“I’ve got a medical trivia question for you, Jaded Julie. What disease was called ‘the old man’s friend'?”
“You certainly should be an expert on that ‘old man’ stuff, Old Man. It’s not a disease, but I always thought that a young wife was an old man’s friend, especially if he had money.”
“Get serious, Julie. The ‘old man’s friend’ was pneumonia (Streptococcus pneumoniae) (1). When an old man was suffering at the threshold of death, the Grim Reaper would arrive in the form of pneumonia and administer the coup de grace.”
“(Coo de what? I guess it means ending the old man’s misery.) Interesting story, Curmudge, which most likely is the introduction to a lesson.”
“It is, of course. Modern antibiotics came along and ended S. pneumoniae’s reign. People felt that most any bacterial infection could be zonked by an antibiotic. Unfortunately however, the bugs got smart and evolved into drug-resistant strains. Now we have infections from bacteria like MRSA (methicillin-resistant Staphylococcus aureus) (2), Stenotrophomonas maltophilia, Pseudomonas aeruginosa, vancomycin-resistant enterococci, and others (3). These are enemies of people of all ages and certainly not anyone’s friend.”
“(One might be my friend if the ‘old man’ were my rich uncle, but I’d better not say that out loud.) MRSA is the one with the greatest amount of well-deserved bad press. It appears most commonly as a skin infection.”
“Right, Julie, but ‘in health care settings, MRSA is a frequent cause of surgical wound infections, urinary tract infections, bloodstream infections (sepsis), and pneumonia.’” (4)
“I shudder at the thought, but I know some things that we can do.”
“With infections as potentially serious as these, ‘we’ is everyone, from health care workers like you to folks like me who might become patients.”
“Let’s start with patients, Curmudge, and what they might do to minimize nosocomial infections.”
“Noso…what? Oh, I suppose you mean infections acquired in the hospital.”
“Of course I do. Curmudge, you’ve known what nosocomial means since you were 70 years old.”
“Just kidding, Julie. So what can hospital patients do to avoid infections?”
“Stay out of the hospital, but sometimes being in the hospital can’t be avoided. Once you‘re there, don’t stay a minute longer than is necessary. Have a single room, and wash your hands (or have your hands washed) as thoroughly as you expect your caregivers to wash theirs. Learn the 15 Steps You Can Take to Reduce Your Risk of a Hospital Infection (5). And if you have a choice, go to the hospital with the best safety record. An increasing number of states are requiring hospitals to report their infection rates (6).”
“As I have said all along, health care quality and safety go hand-in-hand. It’s no secret that a hospital with a culture of quality and safety is also a great place to work. The patient-to-be should inquire about the cultures in the hospitals in his/her community.”
“So now that we have alerted the potential patient about what to do and look for, are we going to talk about what a hospital can do to reduce its infection rate?”
“Next time, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Personal communication many years ago from Ed Zeiss, MD, who as fate would have it, died from pneumonia at an advanced age.
(2) http://www.mayoclinic.com/health/mrsa/DS00735/DSECTION=prevention
(3) http://en.wikipedia.org/wiki/Nosocomial_infection
(4) http://www.medicinenet.com/mrsa_infection/article.htm
(5) http://www.hospitalinfection.org/protectyourself.shtml
(6) http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=109&STORY=/www/story/03-08-2007/0004542368&EDATE= and http://www.abouthealthtransparency.org/node/125
Thursday, January 29, 2009
Thursday, January 22, 2009
Patient Safety--Communications
“Jaded Julie, I had a dream.”
“And I suppose, Curmudge, that you want me to put on my amazing technicolor dreamcoat (1) and interpret what you dreamed?”
“No need, Julie. I remember. I was admitted to a hospital, put in a room, and my records were misplaced. My desiccated remains were found months later when a housekeeper opened the door.”
“How horrible! That wasn’t here was it?”
“Who knows? My dreams aren’t site-specific.”
“I presume, Curmudge, that buried somewhere in your adventure in dreamland is a lesson about patient safety. It better be good, because we’ve already blown a third of a page.”
“You know me, Julie. There’s always a lesson, and here it is: Errors in communication can jeopardize patient safety. In fact, communication failure was a primary contributing factor in almost 80% of about 6000 root cause analyses of adverse events and close calls (2). In my dream I ceased to exist when my paperwork was lost. Here are a few other examples that are much more realistic:
Failure to communicate within a surgical team. This would include an incomplete ‘time out’ prior to surgery and reluctance to ‘sound the alarm’ when an error appears imminent (3).
Incomplete information provided during a ‘handoff,’ i.e., when the responsibility for a patient is transferred from one caregiver to another (4).
Inadequate information exchange among physicians caring for the same patient in the community (5).
Illegible handwritten prescriptions and misinterpreted telephoned orders.
Dysfunctional relationships between hospitals and physicians (6).
Failure to reconcile medications across the continuum of care (7).”
“I’m sure your list could go on and on, Curmudge. Most of these issues are well known within the health care community, and many are the subject of efforts to improve. Of course, some of these problems are going to be easier to fix than others.”
“Correct. The ‘time out before surgery’ issue is corrected by just doing it. Medication order read-back should resolve the problem of phoned orders. Staff training is used to improve patient handoffs; this would include teaching SBAR (situation, background, assessment, recommendation) and other, more complete models (4). A technology fix should improve information exchange among physicians. This is a critical need in a city that has more than one principal health care organization.”
“Isn’t the toughest nut to crack the ‘them and us’ relationship between the docs and the hospitals? That problem must vary in acuity from hospital to hospital; I hope it’s not a big issue here.”
“Julie, where it exists, McGinn and Chabon say that, ‘…solutions must be behavioral, cultural and legal.’ (6) You and I will talk more about physicians in a future series of postings.”
“I have read where one benefit of a new system for patient care, called Collaborative Care (8), is improved communication.”
“I read that too. When doctors make their rounds with a pharmacist, a nurse, and sometimes a care manager, everyone is on the same page.”
“Curmudge, I suspect that hospitals of the future will require better communication and improved teamwork. One way to achieve that is use of a government program, TeamSTEPPS (2).”
“Right, Julie. The program’s goal is to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.”
“Golly, Curmudge. That sounds a lot like Lean.”
Affinity’s Kaizen Curmudgeon
(1) Genesis 37; Joseph and the Amazing Technicolor Dreamcoat by Andrew Lloyd Webber and Tim Rice.
(2) http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Leadership Briefing Slides, slides 3 and 18.
(3) Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(4) http://www.hhnmag.com/hhnmag_app/gateFold/pages/MAY08.jsp
(5) http://www.ncbi.nlm.nih.gov/pubmed/18981442
(6)http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/11NOV2008/081125HHN_Online_McGinn&domain=HHNMAG
(7) Affinity Health System Policy 03514
(8) http://www.jsonline.com/story/index.aspx?id=735770
Wednesday, January 14, 2009
Patient Safety--Medications 2
“Curmudge, we could be a lot more authoritative in our discussion of medications if you were a pharmacist.”
“That’s true, Jaded Julie, but when I was younger most drug stores were one-man operations with a small pharmacy in back, a retail section, and a soda fountain in front. I didn’t want to spend my professional career selling Coca-Cola and Band-Aids. Besides, I was always mystified at how a pharmacist could decipher the illegible handwriting on a prescription.”
“Speaking of sources of medication errors, like illegible handwriting, perhaps we should mention some of the system elements that influence safe medication use: (1)
Patient information (allergies, diagnosis)
Drug information
Drug labeling and packaging
Drug storage and distribution
Environmental factors (poor lighting, interruptions)
Staff competency.”
“Problems can occur in each of those areas. In addition, there are several errors of omission on the part of the pharmacist, physician, or patient that can lead to adverse events. These are individual performance deficiencies: (1)
Failure to detect a disease state contraindication
Failure to detect a drug interaction or allergy
Failure to prescribe the correct dose
Failure to monitor drugs with narrow therapeutic indices.”
“Curmudge, an alert patient and a nurse who is up to date in her profession might be able to head off several of these failures.”
“Also with regard to their individual performance, I hope that all health care professionals know and practice the ‘5 rights’ of medication administration.”
“I presume, Curmudge, that you mean the right patient, the right drug, the right time, the right dose, and the right route.”
“What’s this ‘right route’ stuff? Do they need a map?”
“Oh, that means where in the patient you administer the med, like intramuscular (IM) vs. intravenous (IV). That’s almost always indicated, although everyone should already know that you don’t stick a suppository in the patient’s ear.”
“I think we have alarmed our readers sufficiently. Perhaps we should now mention some of the actions that are taken to minimize adverse medication events. These fall into the category of mistake-proofing (2), although there may be ways to circumvent some of them. Perhaps we could call those mistake-less-likely.”
“I read the AHRQ publication, Curmudge, and picked out some of the mistake-proofing examples applied to medications:
· Pyxis systems to control access to medications
· ‘Tall man’ labels with unusual placement of capital letters to distinguish between look-alike or sound-alike meds. CeleBREX and CeleXA are examples.
· Storage of high-risk medications in red containers
· An orange smock saying, ‘Don’t interrupt me,’ for the nurse delivering meds to patients
· Oral syringes that will not fit into IV tubing so that oral meds cannot be administered intravenously
· In-line hooks for hanging IV bags to make it easy to identify which line comes from which bag. This can also be achieved by color coding each line with a cyalume light.
· Computerized physician order entry. Mistake-proofing features depend on the software. Problems with illegible handwriting are eliminated. Note that programs are available for physicians who want to improve their handwriting (3).
· Machine-made unit doses with bar codes to match medication with patient
· Standard abbreviations, acronyms, and symbols. JCAHO has an official ‘do not use’ list, and Affinity’s list of unacceptable abbreviations is shown in Policy 00803.”
“That’s a good list, Julie, but our ultimate goal is to implant a culture of safety in everyone’s brain. We must use Lean tools to continuously improve the safety of every aspect of our medication processes. As stated by Huminski (4), ‘We are perfecting the medication delivery system to be safe for every patient, every time.’”
Affinity’s Kaizen Curmudgeon
(1)http://www.medscape.com/viewprogram/7099_pnt
(2)http://www.ahrq.gov/qual/mistakeproof/mistakeproofing.pdf
(3)http://handwritingsuccess.com
(4)http://blog.hin.com/?p=391
“That’s true, Jaded Julie, but when I was younger most drug stores were one-man operations with a small pharmacy in back, a retail section, and a soda fountain in front. I didn’t want to spend my professional career selling Coca-Cola and Band-Aids. Besides, I was always mystified at how a pharmacist could decipher the illegible handwriting on a prescription.”
“Speaking of sources of medication errors, like illegible handwriting, perhaps we should mention some of the system elements that influence safe medication use: (1)
Patient information (allergies, diagnosis)
Drug information
Drug labeling and packaging
Drug storage and distribution
Environmental factors (poor lighting, interruptions)
Staff competency.”
“Problems can occur in each of those areas. In addition, there are several errors of omission on the part of the pharmacist, physician, or patient that can lead to adverse events. These are individual performance deficiencies: (1)
Failure to detect a disease state contraindication
Failure to detect a drug interaction or allergy
Failure to prescribe the correct dose
Failure to monitor drugs with narrow therapeutic indices.”
“Curmudge, an alert patient and a nurse who is up to date in her profession might be able to head off several of these failures.”
“Also with regard to their individual performance, I hope that all health care professionals know and practice the ‘5 rights’ of medication administration.”
“I presume, Curmudge, that you mean the right patient, the right drug, the right time, the right dose, and the right route.”
“What’s this ‘right route’ stuff? Do they need a map?”
“Oh, that means where in the patient you administer the med, like intramuscular (IM) vs. intravenous (IV). That’s almost always indicated, although everyone should already know that you don’t stick a suppository in the patient’s ear.”
“I think we have alarmed our readers sufficiently. Perhaps we should now mention some of the actions that are taken to minimize adverse medication events. These fall into the category of mistake-proofing (2), although there may be ways to circumvent some of them. Perhaps we could call those mistake-less-likely.”
“I read the AHRQ publication, Curmudge, and picked out some of the mistake-proofing examples applied to medications:
· Pyxis systems to control access to medications
· ‘Tall man’ labels with unusual placement of capital letters to distinguish between look-alike or sound-alike meds. CeleBREX and CeleXA are examples.
· Storage of high-risk medications in red containers
· An orange smock saying, ‘Don’t interrupt me,’ for the nurse delivering meds to patients
· Oral syringes that will not fit into IV tubing so that oral meds cannot be administered intravenously
· In-line hooks for hanging IV bags to make it easy to identify which line comes from which bag. This can also be achieved by color coding each line with a cyalume light.
· Computerized physician order entry. Mistake-proofing features depend on the software. Problems with illegible handwriting are eliminated. Note that programs are available for physicians who want to improve their handwriting (3).
· Machine-made unit doses with bar codes to match medication with patient
· Standard abbreviations, acronyms, and symbols. JCAHO has an official ‘do not use’ list, and Affinity’s list of unacceptable abbreviations is shown in Policy 00803.”
“That’s a good list, Julie, but our ultimate goal is to implant a culture of safety in everyone’s brain. We must use Lean tools to continuously improve the safety of every aspect of our medication processes. As stated by Huminski (4), ‘We are perfecting the medication delivery system to be safe for every patient, every time.’”
Affinity’s Kaizen Curmudgeon
(1)http://www.medscape.com/viewprogram/7099_pnt
(2)http://www.ahrq.gov/qual/mistakeproof/mistakeproofing.pdf
(3)http://handwritingsuccess.com
(4)http://blog.hin.com/?p=391
Thursday, January 8, 2009
Patient Safety--Medications
“Jaded Julie, today we’re going to start talking about medication safety.”
“How can you do that, Ancient One? You don’t know the first thing about medications.”
“I certainly do. First thing every morning I take a big multivitamin pill. Besides, my colleague on this blog is a nurse who is very knowledgeable and occasionally somewhat respectful. We can do it if you promise to help.”
“Of course. I suppose we’ll start by your telling how it was in the old days.”
“When I was ill as a child, we waited all day for the family doctor to come and felt better as soon as he arrived. We didn’t appreciate how limited the armamentarium in his black bag was…some tongue depressors, a flashlight, and bottles of a couple dozen types of pills. We didn’t hear about medication errors then, probably because the meds weren’t very effective. Patients got better if they were strong and more than a little bit lucky.”
“The armamen...what? Well, those black bags were pretty small. If doctors made house calls today, they’d have to pull a trailer with a pharmacy in it.”
“To a layperson like me, the medications available now are a bewildering array. All of those brand names plus a host of generics. Despite the manufacturers’ best efforts, there are a lot of look-alikes and sound-alikes. No wonder pharmacists are in such high demand.”
“Curmudge, let’s start by listing (in order) the top 10 meds that are most commonly misused or mishandled by health care providers (1). Those folks administering these drugs should be aware that they are dealing with materials that have bad track records for safety.
· Insulin
· Morphine
· Potassium chloride
· Albuterol
· Heparin
· Vancomycin
· Cefazolin
· Acetaminophen
· Warfarin
· Furosemide”
“Good list, Julie; you and I read the same stuff. Errors that occur with insulin—at the top of the list—include look-alike packaging, similarity in brand names (e.g., Humalog and Humulin), and confusing the unit abbreviation ’u’ with the number 0.”
“Consider opioids along with morphine, the second item on the list. Similar names for these can be a source of confusion: Avinza and Evista, morphine and hydromorphone, Oxycontin and MS Contin, hydrocodone and oxycodone, and oxycodone and codeine.”
“Patients should be especially aware of this next list, because these are the principal meds that prompt their visits to the ED. Unintentional overdosing is the main reason for going to the ED; others include side effects and allergic reactions.
· Insulin
· Anticoagulants
· Amoxicillin
· Aspirin
· Trimethoprim-sulfamethoxazole
· Hydrocodone/acetaminophen
· Ibuprofen
· Acetaminophen
· Cephalexin
· Penicillin”
“You know, Curmudge, I see bad news as well as good news in the multitude of potent medications that are now available. The good news is that they can achieve cures that were only an impossible dream when you were a kid. The bad news is that mix-ups can occur more easily and result in a patient’s taking a very powerful—but wrong—medication.”
“Julie, an organization with a Lean culture will devise systems that make it easy to do the right thing and very hard to do something wrong. Until we achieve that, the old rule might still apply, ‘Patients get better if they are strong and lucky.’”
“If that’s true Curmudge, I bet that penicillin shot you received for an infection 50 years ago made you a lot luckier.”
Affinity’s Kaizen Curmudgeon
(1)http://www.medscape.com/viewprogram/7099_pnt
“How can you do that, Ancient One? You don’t know the first thing about medications.”
“I certainly do. First thing every morning I take a big multivitamin pill. Besides, my colleague on this blog is a nurse who is very knowledgeable and occasionally somewhat respectful. We can do it if you promise to help.”
“Of course. I suppose we’ll start by your telling how it was in the old days.”
“When I was ill as a child, we waited all day for the family doctor to come and felt better as soon as he arrived. We didn’t appreciate how limited the armamentarium in his black bag was…some tongue depressors, a flashlight, and bottles of a couple dozen types of pills. We didn’t hear about medication errors then, probably because the meds weren’t very effective. Patients got better if they were strong and more than a little bit lucky.”
“The armamen...what? Well, those black bags were pretty small. If doctors made house calls today, they’d have to pull a trailer with a pharmacy in it.”
“To a layperson like me, the medications available now are a bewildering array. All of those brand names plus a host of generics. Despite the manufacturers’ best efforts, there are a lot of look-alikes and sound-alikes. No wonder pharmacists are in such high demand.”
“Curmudge, let’s start by listing (in order) the top 10 meds that are most commonly misused or mishandled by health care providers (1). Those folks administering these drugs should be aware that they are dealing with materials that have bad track records for safety.
· Insulin
· Morphine
· Potassium chloride
· Albuterol
· Heparin
· Vancomycin
· Cefazolin
· Acetaminophen
· Warfarin
· Furosemide”
“Good list, Julie; you and I read the same stuff. Errors that occur with insulin—at the top of the list—include look-alike packaging, similarity in brand names (e.g., Humalog and Humulin), and confusing the unit abbreviation ’u’ with the number 0.”
“Consider opioids along with morphine, the second item on the list. Similar names for these can be a source of confusion: Avinza and Evista, morphine and hydromorphone, Oxycontin and MS Contin, hydrocodone and oxycodone, and oxycodone and codeine.”
“Patients should be especially aware of this next list, because these are the principal meds that prompt their visits to the ED. Unintentional overdosing is the main reason for going to the ED; others include side effects and allergic reactions.
· Insulin
· Anticoagulants
· Amoxicillin
· Aspirin
· Trimethoprim-sulfamethoxazole
· Hydrocodone/acetaminophen
· Ibuprofen
· Acetaminophen
· Cephalexin
· Penicillin”
“You know, Curmudge, I see bad news as well as good news in the multitude of potent medications that are now available. The good news is that they can achieve cures that were only an impossible dream when you were a kid. The bad news is that mix-ups can occur more easily and result in a patient’s taking a very powerful—but wrong—medication.”
“Julie, an organization with a Lean culture will devise systems that make it easy to do the right thing and very hard to do something wrong. Until we achieve that, the old rule might still apply, ‘Patients get better if they are strong and lucky.’”
“If that’s true Curmudge, I bet that penicillin shot you received for an infection 50 years ago made you a lot luckier.”
Affinity’s Kaizen Curmudgeon
(1)http://www.medscape.com/viewprogram/7099_pnt
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