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PJ’s Healthcare 101

Published Tuesday, September 22, 2009 3:00 PM

By PJ Johnson
Summerville Journal Scene ®

"There is a certain degree of satisfaction in having the courage to admit one's errors. It not only clears up the air of guilt and defensiveness, but often helps solve the problem created by the error."

Dale Carnegie

Welcome back to PJ"s Healthcare 101. As promised, this week's column will focus on the area of "patient safety".

In November of 1999, the Institute of Medicine published a report called "To Err is Human: Building a Safer Health System". This report sounded the alarm about medical errors and created a wave of research, education, and process redesign all geared to improving the care patients receive in hospitals.

Here are some of the statistics (from AHRQ):

• 44,000 to 98,000 people die in hospitals each year as the result of medical errors.

• Using the lower number, this would make medical errors the 8th leading cause of death in this country.

• 7000 die from medication errors alone.

• Errors cost the nation $37.6 billion each year

Next some simplified vocabulary:

Medical Error: When something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place. (i.e. wrong medication or wrong site surgery)

Near miss: When an error ALMOST happened but was caught before it touched/reached the patient. (The medicine is pulled for the patient but the nurse realizes it before she gives it).

Sentinel Event: An unexpected death or serious physical - including loss of limb or function - or psychological injury, or the risk thereof. (removal of the wrong body part, serious overdoes resulting in death, patient fall that results in serious injury)

Never Event: Events that are believed to be entirely preventable and that should not happen (Wrong site surgery).

Hospital Acquired Condition: A list of 27 adverse events occurring in hospitals that are serious, largely preventable and of concern to both the public and healthcare providers.(Bladder infection or decubitus ulcer)

Patient Safety Indicators: A set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are likely amenable to prevention by changes at the system or provider level.

National Patient Safety Goals: A series of requirements that focus on problems in health care safety and how to solve them.

Sobering isn't it? But don't think your hospitals and providers are not paying attention. It was and is the prime area of focus in every hospital.... PREVENT ERRORS. The industry and those that regulate the industry have not stood back and let the numbers go unheeded. There are numerous new and old organizations all of whom have the responsibility to research, create, educate and monitor safety practices in health care facilities. They are the "watchers watching the watchers watch". All hospitals are required to implement, monitor and publicly report these various safety processes to assure they are providing safe care. Within our own state, the SC Hospital Association (SCHA) took this mission to heart and several years back, created an entire team within the SCHA. Headed by its tireless champion, Dr. Rick Foster, Every Patient Counts is a partnership with hospitals and agencies to advance patient safety and quality healthcare in SC hospitals.

Included among the organizations that promote safety are:

The Joint Commission (JCO): They survey most hospitals and implemented the National Patient Safety Goals which includes requirements such as eliminating the use of unclear abbreviations in medical orders, hand off report requirements, hand washing guidelines, labeling of medications that are not in original containers, reconciling home and hospital medication lists, rapid response teams to manage patients whose conditions are changing for the worse, marking surgical sites, time outs in procedure rooms and ORs....the list goes on. (http://www.jointcommission.org/GeneralPubic or http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/ )

Centers for Medicaid and Medicare (CMS): The governmental organization that surveys hospitals (or allows JCO to survey on their behalf) all hospitals that participate in the Medicaid and Medicare. They monitor the Conditions of Participation, a set of rigorous standards about patient care and processes. (http://www.hospitalcompare.hhs.gov/ )

Agency for Healthcare Research and Quality (AHRQ): The nations' lead Federal agency for research on health care quality, costs, outcomes, and patient safety. (http://www.ahrq.gov/qual/ )

National Quality Forum (NQF): The National Quality Forum (NQF) is a nonprofit organization that aims to improve the quality of healthcare for all Americans through fulfillment of its three-part mission:

Setting national priorities and goals for performance improvement; Endorsing national consensus standards for measuring and publicly reporting on performance; and Promoting the attainment of national goals through education and outreach programs.

(http://www.qualityforum.org/)

Leapfrog: The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information as well as rewards for hospitals that have a proven record of high quality care. (http://www.leapfroggroup.org/for_consumers)

South Carolina Hospital Association (SCHA): This partnership will be led by an interdisciplinary team of administrative and clinical leaders from member hospitals across the state that will provide strategic guidance and direction to the SCHA Board and member hospitals in the areas of quality improvement and safety. (http://www.schanew.org/every-patient-counts)

What can YOU do to prevent errors? AHRQ offers 20 Tips to Help Prevent Medical errors (site) as does JCO in their joint effort campaign with CMS called Speak Up (http://www.jointcommission.org/GeneralPublic/Speak+Up/).

Here are the key take aways:

• Speak up if you have questions or don't understand something.

• Make sure you know what your medications are and what you are being given and why and what side effects it might have.

• Know what your allergies are and make sure you tell the staff about them.

• Educate yourself on your illness, tests, treatment plans, etc.

• Ask a friend or family member to come with you and be your advocate.

• Ask the staff who enter your room to wash their hands EVERY time.

• Make sure your hospital and healthcare provider participates in regulatory and quality/safety programs.

Working together, hospitals, doctors, staff members and volunteers are there to do their best. So what is the summary commentary? A hard, cold fact... healthcare is rendered by humans and humans are NOT perfect. A mistake made intentionally or with disregard to safety mechanisms is bad. A mistake made because a system failed or a process didn't prevent it is a mistake and we learn from it and try not to make it again. Good people go to work every day with the inner fire to provide humanistic, compassionate care to every patient they encounter; NOT to make a mistake. It is why we went to school, why we work 24/7/365...to take care.

Next time, we will look at customer service and satisfaction and how hospitals and regulatory agencies measure and report both. As always, your questions, suggestions and gentle feedback are welcome. If you have a topic you want to be featured in PJ"s Healthcare 101, let me know via an email to pjjmgmtconsllc@aol.com.

To Your Health!

PJ Johnson, RN, MSN, FACHE

Legal Nurse Consultant

PJJ Management Consultants, LLC

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