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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.

  • How to prevent maternal mortality

    Maternal mortality is a measure of how many mothers die from pregnancy-related complications while carrying or within 42 days after birth. And in most of the developed world, this number has fallen to historic lows.

    But not in the U.S., where the maternal mortality rate (MMR) has grown 2.7% between 2000 and 2015. Annually, there are 700–900 maternity deaths, 60% of which are preventable. An additional 65,000 people nearly die due to pregnancy complications.

    For perspective, the U.S. MMR is 26.4 deaths per 100,000 live births. In Kazakhstan, the MMR is 26.5 per 100,000. But unlike America, Kazakhstan’s MMR has fallen 5.6% over the past 15 years.

    America’s maternity deaths are even worse when compared to other developed nations. The United Kingdom has an MMR of 9.2, down 2.5% since 2000. In fact, a British man is “more likely to die while his partner is pregnant than she is.” And the UK’s MMR is higher than that of Sweden (4.4), Norway (3.8), Ireland (4.7), Italy (4.2), and many others. 

    While this is bleak news for providers and patients, there are signs of hope out west. In the past decade, California has been the only state to buck the national trend and reduce MMR, down to seven deaths per 100,000. California hospitals have adopted a number of guidelines and best practices around maternal care, blood loss, C-sections, pre-conception planning, and other topics.

    While these tools and guidelines haven’t been implemented nationwide yet, they have great promise in reversing this disturbing health trend in American hospitals and clinics.

    Maternal mortality complications
    Michelle Genova, RNC, MSN, executive director of women’s services at St. Joseph’s Hospital in Orange, California, says the rise in maternal mortality is linked to the rise in chronic health conditions in women, such as high blood pressure, obesity, diabetes, hyper-tension, blood clots, etc. St. Joseph’s is the second largest obstetrics hospital in southern California and conducts 5,000 deliveries and 3,500 outpatient preg-nancy-related visits each year.

    These chronic conditions can be extremely detrimental to pregnancies if not properly managed, Genova says. There are also new concerns over the impact congenital anomalies have on maternal mortality.

    “Specifically cardiac anomalies and some others [in people] that are surviving into womanhood and having children of their own,” she says. “Those kinds of situations are new to this generation of people and something we have to take into consideration.”

    Randy Fiorentino, MD, an obstetrics/gynecology physician at St. Joseph’s, says age is a large determinant in maternal mortality rates, and many women in the U.S. are getting pregnant at older ages.

    “When they’re starting their families and childbearing in their 20s and their early 30s, they have much less chronic health conditions,” Fiorentino says. “When women start their families over the age of 35 and 40, there’s a lot of other chronic health conditions that affect pregnancy.”

  • Service animals in the ER

    At a Roaring 20s party this summer, I saw a flapper in a sparkly dress dance with her service dog, a husky in a red vest. The woman was having a great time, though the dog seemed confused by the whole situation.

    While it was funny to watch then, what if the next day she and her service dog went to your hospital or clinic? Do you know if the dog can ride with her in an ambulance? Is the dog allowed in every area of the hospital? Who takes care of it if the patient becomes incapacitated during care?

    Odds are you’ve probably seen service animals working in a variety of places: grocery stores, state fairs, restaurants, airports, offices, hotels, museums, etc. And in (most) situations, these animals don’t pose a problem. However, when anyone brings an animal into a healthcare setting, it’s reasonable to consider if its presence might pose a risk.

    While fleas, ticks, mites, and more could undermine a facility’s pest and infection control efforts, facilities must also respect the rights of patients and visitors with disabilities to have service animals. Both The Joint Commission and Medicare Conditions of Participation require that hospitals respect and protect the rights of patients.

    That said, balancing the need to keep medical settings safe and clean against the rights of patients with disabilities to bring service animals with them isn’t always easy. Applying the law correctly and consistently requires a significant amount of pre-work and communication, both within the organization and with the public.

    The Americans with Disabilities Act
    Generally speaking, government bodies, businesses, and nonprofit organizations that serve the public are required under the Americans with Disabilities Act (ADA) to permit service animals in their facilities.

    The ADA supersedes any and all breed-specific bans and prohibits facilities from requesting documentation to prove that the animal is a service animal. But there are limited circumstances in which covered entities can exclude such animals, according to the Disability Rights Section of the U.S. Department of Justice (DOJ), Civil Rights Division.

    “For example, in a hospital it would be inappropriate to exclude a service animal from areas such as patient rooms, clinics, cafeterias, or examination rooms,” the DOJ explained in a summary of the ADA’s provisions. “However, it may be appropriate to exclude a service animal from operating rooms or burn units where the animal’s presence may compromise a sterile environment.”

    The ADA has a service animal fact sheet and an FAQ page on the topic.

  • How to spot suicide and ligature risks in your facility

    The handles on the box springs of patient beds in residential areas. The caulking along the wall of otherwise-solid grab bars in showers. Any loops that might hold mattresses onto a bed frame. All of those and more have been cited as potential ligature risks by The Joint Commission and CMS surveyors in the last few months as they have stepped up inspections in the physical environment for suicide hazards in hospitals.

    While last year The Joint Commission issued a Sentinel Event Alert to hospitals urging them to do a better job of identifying suicidal ideation in patients, this year the accreditor is doubling down, issuing specific warnings in Joint Commission publications and FAQs outlining concerns about ligature, or hanging, risks.

    A complete reassessment of the physical environment of the areas where patients with behavioral or mental health problems are cared for could be in order, say consultants and accreditation managers with recent experience in the issue.

    The Joint Commission warns that a finding of significant risk could spur a call for immediate threat to life (ITL), which could threaten your hospital’s accreditation. That and a renewed focus on the physical environment by CMS might require building or equipment changes, warns at least one consultant.

    Even smallest risk is significant
    Patients remain both creative and stubbornly persistent in finding even the smallest opening to self-harm that a hospital might leave behind in a treatment area or patient room. Often that small opening is quite literal.

     A nurse leader in accreditation and quality in a western U.S. behavioral health hospital warns against being lulled into a false sense of security even with physical features designed to mitigate suicide or other self-harm. The hospital had a near miss with a patient who took advantage of loose caulking along the solid metal plate fastening a shower grab handle to the wall.

    After creating a hole, the patient then unraveled a thin but strong nylon thread from a piece of clothing and strung it through the hole to create a ligature. The patient was attempting to tie the other end of the thread around the neck when discovered.

    The grab handle was the kind often recommended for areas where patients who might harm themselves are treated. No one on staff would have thought it possible “had we not seen it for ourselves,” says the manager, who asked that her name not be used. As part of the hospital’s sentinel event response, facility staff examined all the areas where such rails meet or attach to the walls and added caulking where necessary. Now they conduct regular inspections of the caulking to ensure it hasn’t begun to break down.

  • Staff should be alert for mislabeled drugs

    Remind nurses and other clinicians to remain alert for medication errors, including mislabeled products, and empower them to say something if they suspect a problem.

    After a customer complaint, C.O. Truxton Inc., a New Jersey drug company, issued a voluntary recall of a batch of phenobarbital tablets that was twice as strong as the dosage indicated on the label.

    According to the April 21 announcement by both the FDA and the company, Truxton recalled lot no. 70952A of phenobarbital tablets, USP, 15 mg, after confirming the customer had received a bottle labeled as 15 mg tablets that was found to contain 30 mg tablets instead.

    Examine new products thoroughly
    Checks and cross-checks in manufacturing and production should prevent these kinds of errors, notes Kurt Patton, MS, RPh, a pharmacist by training and a former director of accreditation services for The Joint Commission.

    “Unfortunately, these types of errors still happen when people validate or check too quickly. Today there should also be bar coding support to prevent errors like this, but that can go wrong, too. FDA issues an extensive list of recalls every month,” says Patton, founder of Patton Healthcare Consulting.

    “Hospitals should be prudent purchasers, purchasing from entities they know and trust, or the buying group they participate with knows and trusts the manufacturers. When new products arrive, they should always be examined thoroughly,” he notes.

    Report adverse reactions
    Sometimes the appearance of medications can vary by manufacturer. “Pharmacists or nurses might notice different color capsules, different size tablets, different numeric markings on the tablet, or different-than-expected reactions from their patients,” Patton says. “The number of different generic manufacturers and brand switches that occur today is much greater than in the past, but still when you notice something different, you should question it.”

    “When patients mention that the new product made them much more sleepy, or did not help them sleep, or [the patient is] dizzy or whatever—that is another good reason to question the changed drug,” he advises.

    The FDA recall includes a description of the drug and bottle, and says Truxton is notifying all customers it has on record as purchasing the mislabeled product. As always, the FDA is encouraging all healthcare professionals and patients to report adverse events or side effects through the MedWatch program.

  • 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.

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