Patient Safety--Your Lifestyle

“Jaded Julie, I have some good news and some bad news.”

“(Oh, no! Here we go again.) Proceed, Professor. I’ll be hanging on every word.”

“The bad news is that the likelihood of our emerging from this game called ‘life’ unscathed is zilch, i.e., the ultimate mortality rate is 100%. The good news is that most of us will have a chance of influencing the ‘how’ and maybe even the ‘when.’”

“Okay, Curmudge. First you said that we are doomed, and then you sounded as if you had found the Fountain of Youth. Which is it?”

“I doubt that there’s much we can do to extend our life, but there are lots of ways to avoid shortening it. If you believe your life is to follow some sort of grand design, you should avoid a lifestyle that might circumvent the plan.”

“I’ve got it, Curmudge. I read Dr. G’s book (1), and she comes down pretty hard in favor of a healthy lifestyle. As a medical examiner, she is able to describe in intimate anatomic detail what your insides look like when things go wrong. I wouldn’t want to be caught dead looking like that.”

“Nobody would, Julie. However, most of us simply ignore what we know about healthy living. What we need is a good jolt of reality to bring us to our senses. Dr. G does that. Here are some quoted or paraphrased examples:

‘Where healthy lungs are pinkish, a smoker’s lungs are gray and ribboned with black pigment.’

‘The tumor (from advanced lung cancer) …pushed through the wall of his lung into his pulmonary artery. Like a bursting dam, blood began to flow through the hole, filling his lungs.’

‘In the mouth of the corpse was some dark brown material that looked like coffee grounds that we doctors call coffee-ground vomitus. It’s often a sign of gastrointestinal bleeding. In the retroperitoneum there was a pus-filled abscess (from MRSA).’

‘Diverticulitis is a potentially lethal condition often associated with a low-fiber diet and lack of exercise. This condition begins as diverticulosis, the presence of pockets or protrusions in the wall of the colon. Diverticulitis can sometimes lead to perforation of the bowel and an infection in the abdominal cavity.’

‘One who is 100 pounds overweight is characterized as morbidly obese. Diagnosis using an ultrasonogram is more difficult when it is taken through layers of fat. People who are obese run a higher risk of coronary heart disease, stroke, high blood pressure, some cancers, diabetes, gout, arthritis, gallstones, infertility, injuries due to falls, sleep apnea, fatty liver disease, and post-surgical blood clots.’

‘Methamphetamine has a decomposing effect on the body while you are still living. Many addicts have black, rotting teeth, worn down to stumps. They tend to scratch nervously (because of a sensation of imaginary bugs crawling under their skin), causing sores and lesions on their bodies.’”

“Enough, Curmudge! You have my attention. Aren’t there some lifestyle lessons that are less graphic?”

“Of course. Here’s one: ‘Chewing tobacco contains 28 carcinogens.’”

“You know, Curmudge, chewing tobacco was pretty popular during the Civil War. Maybe that’s why all of the Civil War veterans are dead.”

“I can’t fault your data, Julie, but I do question your conclusion.”

“A final question, Curmudge. What does lifestyle have to do with patient safety?”

“The best way to be a safe patient is not to be a patient at all. We hope to achieve that by living a healthy lifestyle and, as we’ll discuss next week, minimizing accidents and trauma. It’s as we said in our discussion on January 29, ‘To avoid a hospital-acquired infection, stay out of the hospital.’”

Affinity’s Kaizen Curmudgeon

(1) Garavaglia, Jan. How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)

Patient Safety--Human Factors

“Curmudge, everything we’ve talked about in the past two months has to do with human factors in patient safety. You do remember, don’t you?”

“Of course. But today ‘human factors’ is just a euphemism for, ‘No one is perfect, but some people are less perfect than others.’”

“A euphe…what? Well it does sound nicer than, ‘Some people mess up.’”

“Okay, Jaded Julie, let’s start with the ‘no one is perfect’ premise. Can you balance on just one foot?”

“(I guess I’d better humor the old guy.) Yes, but for only 10 or 20 seconds.”

“My next question would be, ‘Why not all day?’, but I already know the answer. Perfection is transient; you get tired and distracted; and you are demonstrating necessary fallibility (1). Humans are not infallible. That’s why we can’t say, despite our best efforts, that there will never be another medical error. Of course we must make those best efforts so that the inevitable errors are few and far between.”

“What about diagnoses, Curmudge? Everyone knows that they are not always correct. I have read that about 15% of all patients are misdiagnosed (2). Condition A is unlikely to be cured if an incorrect diagnosis suggests that it is Condition B.”

“Diagnosis is a BIG topic, Julie; it’s discussed at length in Groopman’s book referenced below. He advises patients to ask their doctor these three questions when he/she is making a diagnosis: (a) ‘What else could it be?’ (b) ‘Could two things be going on to explain my symptoms?’ (c) ‘Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?’”

“It seems as if the errors that occur in surgery are the ones that make headlines. Although it is rare, wrong-site surgery is hard to overlook. But even a little nick of the wrong organ can make recovery a lot more difficult. These must be caused by reasons other than necessary fallibility.”

“Right, Julie. Two other types of errors are those that are knowledge-based and those that are skill and experience-based (1). One would expect a surgeon to have the requisite knowledge, but of course he has to perform the surgery on somebody to gain skill and experience. If you are going in for surgery, ask the doc how many times he has performed the procedure. If it will be in a teaching hospital, request the attending physician; let the residents learn on someone else.”

“Teamwork must be critical in the OR. Is it?”

“Teamwork is certainly essential, but recent literature suggests that it is not the major source of surgical complications (3). ‘After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication.’ Fortunately, complications and mortality can be reduced by use of surgical checklists (4).”

“I don’t know about you, Curmudge, but after hearing what you said, I’m afraid to get sick.”

“As usual, Julie, you’ve got that right. Being healthy beats being sick any day. Maybe we both should go back and read Jan Garavaglia’s book that we referenced two weeks ago (5).”

Affinity’s Kaizen Curmudgeon

(1) http://www.emsresponder.com/print/Emergency--Medical-Services/Fallible-MEDICINE/1$5773
(2) Groopman, Jerome. Why Doctors Make Mistakes. AARP p.34-35 (September/October 2008). Based on Groopman’s book How Doctors Think. (Mariner, 2008)
(3) http://www.ncbi.nlm.nih.gov/pubmed/18847639
(4) http://www.mdconsult.com/das/news/body/117277367-2/mnfp/0/204709/1.html?nid=204709&elshs_ca1=enews&elshs_ca2=email&elshs_ca3=20090120&date=week&pos=&general=true&mine=true
(5) Garavaglia, Jan. How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)

Patient Safety--Falls

“So you know something about falls, Curmudge?”

“I am familiar with their effects, Jaded Julie. Mrs. Curmudgeon has a propensity to be vertically challenged.”

“Propensity? Vertically challenged? That must mean that she falls a lot.”

“Regrettably, she tends to fall on her face. She sometimes gets a giant hematoma over one eye or the other. Her face gets discolored, her eye is swollen shut, and she looks like a battered woman. And I get an undeserved reputation as a wife-beater. Surely we can do a better job of shielding our patients from falls than I have done for my wife.”

“We are, Curmudge. Our Fall Assessment and Prevention Kaizen Event in the summer of 2008 was classic Lean. We had a great team that represented a cross-section of disciplines in the hospital. They broke into two simultaneous events to tackle the fall assessment process and standard work for use of fall prevention tools and techniques. Each collected data and considered the present state and desired future state for patient fall assessment and prevention.”

“So what did the data on the present state tell us, Julie?”

“For our three hospitals, the overall fall rate was 3.77 falls per 1,000 patient days. That’s not too bad, but experiencing a fall every 34 hours shows the need for improvement. We’d like to get the fall rate down to 3.4 in 2009 and 2 in 2011.”

“After evaluating our present state, I presume that the team developed a path forward.”

“They created a fall assessment tool for identifying those patients at high risk of falling and also a plan for communicating the tool to our nurses. Standard work was developed for implementing fall prevention techniques and for post-fall assessment and care. A Fall Alert Team was created to respond to all falls within the hospital. The fall prevention protocol will include 1-hour checks of all patients and 30-minute checks for fall-risk patients. The checks will include the Four Ps (Pain, Potty, Position, and Prevention). Some patients will need 15-minute checks or 1:1 care. Technical aids, such as motion sensors, will also be utilized.”

“Other hospitals have most likely tackled the problem of patient falls. Has their work been described in the open literature?”

“You know full well that it has, Curmudge. Ascension Health, the largest not-for-profit health care system in the country, has conducted an extensive program to prevent falls and eliminate falls with injury (1). Their key strategies were:
Assessment and re-assessment of patient risk factors for falls,
Visual identification of patients at high risk,
Communication of patient fall risk status, and
Education of patients, families, and staff about fall prevention.”

“The paper reminds us that falls are the leading cause of injury deaths among adults aged 65 and older. Our team undoubtedly benefitted from the report of Ascension’s experience.”

“Curmudge, our hospitals are making good progress in minimizing inpatient falls, but what can we do to help your ‘vertically challenged’ wife?”

“Maybe I can convince her that wearing a gait belt is the latest fashion. Then I can grab it when I see her start to fall.”

“Yeah, Curmudge. And you’ll both end up in a pile on the sidewalk.”

Affinity’s Kaizen Curmudgeon

(1) Lancaster, A.D., Preventing Falls and Eliminating Injury at Ascension Health The Joint Commission Journal on Quality and Patient Safety, vol. 33, no. 7:367-375 (July 2007).

Patient Safety--Infections 2

“Jaded Julie, back in my professorial days I was advised never to teach everything I know about a topic.”

“But you’ve been violating that rule almost weekly for the past year-and-a-half, Curmudge. And now you are going to teach health care professionals how to minimize nosocomial infections? Isn’t that rather presumptuous for someone whose current intellectual occupation is lawn mowing and snow blowing?”

“Wrong, Julie. As I’ve said before, a blog doesn’t teach. A blog inspires, reminds, refreshes, and sometimes incites; but it’s too short to teach.”

“Okay, have at it. But be sure to cite references so our readers will realize that the info we are passing along is from people who know what they are talking about.”

“To begin, I think health care workers should read last week’s blog to get a ‘heads up’ on what patients are expecting. Then you won’t be surprised when a patient asks you to swab your stethoscope with alcohol (1). And a male physician should be careful not to drag his never-cleaned necktie across a patient’s tummy during an examination (2). In addition, they should jog their memory by skimming Wikipedia’s overview on nosocomial infection (3); there are topics there that we won’t have space to cover.”

“Golly, Curmudge, after reading some of the papers you found I’ve become convinced that many surfaces in patient rooms are coated with invisible creepy-crawly drug-resistant bugs like MRSA and Clostridium difficile (4, 5). Control of C. diff. requires cleaning surfaces with bleach, and hands must be washed with soap and water; alcohol-based hand sanitizers are not sufficient (5). When using soap and water, you know you’ve scrubbed long enough when you have sung ‘Happy Birthday’ twice.”

“Hospital patients are usually in poor health and have impaired resistance to bacterial infections. Because that is likely with patients with central lines or on respirators, IHI has published ‘bundles’ of evidence-based practices to minimize central line blood stream infections and ventilator-associated pneumonia (6). We talked about these back on October 23, 2008.”

“Okay, Curmudge, suppose your are a bacterium living in a hospital and want to impress your friends by infecting someone. How would you do it?”

“I’d head for the OR. It’s a really big score for a bug if he can cause a surgical site infection. Hopefully, I would get a ride into the OR on equipment, clothing, or the patient himself. Once there, I would try to find a way into the sterile field, possibly by someone’s lapse in gowning, gloving, or aseptic technique (7). The likelihood of my succeeding is increased if there are several trainees in the OR (in a teaching hospital), if the operation is of long duration, and if the patient requires a blood transfusion or is not kept warm (8, 9).”

“But what would happen if the patient received a prophylactic antibiotic within one hour prior to surgery?”

“If it were not an antibiotic to which I am resistant, my career would go south in a hurry. The life of a bacterium is not without risk, y’know.”

“Well, Curmudge, since your microbial existence just got zapped, please return to your human curmudgeon role and tell me what you see as the bottom line.”

“I’d be delighted, Julie. Everyone from surgeon to housekeeper must learn, believe in, and practice a culture of protecting our patients from infections. It’s got to become ‘the way we do things around here.’ LEARN IT, BELIEVE IN IT, and DO IT.”

“(Hmm…sounds a lot like a religion.) I presume, Curmudge, that typing in all capitals means that you are shouting. If you continue to behave that way, we’ll have to find you a private office.”

Affinity’s Kaizen Curmudgeon

(1) http://www.hospitalinfection.org/protectyourself.shtml
(2) Garavaglia, Jan How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)
(3) http://en.wikipedia.org/wiki/Nosocomial_infection
(4) http://articles.latimes.com/2007/feb/03/opinion/oe-mccaughey3
(5) http://www.hospitalinfection.org/cdiff.shtml
(6) http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm
(7) Affinity Policies 01689 and 01704
(8) http://www.medscape.com/viewarticle/585849_print
(9) Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).

Patient Safety--Infections

“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

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

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