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Patient Safety Monitor is the premier online destination for news, analysis, and training in the patient safety community.

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  • Patient Safety Crosswalk: an interactive grid that organizes state, CMS, and Joint Commission requirements by topic
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  • Tools Library with sample forms and policies
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Patient Safety Monitor Journal

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.

  • Bringing innovation to your facility

    Editor’s note: Healthcare innovation involves doing something differently than how it’s normally done, whether it’s a new device, policy, or program. Many of these evidence-based practices, promising studies, and groundbreaking programs are never adopted outside their test facilities. Many fail to work or fall short of expectations when implemented elsewhere. And it’s often difficult to get buy-in from healthcare staff and leadership on a new way of doing things.

    PSMJ spoke with Craig Deao, MHA, senior leader at Studer Group, about how to tell whether a new innovation can work at your facility and how to successfully implement it.



    Q: Reading the news every day makes it seem like the healthcare field abounds with “proven methods” and “evidence-based” innovations that could improve healthcare. Is that the reality?
    Deao: For the most part, yes. I remember reading in the IOM’s 2001 Crossing the Quality Chasm that “it takes an average of 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven.”

    And [17 years] is just the median, so there’s still half the market that hasn’t adopted the practice. So there are tons of best practices that are nowhere near application yet. There’s a good case to be made that applying what is already known would drive an incredible amount of gains in quality (and lower cost). We see this every day in our work, where organizations are struggling with a specific metric yet have not hardwired known best practice.

    On the other hand, it’s also true that not every problem can be solved by applying a rules-based solution that worked elsewhere. There are legitimate differences in context that require art as well as science. The art is about knowing the difference between adapting best practices (changing them to fit the context) versus wholly adopting them. The trick is adapting without messing up why it works in the first place. Too often we see organizations adapt best practices to the point that they’re no longer as effective. So, it’s a fine line to walk.

    It’s not just about adopting best practices to achieve our goals, but I’d say that’d get us about 90% of the way there.  

    Q: How many innovations end up being adopted on a widespread scale in healthcare field?
    Deao: Not enough. We often think of innovation as doing new things. But in healthcare, some of the best innovations are deciding what not to do—especially when the current practice has no evidence basis. The “Choosing Wisely” campaign is an excellent resource for both clinicians and patients that identifies lists upon lists of medical practices that should be questioned because they have no medical evidence to support their usage. Yet we still give too many antibiotics for colds and too many x-rays for low back pain.

  • Mixing medicine

    No physician or nurse injects medicine into a patient’s blood planning to make the patient sicker. Sadly, that’s exactly what happened to scores of providers back in 2012. This June, the former president of a Boston compounding pharmacy was sentenced to nine years in prison for racketeering and mail fraud after his company’s products caused a fungal meningitis outbreak, infecting 778 patients nationwide and killing 76.

    Many hospitals, clinics, and pharmacies compound their own medicines for a variety of reasons. Sometimes the medicine patients need isn’t available commercially. Sometimes they’re mixed together so the patient only needs one IV instead of having two. Commonly, medicines are mixed into large-volume solutions. And while the Boston case was exceptionally horrific in scope, every compounding facility runs the same risks when trying to compound safe, sterile drugs.

    Joint Commission and USP
    In January, The Joint Commission unveiled a Medication Compounding Certification (MCC) program that’s open to all compounding pharmacies, not just those accredited by The Joint Commission. The accreditor also called upon healthcare providers to work toward the elimination of medication compounding–related infections (MCRI) like the meningitis outbreak.

     “The health care community, including The Joint Commission, recognize that as the need for compounded medications continues to grow it is more important than ever to ensure safe policies and procedures are being appropriately and effectively implemented to prevent patient harm,” wrote Robert Campbell, PharmD, Joint Commission field surveyor, in a blog post.

    Meanwhile, the U.S. Pharmacopeial Convention’s (USP) Chapter <800> will become fully enforceable by regulators on July 1, 2018. Its regulations aim to protect the 8 million American healthcare workers who are potentially exposed to hazardous vapors/particles from the substances used in compounding each year. The chapter talks about the physical environment and equipment needed to maintain sterility and avoid inadvertently contaminating the employee. USP also has other extant chapters on sterile compounding, such as Chapters <797> and <795>.

    Complexity and risk
      Kurt Patton, MS, RPh, former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting in Naperville, Illinois, says the big risk of compounding IV products is failing to maintain the product’s sterility. When that happens, bacteria or molds could be introduced into the patient’s system.

    “To try and make a sterile product you can deliver intravenously is not as easy as making an oral product,” he says. “Keeping or maintaining sterility is the difficult challenge, but it’s essential when you’re talking about a product going directly into the bloodstream. If you or I ate a product that contained some contamination, once it got into the GI tract, to a large extent our GI tract helps protect us. But if you deliver that same bacteria into the bloodstream, you don’t have that same level of protection.”

     “When not mixed in sterile conditions, compounded medicines can cause multiple types of infections, including bacterial bloodstream infections and cases of fungal meningitis,” he adds.

  • Diagnosing human trafficking when a patient is a victim

    Physicians, nurses, and healthcare staff are in a unique position to help the human trafficking victims who walk through their doors. But for that to work, providers first need to know how to identify them.

    There’s an estimated 1 million human trafficking victims living in America—a population roughly the size of Delaware. And statistics from the National Human Trafficking Hotline and the Polaris BeFree Textline show that reported cases of human trafficking increased 35% in 2016.

    But the statistic most relevant to healthcare providers is this one: 87% of trafficking victims visit a provider at least once during their captivity and aren’t recognized as victims. These patients tend to live short, harsh lives, and less than 1% of them are rescued each year.

    To change those numbers, the National Association of Pediatric Nurse Practitioners (NAPNAP) is launching a new national initiative on human trafficking and healthcare. The initiative will include tools for human trafficking awareness and prevention in healthcare, as well as the formation of the Alliance for Care Coordination of Children in Human Trafficking.

    NAPNAP will be reaching out to stakeholders in the coming months to work with the Alliance on ensuring continuity of best practices in identification, treatment, and referral protocols. They’re seeking to unite professionals from healthcare, mental health, social service, law enforcement, and legal industries to coordinate public education, best practices, and resources. One of NAPNAP’s resources, online continuing education modules for all pediatric healthcare providers, will go live in August on PedsCESM.

    Jessica Peck, DNP, RN, MSN, CPNP-PC, CNE, CNL, an associate professor of nursing at Texas A&M University College of Nursing in Corpus Christi and a former NAPNAP board member, says the problem of human trafficking is widespread.

    “Trafficking occurs in every community, in every clinical setting,” she says. “All healthcare providers should be aware of signs of potential human trafficking.”
     

  • Be prepared for summer patient safety hazards

    Hospital EDs are extremely busy during the summer months because of accidents and injuries. While there’s no word yet on whether 2017 will break a heat record (though we hope not), you can expect it to bring a familiar brand of dangerous situations. But are you prepared for them?

  • The impact of cybersecurity on patient safety

    In the TV show Mr. Robot, there’s a scene where the main character hacks his hospital’s computer system to change his drug test results from positive to negative.  Naturally, doing such a thing in real life isn’t as easy as the show makes it out to be. But it does touch upon a real problem in today’s healthcare system: Computer crimes can have real-world effects.
     

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