Tag Archives: patient safety

General Safety Issues, Health Issues

WORKER SAFETY IN HOSPITALS INFORMATION IS AVAILABLE ON NEW WEBSITE!

Occupational Safety and Health Administration's Worker Safety in Hospitals website.

The Occupational Safety and Health Administration has introduced a suite of online resources to support hospitals in fostering a safer workplace for employees and patients. The extensive materials include fact books, self-assessments and best-practice guides designed to help hospitals prevent worker injuries and illness, assess workplace safety needs, enhance safe patient handling and implement safety and health management systems. “These new materials can help prevent hospital worker injuries and improve patient safety, while reducing costs,” said Dr. David Michaels, assistant secretary of labor for occupational safety and health. In a teleconference held on Jan. 15, Dr. Michaels was joined by Dr. John Howard, director of the National Institute for Occupational Safety and Health; Dr. Lucian Leape, chairman of the Lucian Leape Institute at the National Patient Safety Foundation; and Dr. Erin S. DuPree, chief medical officer and vice president of the Joint Commission Center for Transforming Healthcare.

Every morning at Cincinnati Children’s Hospital, staff from each department gather together in a conference room to begin the day the way they always do – by talking about workplace safety.  One staff member is designated the new “safety officer of the day,” and the agenda includes, as always, a review of recent safety inci­dents and concerns. As Health Director Alison Muth explains, “Starting the day without these meetings would be like pulling out of the driveway without your seatbelt on.”  What a unique idea – starting each day with a safety meeting.

It’s no coincidence that Cincinnati Children’s is generally acknowledged as one of the very best pediatric hospitals in the country. Both the current and previous CEOs have run non-health care companies and recognize the value of a safe workplace – to workers, to customers and to the bottom line.  There are many other hospitals across the country that do it right. There are even 14 hospitals – such as University Medical Center at Brackenridge in Austin, Texas, and Saint Thomas Midtown Hospital in Nashville, Tenn., who participate in OSHA’s Voluntary Protection Programs, an elite group of companies whose proactive approach to injury and illness prevention have resulted in dramatic decreases in workplace injuries, accompanied by a transformed workplace culture that leads to higher productivity and quality, reduced turnover, reduced costs and greater employee satisfaction.

It’s important for all hospitals to follow suit. In 2012, U.S. hospitals recorded 248,100 work-related injuries and illnesses, nearly 58,000 of which caused employees to miss work. The good news is that injuries and illnesses can be prevented.

Hospitals have seen an unusual amount of flu this season, with many resulting in pneumonia, and even death.  Hospital employees are the first ones to be exposed to many illnesses, and are given preventive vaccines  to help them stay well.  By using face masks, gloves, and other protective clothing to combat the spread of germs, workers try to remain healthy.  Washing hands is important to healthcare givers and anyone else who has touched the surfaces or door knobs, pens, or anything else that a sick person has been in contact with.

The mission of all hospitals is to give the best patient care possible.  Handling patients in a safe way, having fall prevention on their beds (bed alarms), and monitoring them often is very important.  That is why holding daily safety meetings with department staff makes sense.  Their employees may report any incidents to them in order that they discuss this in the meetings and together come up with better solutions.

Nurses, aides, and other hospital employees that help patients to their wheelchairs or bathroom, should use a lift if the patient is too heavy, in order that the caregiver not be injured.  There are many ways that hospital employees must stay as healthy as possible;  management should ensure that they do.  Personal protective equipment is a big part of hospital attire. Lab coats, shoe covers, face shields, examination gloves, hair covers, surgical gowns, and other clothing you  see hospital personnel wearing is considered personal protective equipment.

Anyone connected with a hospital should check out this informative website. 

Source: Department of Labor

 

General Safety Issues, Health Issues

March 3-9: National Patient Safety Awareness Week

Patient Safety Awareness Week is an annual education and awareness campaign for health care safety led by NPSF. Each year, health care organizations internationally take part in the event by prominently displaying the NPSF campaign logo and promotional materials within their organizations, creating awareness in the community, and utilizing NPSF educational resources among hospital staff and patients. Visit the NPSF Store to order materials.

The theme for Patient Safety Awareness Week 2013 is Patient Safety 7/365: 7 days of recognition, 365 days of commitment to safe care. This is a week to recognize the advancements that have been made in the patient safety arena, while acknowledging the challenges that remain—and committing to work on them, every day.

Key Facts About Patient Safety

Doctors, nurses, and other health professionals dedicate their lives to caring for their patients. But providing health care can be complicated. There are often multiple steps involved in a health care visit. A number of different medical staff may be take part in the care of a single patient. And patients may be confused by unfamiliar words and technical language.  If the patient is elderly, there should be a caregiver or family member present to be sure everyone understands the physicians’ instructions.

Although hospitals, clinics, and doctor’s offices take many steps to keep their patients safe, medical errors can happen. Often, medical errors (also called adverse events) happen when there is a single misstep in a chain of activities.

Researchers and experts in the field of patient safety have identified a number of ongoing patient safety challenges. Below are descriptions of some of the most common and worrisome issues.  Have you or a friend or family member experienced an incident regarding safety issues while you were a patient? 

Wrong-Site Surgery

Wrong-site surgery means an operation done on the wrong part of the body or on the wrong person. It can also mean the wrong surgery was performed.  Wrong-site surgery is rare and preventable, but it does still occur. Between 1995 and 2010, 956 wrong-site incidents were reported to the Joint Commission (the Joint Commission is an organization that reviews and grants accreditation to health care institutions). One study surveyed surgical procedures from 28 hospitals and found the incidence of WSS to be approximately 1 in 112,994 procedures. For the average hospital, this means only one error every 5 to 10 years. 

However, to ensure that you aren’t that “one” error, be sure to ask the surgical staff  if the correct surgical site is marked, and ask any other questions you may have prior to the surgery.

Medication Errors

Medication errors are when a patient receives the wrong medication, or when he or she receives the right medication but in the wrong dosage or manner.  Medication errors are unfortunately very common. According to the Institute of Medicine’s July 2006 report Preventing Medication Errors, medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs. Medication errors include cases where the wrong medication is given, where the wrong dose of the right medication is given, or when medication is given the wrong way (for example, in pill form rather than liquid) or when it is given at the wrong time. 

Health Care-Acquired Infections

A health care-acquired infection (HAI) is an infection a person gets while being treated for a medical condition. HAIs may occur in patients who are treated at a medical facility or in their homes. An infection is considered to be an HAI when it occurs after treatment begins. HAIs are often discovered within 48 hours of admission to a health care facility, but other infections may also be considered HAIs.  In the United States, 1 out of 20 hospitalized patients contract HAIs. These complications of care lead to extra time in the hospital and longer recovery times.

The three most common types of HAIs are

  • Catheter-related bloodstream infections: Catheter-related bloodstream infections, or CRBSIs, are among the most common infections in patients who are admitted to critical care units. These infections occur when bacteria and other germs travel down a “central line” and enter the bloodstream.
  • Hospital-acquired pneumonia: Hospital-acquired pneumonia (HAP) is an infection of the lungs that occurs 48 hours or longer after admission to a hospital. This pneumonia tends to be more serious because patients in the hospital are often sicker and unable to fight off germs than otherwise health people. Hospital-acquired pneumonia occurs more often in patients who are using a respirator (machine) to help them breathe. Ventilator-associated pneumonia (VAP) falls into the HAP category. It may occur in patients who need a tube to breathe.
  • Surgical site infections (SSI): A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections sometimes only involve the skin. Others are more serious and can involve tissues under the skin, organs, or implanted material (such as knee or hip replacements). 

Falls

Falls are a common cause of injury, both within and outside of health care settings. According to the U.S. Centers for Disease Control and Prevention, more than one-third of adults over 65 fall each year. Injuries that result from falls can include bone fractures, excessive bleeding, or even death.  Researchers estimate that more than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries. Patients may be at increased risk of falls if

  • They have an impaired memory
  • They have muscle weakness
  • They are older than 60
  • They use a cane or walker to help them walk

Medications may also play a role in increasing a person’s risk for a fall. Studies have also shown that elderly patients taking four or more prescription medications are at three time’s greater risk for falls than are other patients.  Hospitals and other health care organizations take steps to prevent falls among their patients, such as placing a sign on the door that this patient is a fall risk. You can help prevent falls by asking your doctor or nurse about your risk and taking steps to reduce your chance of a fall.  Bed alarms are also placed on the beds of fall-prone patients.

Readmissions

A readmission is when a patient needs to return to the hospital less then 30 days after being discharged. Many factors may lead to hospital readmissions, such as poor quality care or a gap in the transition between different providers and care settings. Readmissions may also occur if patients are discharged from hospitals prematurely, or if they are discharged to inappropriate settings, or if they do not receive adequate information or resources to aid in recovery.

Patients can help avoid readmission by making sure they understand their care plan before they are discharged from the hospital. They also need to be sure to follow up on care once they leave the hospital.

Diagnostic Errors

Diagnostic errors mean a diagnosis that was either “wrong, missed, or unintentionally delayed.” No-fault errors may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care. Diagnostic errors may also result from system-related problems, such as equipment failure or flaws in communication. A wrong diagnosis may also occur when the clinician relies too much on common symptoms, and choosing an obvious answer, without looking further into what may be causing them.

We all want to know there is a hospital nearby when one falls ill or has an accident.  We also want to trust that we will receive professional care.  My husband developed a Strep B infection following a hip replacement, resulting in more surgery, and six weeks of home health care, including wearing an iv bag for six weeks.  Luckily, the infection cleared up, but he should not have had to go through that.  I could list numerous friends and family that have been made more sick after being hospitalized than before they went in.  I feel most of you can, too.

The best advice is to feel free to ask the doctors and nurses as many questions as you have.  Nurses and aides should do their job and give the same attention they give to patients who have no one sitting in the room with them to those who do have someone present.  It is not the sitter or family members’ job to bathe, or take care of the patient.  This happens in hospitals all too frequently.  We all are paid to do our own jobs.  It is our responsibility to be aware of negligence and/or mistakes, and report it to the compliance officer of the hospital.

I just had to add my two cents to this article.  Most of us have experienced some type of incident while in a hospital.  The statements in italics are my comments.  Feel free to send yours, too. pb

Source: National Patient Safety Foundation

First Aid Safety, General Safety Issues

HOW TO MAKE OUR HEALTHCARE SAFER

We are midway through National Patient Safety Awareness Week, an important observance to remind us all that we, as patients, must do what we can to stay safe when we are in a healthcare setting, such as a hospital.  Mistakes do happen, and may seem small, but it all adds up to the saying, “the worst place to be if you are sick – a hospital”.  We know that many lives are saved by treatment and surgeries that were unimaginable years ago; however, there have been patients who have been harmed by medical errors.  If this happens, it is often a result of a series of small failures that are individually not big enough to cause an accident, but combined can result in an error.  Patients must become involved and informed about their treatment.  Everyone has a role in patient safety, and all will benefit from its successes when patients and caregivers communicate more effectively.

Here are some suggestions from the National Patient Safety Foundation:

  • Keep track of your history: Include medical conditions you have, allergies, hospitalizations, etc.
  • Have the names of your pharmacy, doctors, and clinics ready for quick references.
  • Become a more informed health care consumer: seek information about illnesses or conditions that affect you.  Don’t hesitate to ask questions of your doctor, nurse, pharmacist, or insurance coordinator.
  • Work with your doctor and other health care professionals as a team: give up to date information to everyone who is treating you.  Be sure you understand the care and treatment you will be receiving.
  • Pay attention.  If something doesn’t seem right, call it to the attention of your doctor or health care professional.
  • Involve a family member or friend in your care.  If you are not able to observe or participate fully in your care, ask a family member or friend to help you.  Everyone should have an advocate – a friend or family member, especially for check-in and discharge or doctor’s visits.
  • If you have to be in the hospital, bring a notebook with a list of your medications.  If questions arise, write them down.  Take a big bottle of hand sanitizer, and place it by your bed to remind you and the staff to keep hands clean.
  • Follow the treatment plan agreed upon by you and your doctor.  Ask questions about any instructions that are confusing or unclear.  Take medications exactly as prescribed.  Report anything unusual to your doctor.

Infections can occur after many types of medical procedures.  This is particularly true if you have surgery.  My husband contracted a Strep B infection after hip surgery, which required six weeks of home health care.  Staph infections are very serious and difficult to get over, so both the patient and staff must take all precautions to not allow an infection.

Remember, you are your best advocate when it comes to your health.  Don’t be afraid to ask questions if you didn’t understand the first time.  Especially when in the hospital, and you have waited for the doctor to make rounds, have your questions ready so you won’t forget important things to ask.  Our hospitals are there to help restore us to good health.  They are making strides to correct errors that have been made in the past.  Many times our lives may be in the hands of nurses and physicians.  It is only right to hope for the best care possible.

General Safety Issues, Health Issues

WHEN IT COMES TO PATIENT SAFETY, YOU MUST BE YOUR OWN ADVOCATE!

We are all human, and make mistakes, but in the field of medicine, errors may be costly.  In a recent report by the Institute of  Medicine, between 44,000 and 98,000 people die in U.S. hospitals as a result of medical mistakes.  More persons die from medical errors than motor vehicle accidents, breast cancer, or Aids.

Most people hate to ask their doctors many questions, because they are intimidated by the fact that the doctor is busy and in a rush to get to the next patient.  You are as important as that next person.  If you leave your doctor’s visit with questions on your mind about a certain procedure or medication they have prescribed, you are putting your complete faith in them.  You must be an integral part of your healthcare team.  If you have children or elderly parents, you are a very important member of their healthcare team! 

Be sure to tell your physician every type of medication you are taking, vitamins, herbs, over-the-counter drugs, as well as all prescriptions, and any adverse reactions you have had in the past to certain medications.  If you have trouble reading the doctor’s script, ask him the name of it, and be sure your pharmacists can read it, as well.  This is one way to ensure that a mistake won’t be made.  Most pharmacies include written instructions and information on side effects of the medicine, so be sure you read that completely. 

Medical errors can occur in hospitals, clinics, doctor’ offices, nursing homes, patient homes, or outpatient services.   Mistakes can be made during operations, diagnostics, with equipment, reading lab reports, or from a routine task such as giving a high-salt meal to a patient on a salt-free diet.  Hospital patients should ask their health care workers if they have washed their hands before touching them; hospital-associated infections are very common.  The American Academy of Orthopaedic Surgeons urges its members to initial the surgery site prior to surgery; you want to be sure they are putting a new joint in the right place! 

Should you receive a diagnosis that you question, make arrangements to see another physician, someone who is not associated with your doctor.  Getting a second opinion is very important in certain illnesses.  Sign a release to pick up your lab work results.  Too often the nurse will call and say “everything’s fine,” and hopefully it is.  But they may miss some critical part of the report, and it doesn’t hurt to ask a professional to look at your results.  Your doctor may not make the mistake; it could be a radiologist or pathologist that may misinterpret the x-rays or other tests.  My physician asked one time for a third reading of an x-ray for me because two radiologists came up with completely different diagnoses.  He sent it to a third one, whose opinion barely agreed with one of the others.  If that happens, who are you to believe?  It can be very scarey.

We aren’t undermining hospitals and physicians in any way; they are diligent in their efforts to keep us well.  It is merely an effort to encourage you to be involved and understand what is going on anytime you are being cared for.  Don’t be afraid to ask questions.  From experience, most of us have sat in hospital rooms with family members and wondered if the outcome would have been different if we had asked for more information.  If you feel that you or a family member is not being attended as you/they should be, speak up.  Remember, you must be the guardian for yourself, as well as your loved ones.

 

Source: AHRQ.gov