Transitions in Care: A Challenge and an Opportunity
Transitions in care occur any time that a patient moves from one healthcare setting to another setting or to home. This transition is a very vulnerable time when information that is not adequately conveyed or understood can lead to unnecessary health crises. In fact, the Medicare Payment Advisory Committee (MedPAC) estimated that up to 76 percent of rehospitalizations occurring within 30 days of a medicare patient’s discharge are potentially avoidable.(1)
Adverse Event Reporting Drives State-Wide Shared Learning
In recent decades, advances in knowledge and technology have considerably increased not only the capabilities of modern healthcare but also the complexity of healthcare systems. The unique combination of processes, technologies, and human interactions means that our healthcare systems are among the most complex in the world. With those complexities comes the inevitable risk that things will not always go as planned and adverse events (many resulting in patient harm) will occur.
How healthcare organizations respond to adverse events is representative of their culture of safety. The cornerstone of a strong culture of safety is transparency about adverse events. By reporting adverse events, organizations are able to learn and improve their complex systems. (Read about the connection between reporting and a culture of safety in one Oregon hospital in Linking Transparent Reporting and Safety at Asante.) A good internal reporting system can help identify potential risks, promote learning from experiences, and play a role in monitoring the progress of improvement efforts. However, sharing lessons among internal staff and teams is only the first step. Lessons learned can be shared externally so that other organizations can benefit as well.
Patient Safety: 7 Days a Week, 365 Days a Year
Over ten years ago, the National Patient Safety Foundation established Patient Safety Awareness Week as an annual healthcare safety education and awareness campaign. This year, Patient Safety Awareness Week runs March 3-9 and is marked by the theme “Patient Safety 7/365”—seven days to celebrate the progress healthcare professionals and organizations have made in patient safety, and 365 days to recommit to the challenges that remain. The patient safety movement has come a long way on the path to making healthcare safer for patients. For example, catheter-related bloodstream infections and ventilator-associated pneumonias were historically considered to be known, unavoidable risks. The ongoing dedication to patient safety by healthcare providers across Oregon and the nation has proven that issues like these are, in fact, preventable.
Take Action to Beat Winter Infections
Oregon, like the rest of the nation, is currently experiencing a confluence of respiratory and gastrointestinal illnesses (Oregonian, January 11, 2013). News reports across the country are telling stories of emergency room departments being slammed with patient visits and mayors declaring public health emergencies and encouraging those without high risk conditions or with non-emergent illness to remain home.
As of January 19, the Oregon Health Authority’s Public Health Division reported that Oregon is experiencing high influenza-like illness activity across the state. There have been 124 influenza-associated hospitalizations reported in Clackamas, Multnomah, and Washington counties since October 1, 2012. Additionally, the Oregon Health Authority reported to the Commission that there were 89 outbreaks of gastroenteritis reported during December and January with 36 confirmed, and many others suspected, to involve norovirus. The Oregon Health Authority confirmed that the new Sydney norovirus strain has been identified in Oregon.
What can healthcare organizations and staff do to respond to the current level of illness? Consider the following actions you can take to keep healthcare employees and patients safe during the winter season:
Risk Mitigation for Patient Safety
Safety is, and should be, a top priority in every healthcare organization. Not only is safety a basic patient expectation, but safety can have a considerable impact on a healthcare organization’s reputation. In addition, an organization’s ability to provide safe patient care can impact accreditation status and even reimbursement levels. Healthcare organizations must develop strategies that mitigate or reduce the risk of patient harm. Such risk-mitigation strategies should be implemented to support the organization’s safety culture, and should be designed to target and strengthen the healthcare delivery system to proactively assure safety.
Is Your Organization Health Literate?
Health literacy— the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate healthcare decisions – is a significant issue in the United States . More than 36% of our adult population (approximately 80 million people) have poor health literacy . Healthcare organizations must build systems that make it easier for people to understand the healthcare information provided to them. Patients can then use the information and services offered to understand their own health and more effectively navigate the healthcare system. Paying strong attention to health literacy in your organization can lead to fewer patient safety-related events, improve patient satisfaction, and lower the overall cost of care.
In June 2012, the Institute of Medicine (IOM) released a discussion paper, Ten Attributes of Health Literate Health Care Organizations. The list of attributes is not intended to be exhaustive, but attempts to gather science and knowledge in the new field of health literacy. The paper is designed to assist organizations working toward health literacy, and offers various strategies for that work. Although individual organizations will likely choose different paths, these strategies, if embraced and implemented, can create wider access to, and deeper understanding of, healthcare services and healthcare information. This discussion paper may be most beneficial to healthcare organizations providing direct patient care. Some of the health-literate attributes discussed are also relevant to payers and health plans, vendors of health information technology, health education product vendors, accreditation and credentialing organizations, and benefits managers.
Building Strong Systems to Support Medication Safety
It can be challenging to design systems that support safe medication management practices and help reduce the number of preventable medication-related events (sometimes called adverse drug events or ADEs). There are a variety of process steps where breakdowns can occur: purchasing, storing, prescribing/ordering, transcribing, preparing, dispensing, administering, and monitoring medications. Despite these complexities, there are many strategies healthcare organizations can use to strengthen the medication management system and improve medication safety.
Advancing Safety Culture with Measurement
Measuring, analyzing, and sharing data is central to a culture of patient safety. Healthcare workers start each day wanting to provide high quality, safe care, but they need the right tools for the job. Using data to inform decisions and understand performance, healthcare organizations are able to track progress and identify problem areas to monitor risk for harm; however, measurement can’t be done in a vacuum.
For example, infection rates, days between events, or the number of patient falls, can all be utilized to determine if interventions are working and to sustain improvements. External reporting programs can also help inform the safety culture. The Commission offers insights into the frequency and type of adverse events occurring across Oregon healthcare facilities. For a look at the aggregate reports available for your facility type, information is available on the Commission’s website under reporting programs.
Improving Patient and Employee Safety Through Influenza Vaccination
Influenza is a highly contagious disease that, according to the Centers for Disease Control and Prevention, results in about 226,000 hospital admissions and 36,000 deaths annually. The Oregon Emerging Infections Program reported that there were 228 laboratory-confirmed influenza-related hospitalizations in Clackamas, Multnomah, and Washington counties during the 2010-2011 influenza season.
Recent evidence indicates that healthcare workers can unintentionally expose patients to seasonal influenza if the workers have not been vaccinated. Healthcare workers may carry the influenza virus even if they are not displaying any symptoms. One study showed that among healthcare workers whose blood test showed evidence of recent influenza infection, 59 percent did not remember having influenza and 28 percent could not recall any respiratory infection (Elder et al., 1996). Regardless of whether healthcare workers know they are sick, they can transmit the influenza virus to others, including patients who may be at high risk for complications from influenza.
Preventing Harm through Proactive Assessment of Risk
For years, patient safety professionals have worked to prevent harm to patients. The Institute of Medicine (IOM) defines safety as freedom from accidental injury and explains that “patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in healthcare…Although not all errors cause injury, accidental injury can be due to errors, defined by the IOM as either 1) the failure of a planned action to be completed as intended or 2) use of a wrong plan to achieve an aim” (Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press).
Learning from Experience to Improve Patient Safety
In seeking to improve safety, one of the most frustrating aspects for patients and professionals alike is the apparent failure of health-care systems to learn from their mistakes. Too often neither health-care providers nor health-care organizations advise others when a mishap occurs, nor do they share what they have learned when an investigation has been carried out. As a consequence, the same mistakes occur repeatedly in many settings and patients continue to be harmed by preventable errors.
-World Health Organization, 2005
In complex healthcare systems, a majority of problems are caused by breakdowns in system and processes, not by poor practices or incompetent practitioners. The World Health Organization (WHO) has recognized that “We know that most problems are not just a series of random, unconnected one-off events. We know that health-care errors are provoked by weak systems and often have common root causes which can be generalized and corrected. Although each event is unique, there are likely to be similarities and patterns in sources of risk which may otherwise go unnoticed if incidents are not reported and analyzed” (World Alliance for Patient Safety, 2005). One of the Oregon Patient Safety Commission’s primary goals is to identify these events and learn from them in order to improve the healthcare system.
Patient Safety Then and Now
Each year, the National Patient Safety Foundation leads Patient Safety Awareness Week, an annual education and awareness campaign for healthcare safety. This year, Patient Safety Awareness Week runs Sunday, March 4 through Saturday, March 10 with the theme Be Aware For Safe Care. The theme encourages both healthcare providers and patients to take advantage of opportunities to learn how we can all contribute to making healthcare safer. In honor of Patient Safety Awareness Week, we reflect on some of the patient safety movement’s beginnings and one of the most critical factors necessary to improve patient safety – establishing a culture of safety.
Improving Patient Safety Through Provider Communication
A patient was given 30mg of Toradol in the operating room (OR); however, the medication was not reported to the recovery nurse. During the patient’s first 15 minutes in the post-acute care unit, the patient was restless and disoriented and complained of pain. One recovery nurse attended to the patient while a second recovery nurse retrieved Toradol per the post-operation orders. The first nurse drew up the Toradol and administered another 30mg to the patient, not knowing that the patient had already received Toradol in the OR. After the patient was resting and calm, the first nurse read through the chart, discovered her mistake, and immediately informed the anesthesiologist and surgeon.
-Event reported to the Commission
The Agency for Healthcare Research and Quality (AHRQ) recently released the sixth annual edition of the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, which provides survey results from 567,703 staff from 1,128 U.S. hospitals. The survey revealed that handoffs and transitions were the second most commonly identified area needing improvement. AHRQ reported that “only 45 percent of hospital staff have positive perceptions of handoffs and transitions across hospital units.”
Engaging Patients & Families for Safe, Quality Care
A 71 year-old male was discharged home following a colonoscopy. A short time later the patient started having progressively severe abdominal pain and went to the ED where a CT scan revealed evidence of a bleed and a slightly enlarged spleen. It was discovered that the patient had not discontinued his Coumadin prior to surgery as indicated in his pre-surgical instructions. He was admitted for monitoring and received six units of blood.
- Event reported to the Commission
Breakdowns in communication were one of the top three leading root causes of sentinel events reported to The Joint Commission in the United States between 2004 and 2011. These communication breakdowns occurred among healthcare professionals and also between healthcare professionals and patients or families. The Oregon Patient Safety Commission’s aggregate summaries of events reported in 2010 by Oregon hospitals, nursing homes, and ambulatory surgery centers identified similar trends in Oregon. In hospitals, communication concerns were a contributing factor in two out of every three events reported (66% of the time). In both nursing homes and ASCs, communication was among the top three reported factors that contributed to adverse events.
