Medical Professionals The Patient Safety Challenge

In today’s health care environment patient acuity levels continue to rise. In hospitals, the average acuity scores of patients are continuously increasing, yet most patients are admitted to a non-ICU setting. Hospitals are increasingly implementing new initiatives geared towards early detection of patient risk situations and faster intervention once a problem has been detected.

2010 National Patient Safety Goals – The Joint Commission

The Joint Commission Guideline – Goal 9:

Reduce the risk of resident harm resulting from falls.

NPSG.09.02.01

Reduce the risk of falls.

Falls account for a significant portion of injuries in hospitalized patients, long term care residents, and home care recipients. In the context of the population it serves, the services it provides, and its environment of care, the organization should evaluate the resident’s risk for falls and take action to reduce the risk of falling as well as the risk of injury, should a fall occur. The evaluation could include a resident’s fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments.

The Joint Commission Guideline – Goal 14:

Prevent health care–associated pressure ulcers (decubitus ulcers).

NPSG.14.01.01

Assess and periodically reassess each resident’s risk for developing a pressure ulcer and take action to address any identified risks.

Pressure ulcers (decubiti) continue to be problematic in all heath care settings. Most pressure ulcers can be prevented, and deterioration at Stage I

can be halted. The use of clinical practice guidelines can effectively identify residents and define early intervention for prevention of pressure ulcers.

The Joint Commission Guideline – Goal 16:

Hospitals should “Improve recognition and response to changes in a patient’s condition” “A significant number of critical inpatient events are preceded by warning signs for an average of 6 to 8 hours.” “Critical events… are estimated to occur in 4% to 17% of patient admissions.”The joint commission in its 2010 Treatment and Services Standard PC.02.01.19 requires hospitals to:

Have a process for recognizing and responding as soon as a patient’s condition appears to be worsening.
Develop written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance.
Based on the hospital’s early warning criteria, have staff seek additional assistance when they have concerns about a patient’s condition.
Inform the patient and family how to seek assistance when they have concern about the patient’s condition

General Statement in Joint Commission Publication:

“Research shows that virtually all critical inpatient events are preceded by warning signs for an average of 6.5 hours.”

Reference: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

Responding to early warning signs (under 4 hours) for ICU transfer – reduces mortality by 75% and cost of care by 40%.

Young MP et al, J Gen Intern Med. 2003; 18: 77-83

http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.2003.20441.x/full

The two most important predictors for patient adverse events are Respiratory Rate and Heart Rate.

Chaboyer, W et al, Am J Crit Care. 2008;17: 255-263 http://ajcc.aacnjournals.org/content/17/3/255.abstract

10%-20% of hospitalized patients develop complications and 5%-8% of all patients die in-hospital. An estimated 37% of these events may be preventable.

Leape LL et al, N Engl J Med 1991, 324:377-384 http://www.nejm.org/doi/full/10.1056/NEJM199102073240605

“An estimated 134,000 Medicare beneficiaries experiencing at least 1 adverse event in hospitals during the 1-month study period”.

“Nearly half of preventable events (46 percent) involved care provided in a substandard way, most frequently because of delay in diagnosis or treatment. Other common factors associated with preventable events were inadequate monitoring of patients (38 percent) and inadequate assessment of patients (23 percent). These factors often led to delays in treatment and worsening of patient conditions. In several of these cases, patients displayed symptoms of infection but were not given antibiotics until they reached the point of sepsis”.

“We identified a total of five NQF events in the sample: two medication-related deaths and three Stage III pressure ulcers. 50 One of the medication-related deaths illustrates the nature of the NQF list as a measure of the most egregious preventable outcomes. In this case, a disabled Medicare beneficiary with muscular dystrophy affecting the respiratory system entered the hospital for signs of respiratory failure. Medical staff at the hospital gave the beneficiary a medication known to further suppress respiration, resulting in progressive respiratory distress and subsequent death. Physician reviewers concluded that medical staff administered the wrong medication because they lacked clinical understanding of the patient’s unique condition”.

For the full study: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

An estimated 1.3 to 3 million patients in the US have pressure ulcers; incidence is highest in older patients, especially when hospitalized or in long-term care facilities.

CMS no longer pays for hospital-acquired pressure ulcers, since they are considered preventable in the hospital setting.

Immobility either from decreased spontaneous movement or inability to change position frequently because of weakness is considered the most important factor in hospital acquired pressure ulcers.

The World Health Organization (WHO) emphasizes that nurses have a vital role in prevention of pressure ulcers among hospitalized patients by regularly changing the patient’s position in bed.

Reference: http://www.nestle-nutrition.com/media_room/Article_Detail.aspx?ArticleId=9f790336-5675-45c9-b1b3-eacd7011ab93

Falls are one of the major hazards leading to injuries, complications or even mortality among hospitalized patients, especially in the elderly and those with dementia. Accidental falls in inpatients account for 30–40% of reported safety incidents. Falls occur at a frequency of 4–14 per 1,000 bed-days, or approximately 10 falls per month on a 28-bed ward. Regulatory bodies have implemented strict standards regarding the use of restraints in the acute care setting.

¹ National Patient Safety Agency(2007) Slips, Trips and Falls in Hospital. London: NPSA.

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=74565&type=full&servicetype=Attachment

² Oliver, D. et al. 2007a. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment. Systematic review and meta-analyses.BMJ;334: 7584, 82–87

http://www.bmj.com/content/334/7584/82.full?rss=1