| Subject: Patient Safety News Bulletin: January 19, 2007 |
| From: "Jennifer Hayes" |
| Date: Fri, 19 Jan 2007 10:57:34 -0800 |
| To: |
Dear Patient Safety Consortium:
We hope that you find the following patient safety news of interest to
you and your organization.
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New
patient safety panel ready to focus on
hospitals'
reports of 'near misses'
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A new nonprofit organization responsible for
improving patient safety in
The corporation is holding a patient safety
awareness week in March," she said. "It's about empowering consumers
to ask questions and to not be afraid to ask nurses and doctors
questions. I think we take a lot for granted.
We don't know how to approach physicians and nurses, and we need to teach
people how to do that." The 15-member board of directors
for the patient safety organization represents hospitals, insurance companies,
the pharmaceutical industry and consumer groups. The board intends to hire a
full-time patient safety specialist next month to help forge relationships with
other patient safety organizations, to work with state regulatory agencies and
to seek private grant funding, she said.
To read the complete article, go to: http://www.naplesnews.com/news/2007/jan/13/new_patient_safety_panel_ready_focus_hospitals_rep/?local_news
Source:
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Physicians' Extended Work Shifts
Associated With
Increased Risk of Medical Errors
That Harm Patients
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First-year doctors-in-training reported that working
five extra-long shifts—of 24 hours or more at a time without
rest—per month led to a 300 percent increase in their chances of making a
fatigue-related preventable adverse event that contributed to the death of a
patient. Preventable adverse events are defined as medical errors that cause
harm to a patient. Interns were three times more likely to report at least one
fatigue-related preventable adverse event during months in which they worked
between one and four extended-duration shifts. In months in which they worked
more than five extended-duration shifts, the doctors were seven times more
likely to report at least one fatigue-related preventable adverse event and
were also more likely to fall asleep during lectures, rounds, and clinical
activities including surgery. The study, funded by AHRQ and CDC's National
Institute for Occupational Safety and Health, was published on December 12,
2006, in the online journal PLoS Medicine.
To read more about this study, “Impact of
Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional
Failures,” go to:
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Safety culture: Is the unit the
right unit of analysis?
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An excerpt from an editorial by David
Gaba, MD; Sara Singer, MBA and Amy Rosen, PhD. appearing in this month’s
Critical Care Medicine.
All healthcare
organizations strive to be high-reliability organizations, with excellent
outcomes and very low rates of failure, despite high intrinsic hazard and high
throughput. An essential element of being a high-reliability organization is
having a strong culture of safety. Many research groups have been trying to
understand and measure what safety culture really means, particularly in the
special context of hospital-based care. In this issue of Critical Care Medicine, Dr. Huang and
colleagues extend our knowledge about safety culture in the specific
high-hazard setting of intensive care units (ICUs), focusing attention
primarily on the comparison of different ICUs within a single hospital.
In particular, the
authors found that safety climate differed among the four ICUs studied inside
the same hospital. Particularly noteworthy (although not fully articulated by
the authors) is that one unit's personnel had collective safety climate scores
that were distinctly lower than those from other units on five out of the six
factors measured.
One interpretation of
these data is that there is a poor-performing ICU that needs to be fixed.
However, the authors point out that their data do not suggest inter-unit
variation in outcomes. On the surface, this unit has good results-it takes care
of many elderly patients, conducts significant interventions, but has a lower
actual-to-expected mortality rate than the other units. The outcome measures
examined are limited to mortality and do not include measures of morbidity that
might have been useful in further delineating the relationship between safety
climate and outcome. In addition, there may have been patient- and hospital-level
variables that were not taken into account, potentially confounding the
results. Further, the study may not be sensitive enough to detect a
climate-outcome relationship with only a few units sampled, and the small size
of the study makes it difficult to determine whether the differences found in
safety culture between units were due to statistical fluctuations or to true
differences.
Another interpretation,
equally plausible and consistent with findings from Anita Tucker and Amy
Edmonson, is that healthcare workers are incredibly resourceful and resilient,
working exceptionally hard to achieve good results, even when they encounter
major systemic problems in their work units or institutions. Lacking
demonstrable proof of poor outcomes, worker efforts to raise patient safety
concerns often fail to motivate management intervention, leaving workers to
address problems themselves. The workarounds they employ to achieve positive
results further hide the need for deeper problem solving and systemic change.
Coping with repeated
To read the complete article, go to: http://www.ccmjournal.com/pt/re/ccm/fulltext.00003246-200701000-00058.htm;jsessionid=FwNLQRdJwtDKSYr00FGBCWLzgVY2NvlPJTn1q8TLzB1hrjVPqZ15!990059801!-949856144!8091!-1
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New
color scheme for cleaning equipment
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A national
color coding scheme for cleaning materials has been launched, designed to help
hospitals in
Color coding
of hospital cleaning materials and equipment – for example red for
bathrooms or yellow for isolation areas – ensures that they are not used
in multiple areas and reduces the risk of cross-contamination. Although
most hospitals already have a color coding scheme for cleaning materials and
equipment, there is no consistency across the
In some
cases, even hospitals within the same trust have different schemes in place.
This presents a potential risk when domestic staff move from trust to trust or
from site to site.
To
standardize the system, free starter packs of posters and credit card-sized
reference guides illustrating the national color coding scheme will be sent to
every NHS organization in
“This
is a great example of a really simple, practical idea that’s easy to
implement and will have immediate benefits,” Murray Devine, safety
strategy lead at the Healthcare Commission, said. “A standardized
color code across the NHS will cut the risk of cleaning materials being used in
the wrong areas of the hospital, making hospital cleaning safer for patients
and easier for staff.”
The
Healthcare Commission plans to refer to the importance of color coding in a
revision of its inspection guides for assessing compliance with core standards.
Adoption of the national color code will also be monitored through the Patient
Environment Action Team (PEAT) inspection process.
Adapted
from: http://www.hesmagazine.com/story.asp?sectioncode=196&storyCode=2041430
SOURCE: Healthcare
Equipment and Supplies
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Conference:
Patient Safety in the Office-Based Surgery Setting
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The American Association for the
Accreditation of Ambulatory Surgery Facilities (AAAASF), in conjunction with
the Joint Commission on Accreditation of Health Care Organizations (JCHCO), the
Accreditation Association for Ambulatory Health Care (AAAHC), the
The Patient Safety Summit Conference
2007 brings together leaders of the major national healthcare accreditation
agencies to assess the impact of national accreditation processes for assuring
compliance with universal quality standards to lower risks and improve overall
safety of surgical procedures performed in ambulatory facilities. It is
estimated that 30 percent of all
For more
information, go to: www.aaaasf.org
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The Stanford Patient Safety Team
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