2011

The ECRI Institute published its annual listing  of  the 10 top technology hazards.  This 2011 listing  provides a guide for prioritizing patient safety initiatives.   Each hazard includes a description of the problem, recommendations for a plan of action and helpful resources.

1. Radiation Overdose and Other Dose Errors during Radiation Therapy
2. Alarm Hazard
3. Cross-Contamination from Flexible Endoscopes
4. The High Radiation Dose of CT Scans
5. Data Loss, System Incompatibilities, and Other Health IT Complications
6. Luer Misconnections
7. Oversedation during Use of PCA Infusion Pumps
8. Needlesticks and Other Sharp Injuries
9. Surgical Fires
10. Defibrillator Failures in Emergency Resuscitation Attemps

Top 10 Technology Hazards for 2011.  Health Devices 2010 Nov: 386-398.

ICU-Acquired Delirium and Weakness

The ICU literature recognizes that many ICU survivors  suffer from ICU-acquired delirium and weakness that impacts the quality and quantity of their lives.   While piecemeal efforts to address these problems have been initiated, the authors of this article in the November 2010 issue of Chest make the case for an aggressive ABCDE bundle to improve outcomes for ICU survivors.

ABCDE bundle stands for awakening and breathing coordination, delirium monitoring, and exercise/early mobility.  The authors state “ICU-acquired delirium and weakness are disorders of epidemic proportions and should be viewed as potentially preventable and/or modifiable outcomes for ICU survivors. ”  They also advocate that the bundle be protocolized and all ICU team members be empowered to enact the protocol.

Reducing iatrogenic risks; ICU-acquired delirium and weakness – crossing the quality chasm.  Vasilevskis EE and others.  Chest 2010 Nov;138(5):1224-1233.

AHRQ Effective Health Care Program

The AHRQ Effective Health Care Program “funds individual researchers, research centers, and academic health organizations to work together with the Agency for Healthcare Research and Quality (AHRQ) to produce effectiveness and comparative effectiveness research for clinicians, consumers, and policymakers.”

The Effective Health Care Program produces:

• Research Reviews
• Original Research Reports
• Summary guides (summarize  research review findings on benefits and harms of different treatment options)

The plain language summary guides for clinicians provide a way of integrating comparative effectiveness research into every day practice.   In addition, the plain language consumer guides support  clinicians in their patient counseling concerning the effectiveness, benefits, and harms of different treatment options.  Although there are only a limited number of existing clinician guides, many research reviews and original research reports are in the process of development.   The Effective Health Care Program website invites comments and collaboration.

Example of a Clinician Guide  Treatments for Clinically Localized Prostate Cancer.

AHRQ Effective Health Care Program

Issues in the Prevention of Ventilator-associated Pneumonia

Ventilator-associated pneumonia (VAP) continues to be a major problem in intensive care units in spite of VAP bundles based on the guidelines of scientific societies.   Scientific societies and clinicians need to continually evaluate new or additional measures for addressing the problem of VAP.   The October 1st issue of the American Journal of Respiratory and Critical Care Medicine includes a concise clinical review,  New Issues and Controversies in the Prevention of Ventilator-associated Pneumonia.

Table 1 RECOMMENDATIONS BY CURRENT GUIDELINES, NEW EVIDENCE, AND OUR RECOMMENDATIONS provides a concise outline of measures with new evidence.  In conclusion the authors state “we believe that the use of an endotracheal tube with an ultrathin and tapered-shape cuff and coated in antimicrobial agents can reduce the risk of VAP.  The combination of both these features with SSD offers an attractive way of optimizing VAP prevention.”

Lorente L, Blot S, Rello J.  New issues and controversies in the prevention of
ventilator-associated pneumonia. Am J Respir Crit Care Med. 2010 Oct
1;182(7):870-6.  PMID 20448095.

Guided Care

Guided Care is a new model of delivering healthcare for older adults with multiple chronic diseases.  Key to this model is the  specially trained Guided Care nurse based in the primary care office.    This nurse “… assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met.”

Researchers at Johns Hopkins University, who began developing this model in 2001, are conducting studies and publishing some promising results.   At present CMS does not cover the case management services but there is the possibility that  CMS will begin covering Guided Care as a component of the Medical Home.

The Guided Care website provides describes the model in more detail and provides links to publications.  www.guidedcare.org

Connecting Those at Risk to Care

This AHRQ publication provides a step-by-step guide on how communities can set-up an infrastructure to:

• Find:  Identify those at greatest risk
• Treat:  Ensure that they receive needed evidence-based health and social services.
• Measure:  Document and evaluate benchmarks and final outcomes.

This infrastructure, termed Community “HUB” promotes “…a system of collaboration, accountability, and improved outcomes.”

The Appendix includes descriptions of existing community Hubs and examples of forms, contracts and training curriculum.

Those concerned with the healthcare needs of those at risk in their communities may find this publication very helpful in providing a starting point for meeting these needs.

Community Care Coordination Learning Network.  Connecting those at risk to care: a guide to building a community “HUB” to promote a system of collaboration, accountability, and improved outcomes.  Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); September 2010.  AHRQ Publication No. 09(10)-0088.

Fall Initiatives

The September 2010 issue of The Journal of Nursing Administration features an article that describes the redesign efforts of the  University of Pittsburgh Medical Center.  The authors present a concise summary of  their analysis of current evidence and best practice in the area of fall prevention.

Their rapid improvement event process led to some significant changes:

• Nurses accept that all patients are at risk of falling; the new process seeks to target those patients who are at risk for injury.
• The development of a new risk assessment tool with only three questions and some check boxes that was specific enough to predict injury risk and reduced the time that a nurse needed to complete the assessment by more than 85%.
• The institution of “Lightening Rounds”.  These Lightening Rounds are performed on the identified ‘vital few’ patients ONLY.  Previous comfort rounds are no longer performed on all patients.

Kolin MM, Minnier T, Hale KM, Martin SC, Thompson LE.  Fall initiatives: redesigning best practice.  The Journal of Nursing Administration 2010 Sept; 40(9):384-391.