Safety Watch: Elopement

TARGET AUDIENCE

  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

SAFETY WATCH: ELOPEMENT
Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.

THE CULTURE CONNECTION

  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.

RESOURCES

NEXT STEPS

  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

PSO Alert: Fall Risk

The Center for Patient Safety issues this alert regarding falls based on our data analysis.

Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death.  The CPS recommends you re-evaluate your fall risk program, considering the following best practices:

  • Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
  • Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
  • Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
  • Make certain the preventative measure match the patient’s risk factors
  • Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
  • Include consistent patient rounding as part of your preventative measures
  • Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
  • Routinely/daily review medications and their effect on each patient’s fall risk potential

This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.

 

Resources:

http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

http://www.patientsafety.va.gov/professionals/onthejob/falls.asp

http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman1.html

http://centeronaging.med.miami.edu/documents/Evidence-BasedStrategiestoReduceFallRisk.pdf

http://www.champ-program.org/static/Falls_BPIP.FromHHQIWebsite.pdf

https://www.cdc.gov/steadi/

Safety Watch: Bariatric Patients

According to the latest data published by the CDC in September 2015, more than 1/3 of the adult population is considered obese.  Coupled with often other complex health conditions this growing patient population brings with it new challenges for the EMS provider.
Based on industry data and recent findings from event data being submitted to the PSO, the Center for Patient Safety is issuing a Safety Watch as these patients have been found to have an increased risk of:

  • airway related events
  • stretcher related events or other device failure-related events
  • patient handling, including lifting and safely moving the patient
  • medication mistakes

Some suggested safe practices include:

  • Maintain the appropriate equipment and training for the bariatric patient.
  • When moving a patient, ensure the appropriate number of personnel are present (at minimum 4 persons for patients weighing more than 300 pounds).
  • Communicate with the receiving or destination hospital to ensure appropriate equipment and staffing are available for the transition of care.  Consider an alternative destination or contingency plan if the primary receiving facility does not have the necessary equipment or staffing to provide the safe transition of care.
  • Discuss this patient population with your medical director for specific needs, equipment or other requirements.

Resources:

http://www.cdc.gov/obesity/data/adult.html

http://www.boundtreeuniversity.com/Patient-handling/articles/1320927-Managing-and-moving-the-very-large-EMS-patient

http://www.fireengineering.com/articles/print/volume-165/issue-5/departments/fire-service_ems/treatment-transport-of-bariatric-patients.html

http://www.emsworld.com/article/10654895/prehospital-bariatric-care

Downloadable version

Safety Watch: AHRQ Guidance

Patient Safety Organizations (PSOs) and their participants have struggled with interpreting the Patient Safety and Quality Improvement Act (PSQIA) with respect to handling patient safety work that may be necessary to satisfy mandatory reporting or other operational requirements. In an effort to ease anxiety and develop a common understanding, the Agency for Healthcare Research and Quality (AHRQ) has issued a statement (“Guidance”) on the interface of (1) PSO protection of Patient Safety Work Product (PSWP) and (2) mandatory reporting and operational requirements. AHRQ’s statement is available here. Below are some highlights, based on the questions CPS gets most often from its participants. CPS participants can always contact the Center’s staff with questions.

  • The PSQIA has always required that PSO participants keep the information required to satisfy mandatory reporting requirements outside of the PSWP “protected” space. The Guidance reinforces that requirement. However, the PSQIA and the Final Rule allow participants to gather information inside the PSES until they know whether it will need to be reported. If outside reporting is required, then the information gathered in the PSES that has not yet been reported to the PSO can be pulled back out, so that it can be used to satisfy the outside reporting requirement. The Guidance recognizes both this early PSES protection and the opportunity to pull information from the protected space when necessary.
  • Like the Final Rule, the Guidance emphasizes that analysis that takes place in the PSES cannot be “dropped out.” It must remain as PSWP.
  • If a participant has a known obligation under state or federal law to report certain information, the provider should plan on developing it outside the PSES, as it cannot be PSWP.
  • The Kentucky Supreme Court’s Tibbs decision held that work surrounding mandatory state reporting could not be protected, as the state retained the right to investigate how the provider was accomplishing its reporting obligations. AHRQ’s Guidance seems to question that position, noting instead that information related to the required reporting “form” could be protected once the essential reporting obligation has been fulfilled by submitting the actual form, as long as the original documents from which the report was developed are still available.
  • A variety of projects may take place after a patient safety event. AHRQ’s Guidance contains some helpful examples on pp. 6-7 of how that work can be viewed as inside or outside of the PSES, and when it will have to be non-PSWP because of outside reporting requirements.
  • AHRQ encourages PSOs and their participants to work with state agencies and regulators to determine what information they need access to and what can reliably be viewed as PSWP, so that there are fewer confrontations on the front lines about those issues. (NOTE: CPS has historically supported its participants in this communication wherever possible.)
  • The Guidance emphasizes that PSWP is protected because it has been developed for reporting to the PSO, and that the PSES is a protected space for developing that information. CPS has encouraged its participants to view PSO reporting as the end point of their PSES activities, and to actually report to the PSO. AHRQ’s Guidance underscores the importance of reporting.
  • The Guidance specifically mentions hospitals’ requirement under the Conditions of Participation to track adverse events, noting that there is a “legitimate outside obligation” to keep those records. 42 CFR 482.21(a)(2) (https://www.law.cornell.edu/cfr/text/42/482.21). Incident reports have been a flashpoint in many states with respect to surveyors’ ability to see PSWP. PSO participants should carefully consider what routinely reported event information goes into or out of the PSES.  For example, some PSO advisors recommend that basic incident data that includes just patient name, date, location and a brief description would allow regulators to conduct their own investigations while protecting the PSO participant’s deeper investigation and analysis of those events.
  • The action plans or other actions or changes that result from analysis inside the PSES cannot be protected and can always be shared with surveyors.

Safety Watch: Contaminated Supply

PSOwatchIt has been reported to the Center for Patient Safety that some organizations have experienced sterile syringes and butterfly needles being contaminated within their sterile packaging.

Recommendations:

  • Encourage staff to please be watchful of all sterile packages.
  • If the supplies/equipment are noted to be contaminated, they should not be utilized
  • Remind staff to file a report in your event reporting process to notify leadership
  • Leadership should follow up with the vendor

Safety Alert: Home Health Medication Management

PSOalertA Home Health Care News article came out on 5/3/16 noting that medication mismanagement is an area in which home health agencies are woefully lacking. This article cited a Kaiser Health News Analysis of government records showed that inspectors identified 3,016 home health agencies (nearly a quarter of all agencies examined by Medicare) that inadequately reviewed or tracked medications for new patients. Medication mismanagement is seen as a major post-discharge complication as federal data shows that fewer than 50% of discharged patients are confident that they understand and can follow their discharge instructions.

Contributing factors to these medication errors include, lack of organization, lack of patient education and a lack of communication. Another factor which plays into the lack of communication is the fact that the government incentive to shift to electronic medical record was not set up to work across the continuum of care.  In effect, it contributes to setting up silos within the healthcare continuum as hospitals are not connected with home health care agencies outside of their own system and maybe not even within their own system depending on the software utilized by the hospital and the home health agency.

A review of data submitted to the Center for Patient Safety shows a similar trend in medication events.  Over a third of the medication events reported in the home health arena can be attributed to errors during med reconciliation and lack of communication during the transition from hospital to home health.

Suggested practices to reduce these errors include:

  1. Standardizing communication when a patient is being discharged from the hospital to home health. Include:
    1. Medication changes
    2. Completed and pending tests
    3. Follow up appointments
    4. DME needed by the patient
    5. Education provided to the patient
  2. Double-check medication
    1. Ensure important chronic medications were not stopped
    2. Make certain new medications are safe
    3. Double-check the interactions between medications
    4. Make certain patient hasn’t been prescribed two duplicate medications
  3. Transition the patient to home during the week
    1. Ensures that the patients primary care physician is available for medication questions
    2. Ensures that DME agencies are available to provide the patient with any equipment needed
  4. Patient Education
    1. Make certain the patient (and the family/primary caregiver) understand the diagnosis and medication prescribed
    2. Ensure they understand who they are to contact with any questions
    3. Is the patient/family aware of follow up appointments?
    4. Are they aware of lifestyle changes that may be required?
    5. If so have they been provided with information for support groups?

Patient safety is a major health issue which adversely affects patients in every health care setting.  Improving patient safety is a complex issue, which requires a total systems approach.  Implementing a patient safety culture in which leaders and front line staff put patient safety as a priority across the continuum of care is the foundation for preventing harm.  Reviewing processes and completing RCA’s of all events provides learning opportunities and also identifies areas of improvement.  But for the total systems process to work, an organization must have in place that strong patient safety culture where employees feel free to identify errors and unsafe conditions.

Resources:

http://homehealthcarenews.com/2016/05/spotty-medication-management-in-home-health-causes-dire-results/

https://www.washingtonpost.com/news/to-your-health/wp/2016/04/29/from-hospital-to-home-a-dangerous-transition-for-many-patients/

https://psnet.ahrq.gov/primers/primer/23

https://psnet.ahrq.gov/primers/primer/1

https://psnet.ahrq.gov/primers/primer/11

http://health.gov/hcq/ade-action-plan.asp

http://champ-program.org/static/MM_BPIP.FromHHQIWebSite..pdf

http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf

Safety Watch: Patient Destination Decisions

PATIENT DESTINATION DECISIONS
Thousands of patients are treated and transported by EMS to a destination hospital every day. Most hospitals can meet the required needs of EMS patients; however, patients who have certain conditions, i.e. Stroke, STEMI, Trauma or Pediatrics, often require more specialized care as quickly as possible. These patients have time sensitive conditions called Time Critical Diagnosis (TCD).

TCD is about:

  • Early Identification
  • Appropriate Treatment
  • Appropriate Destination

Many EMS leaders, hospitals and other stakeholders have adopted the TCD concept of. This approach allows for specialized treatment when minutes matter. (more…)

CDC Urging Dialysis Providers and Facilities to Assess and Improve Infection Control Practices to Stop Hepatitis C Virus Transmission in Patients Undergoing Hemodialysis

The CDC issued a health advisory urging dialysis providers and facilities to assess and improve infection control practices to stop Hepatitis C viral transmission in patients undergoing hemodialysis. A health advisory may not require immediate attention but provides important information for a specific incident or situation.

The CDC received an increased number of reports of HCV infections between 2014 and 2015 associated with hemodialysis clinics in eight different states.  While investigations are ongoing initial evaluation demonstrated lapses in infection control associated with these infections. (more…)

Safety Watch: EKG strip

Safety Watch - buttonThe Center for Patient Safety is issuing a PSO Watch in regards to documentation/chart accuracy. An event was shared where there was confusion regarding the appropriate identification of a patient’s EKG strip, resulting in a patient being treated for a dysrhythmia they did not have. This event brought to light many difficulties currently faced by hospitals and EMS providers:

  • Many hospitals are still in the process of transitioning from paper charts to electronic charts, causing confusion with processes.
  • In the hospitals, most units have systems that automatically print patient labels, or have patient names on EKG strips.
  • The ED departments and EMS agencies have very different systems to label orders/tests/blood work/EKG strips which causes confusion and communication breakdown.

To improve accuracy of patient documentation and communication between departments, CPS recommends the following:

  • Review processes for labeling documentation, and labeling placement, in the chart
  • Ensure standardization of processes
  • Reach out to other departments to ensure processes are standardized throughout system
  • Utilize standardized tool for communication/handoff of patient and test results

BLOG:

Press Release: EMS Medical Advisor:

CENTER FOR PATIENT SAFETY WELCOMES EMS MEDICAL ADVISOR Brian Froelke, M.D., is named first EMS Medical Advisor at the Center for Patient Safety. Download the Press Release Jefferson City, Mo. – The Cente

Safety Watch: Elopement:

TARGET AUDIENCE Nursing, Medical & other Clinical Leaders Clinical Educators Patient Safety/Quality Improvement Leaders Legal/Risk Management And Leaders in: Hospitals EMS LTC Home Care SAFETY WATCH: E

CPS Safety Culture Assessment:

“I am very impressed with the reports. I know my leadership team will be thrilled to have the individual reports by their division. This has been a very positive experience for me.” “We love the Cent

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RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.