Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.
Q&A: How to respond to the WHO's top 12 superbugs list
Q&A: How to respond to the WHO’s top 12 superbugs list
Editor’s note: In February, The World Health Organization (WHO) published its first list of a dozen families of antibiotic-resistant “priority pathogens” that pose the greatest threat to humanity.
"This list is a new tool to ensure R&D responds to urgent public health needs," said Marie-Paule Kieny, WHO's assistant director-general for health systems and innovation, in a press release. "Antibiotic resistance is growing, and we are fast running out of treatment options. If we leave it to market forces alone, the new antibiotics we most urgently need are not going to be developed in time."
The pathogens on the list were chosen based on:
• How long a hospital stay they require
• How frequently they’re resistant to existing antibiotics
• How contagious they are
• Whether they can be prevented through things like good hygiene and vaccination
• The number of treatment options available
• Whether there are new antibiotics to treat them in the research and development (R&D) pipeline
The following is an edited Q&A about the WHO’s list with Jennifer Pisano, MD, medical director of the antimicrobial stewardship program (ASP) at the University of Chicago Medicine and Biological Sciences, and Trevor Van Schooneveld, MD, FACP, medical director of the University of Nebraska Medical Center’s ASP, program director of its infectious disease fellowship, and associate professor in its Division of Infectious Disease. The interviews were conducted separately.
PSMJ: Why is it so hard to develop new antibiotics? Are there any reports or signs of new antibiotic(s) coming out in the next five years?
Pisano: It is very expensive to develop any drug, and antibiotics are particularly difficult. A lot of times it’s likely not worth a pharmaceutical company investing the money into creating a drug that will only be used for a short period of time (around seven to 14 days) when drugs that people take for lifestyle diseases like HTN [hypertension] and DM [dermatomyositis] are taken for much longer periods—often a lifetime.
Additionally, since there’s a bigger emphasis on stewardship programs and saving drugs for when you really need them, any new antibiotic likely will be restricted to “save” it and hinder the development of resistance. It has been frustrating that even with the new antibiotics that have come out to treat resistant Gram-negative infections, they’ve offered new beta-lactamase inhibitors but not necessarily new mechanisms of action.
Van Schooneveld: The process of developing and obtaining regulatory approval for a new antibiotic takes roughly 10 years and many hundreds of millions of dollars. There are new antibiotics in the pipeline, but there are not very many, and there are very few truly new antibiotics. Additionally, there are very few new antibiotics which will have activity against some of these highly resistant pathogens.
Bringing universal suicide screening to your hospital
With suicide rates high and getting higher, hospitals and clinics need to revamp how they work with suicidal patients. The first step is developing a system to identify struggling patients so they can get the care they need.
In 2014, the Parkland Health and Hospital System (PHHS) in Dallas became the first in the nation to establish a universal suicide screening program (SSP) in all its departments. The program screens every admitted patient for suicidal ideation, regardless of the patient’s chief complaint or estimated risk. The screening is incorporated into PHHS’ electronic health record (EHR), and the entire staff have been trained on suicide screening and prevention.
Since the go-live, PHSS has achieved almost 100% program compliance, screened over a million patients, collected invaluable suicidal ideation data, and helped countless patients get the care and treatment they need—all without slowing down hospital workflow or straining resources.
Celeste Johnson, DNP, APRN, PMH CNS, PHHS director of nursing and psychiatric services, and Kimberly Roaten, PhD, director of quality for safety, education, and implementation in the system’s department of psychiatry, were the driving forces behind PHHS’ universal SSP. The two presented an HCPro webinar on the topic in February (visit http://hcmarketplace.com/suicide-risk-screening for more information).
“There’s many people out there who’ve contemplated suicide who may not voice that when they’re coming in for a medical complaint,” said Johnson. “We’re missing a lot of folks who are coming to us every day. That’s what the research shows.”
According to the CDC, suicide is the seventh leading cause of death for American men, the 14th for American women, and the 10th overall. In 2013, the agency found that 9.3 million adults had suicidal thoughts, 1.3 million attempted suicide, and 41,149 died. In addition to the loss of life, suicides cost $51 billion annually in combined medical and work costs. Even more worrying is that the rate of suicides has increased 24% between 1999 and 2014.
At the healthcare level, there’d been limited information on the number of patients considering suicide who were seeking treatment for other issues. In that regard, the data gathered at PHHS has been eye-opening. Out of the 502,000 patients who visited the health system in 2015, 14,900 were screened as moderate suicide risk, and 5,249 were high risk. That's equal to one out of every 25 patients experiencing suicidal thoughts.
PHHS also found that people who commit suicide often have contact with the healthcare system before their deaths. Within the year prior to their death, 77% of people who committed suicide have contact with a primary care physician, 40% have contact with an ER physician, and 24% have contact with a mental health provider.
ECRI: The rules on copying and pasting medical information
In 2016, the ECRI Institute’s Partnership for Health IT Patient Safety released its Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. The toolkit outlines the risks and benefits of reusing medical information in electronic health records (EHR), along with four safe-practice recommendations on copy and paste policies. It also provides checklists, educational materials, and implementation tools to assist in identifying hazards and adopting safety practices.
The toolkit and its recommendations were derived from evidence-based studies, reported events, and the expertise of organizations such as the American Health Information Management Association, the AMA, Agency for Healthcare Research and Quality (AHRQ), and the American College of Physicians. Its information and materials can be equally applied to facilities, healthcare organizations, vendors, and individual clinicians.
Lorraine Possanza, DPM, JD, MBE, program director of patient safety, risk, and quality at the ECRI Institute, says people are often unaware of the role copy and paste can have in adverse events and hazards.
“Oftentimes instances of copy and paste go unreported and are often under-recognized for their contribution to events and hazards,” she says. “This was one of the reasons that the Partnership chose to focus on this issue.”
The ECRI toolkit says that between 2013 and 2015, there were only 12 copy and paste errors. However, Possanza says that’s just the number of events voluntarily sent to ECRI. Facilities aren’t required to report copy and paste errors, nor is there any guidance on whom they should report to; therefore, the exact number of errors is hard to determine. This is similar to how The Joint Commission’s Sentinel Events statistics only show a small portion of the never events that occur each year. And unlike other types of accidents (like medication errors or falls), it’s not always apparent when there’s been a copy and paste error.
“Recognizing whether health IT, and in particular copy and paste, contributes to an event is not always straightforward,” she says. “The goal [of this toolkit] is to increase awareness of the potential safety implications associated with this functionality and to implement recommendations to mitigate those safety issues.”
Innovation in pursuit of high-reliability culture
The Institute of Medicine sent waves racing across the surface of American healthcare when it published To Err Is Human in 1999. The unsettling report suggested medical errors were killing at least 44,000 and as many as 98,000 patients nationwide each year. Even the lower end of that spectrum would rank such mistakes eighth among leading causes of death—ahead of breast cancer, AIDS, and motor vehicle accidents.
The report challenged the self-perception of modern healthcare personnel and inspired reforms designed to prevent errors or at least catch them before they impacted patients. Ambitious goals were set. But the path forward proved complex, and the fallout from that disturbing report continues to ripple from coast to coast as innovators pursue what has become known as “high-reliability culture.”
Almost every hospital in the country has in recent years pursued initiatives to improve quality and safety in one or more key areas, says Brent Ibata, PhD, JD, MPH, FACHE, research compliance officer for Sentara Healthcare based in Norfolk, Virginia.
“But they’re doing it in what I call a ‘whack-a-mole’ approach,” Ibata says. “There’s very few hospitals that are stepping back and taking it from a cultural perspective.”
Although patient safety advocates have made strides in the past two decades, getting an entire medical staff to embrace high-reliability culture—also known as becoming a high-reliability organization (HRO)—requires a drastic shift in thinking, Ibata says.
“The big picture is we’re making fantastic progress in avoiding the big avoidable things,” Ibata says. “We’re making incremental progress in avoiding the higher-hanging fruit.”
FDA ban on powdered medical gloves now in effect
The Food and Drug Administration’s (FDA) ban on powdered medical gloves went into effect on January 18. It’s now forbidden to use, advertise, and market powdered surgeon's gloves, patient examination gloves, and absorbable powder for surgeon's gloves at medical clinics and hospitals.
The Joint Commission also announced that all accredited programs are expected to comply with the FDA’s ban. Joint Commission surveyors will now issue citations on the ban under LD 04.01.01 element of performance (EP) 2.
Powders have been used to lubricate gloves for easy removal for more than 100 years. But since the 1930s alone, the type of powder used on medical gloves has been changed three times due to various medical risks. The powder currently used in medical gloves came under fire in 1997 when an FDA report found that it could cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Furthermore, aerosolized glove powder on natural rubber latex (NRL) gloves can carry allergens that can spark a respiratory allergic reaction in a patient or wearer.
“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”
The current ban was published in March 2016 and was the result of three citizen petitions sent to the FDA between 2008 and 2011. That said, the FDA was certain of the harmful effects of powdered gloves back in 1997, but it chose not to ban them due to a lack of alternatives. The most common lubrication alternative at the time was chlorination, which was known to damage gloves’ material. The agency believed a ban at that time would cause a medical glove shortage or promote the use of unsafe alternatives.
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