Ideas for patient safety: collaboration, transparency, more nurses in hospitals and nursing homes, surgical patients’ risk awareness

By Melissa Patrick
Kentucky Health News

Patient safety was the topic at the 2016 HealthWatch USA conference this month in Lexington, with health advocates calling for a more collaborative and transparent health-care system to better prevent medical errors, improved nurse-to-patient ratios and a call for patients to become their own advocates to improve their safety in the operating room.

Former surgeon general Joycelyn Elders, professor emeritus of pediatric endocrinology at the University of Arkansas, said preventable medical errors are the third leading cause of death in the U.S., behind heart disease and cancer, and the errors cost the nation “billions of dollars each year.” The latest study says between 200,000 and 400,000 Americans die each year from preventable medical errors, she said.

“You will find very few death certificates that will have medical error on them,” she said. “That is not the culture that we have. . . . but we’ve got to change the culture.”

Elders said to increase patient safety in hospitals, we have to create a culture of transparency and open reporting; that hospitals need to create systems of collaboration that allow for transparency; and that these systems must be “consistent and persistent” in these efforts.

Daniel Saman, research scientist at the Essentia Institute of Rural Health in Minnesota, talked about the rising cost of care, noting that while the U.S. pays more for care than most developed nations, its life expectancy is lower, its infant mortality rate is higher, the number of people over 65 with two or more chronic conditions is higher, and its obesity rates are higher than those countries’.

Saman, chief epidemiologist for HealthWatch USA, said the increased cost of care in the U.S. is largely driven by high administrative costs, high drug prices and increased use of medical technology, rather than more frequent doctor visits or hospital admissions.

Said Abusalem, an assistant professor in the School of Nursing at the University of Louisville, talked about building a culture of safety in health care, especially in nursing homes, through appropriate staffing, improved communication systems, non-punitive responses to mistakes and effective leadership.

“You cannot talk about patient safety without talking about the culture of safety,” he said.

He noted that most adverse events in nursing homes are related to falls and pressure ulcers. He said 6 to 25 percent of nursing-home patients have pressure ulcers, and the annual rate of falls in the homes is 1.7 per bed, with 10 to 25 percent of the people who fall sustaining serious injuries resulting in death.

Abusalem discussed his study, “In an Era of Reform: The Culture of Safety in Long-Term Care Facilities.” He found nursing homes that reported good teamwork had fewer pressure ulcers and fewer falls; nursing homes with better communication systems had fewer falls; and those that staffed more hours with registered nurses had fewer pressure ulcers.

As the number of RNs plus licensed-practical-nurse staff hours per resident per day increased, the rate of falls decreased by 79 percent, he said, noting “This is a very significant finding.”

He added: “As the culture of safety scores increased, the risk of falls decreased 26 percent, UTIs [urinary tract infections] decreased 20 percent and the short-stay ulcers decreased 7 percent. So the more culture of safety, the less the adverse risk for our residents in nursing homes.”

He said his study shows the need to build a strong culture of safety in nursing homes to promote employee retention and the value in hiring RNs to improve safety.

Nurse-to-patient ratios can be critical

Texas RN Deena Sowa McCollum said a series of delays in her father’s care, despite her strong advocacy, contributed to his death in 2015.

McCollum said she had worked in leadership positions for 11 years and thought she was in tune with the needs of her nurses, but after her father died, she had to return to bedside nursing to try to figure out the shortcomings in the system. “I needed a better understanding of why so many things could go wrong for one person,” she said.

McCollum said she had no idea that higher rates of errors were associated with nurse-to-patient ratios above 1:5. Now she knows that for every patient above five assigned to a nurse, there is a 7 percent increase in error.

“When I have six patients, I know my patient. I know their medications and their diagnosis. I may know a family member, but probably not. And I will have to be very deliberate at making sure that I catch subtle changes because we are so easily disrupted with tasks,” she said.

“When I have seven or eight patients, which is the norm — 90 percent of the time I have seven or eight patients on a med-surg kind of floor– they all start looking alike. I spend a great deal of my time prioritizing who is the sickest and who is the most unstable and what do I need to do for them. I don’t always remember why they are in the hospital or what medications they are on. I often know them by room number and that is embarrassing to say. I am going to miss subtle changes and I am going to make medication errors. The patient that is going home that needs a lot of discharge instructions, I am barely going to see them.”

McCollum cited research from California that found the difference between a 1:4 and a 1:8 nurse-to-patient ratio is approximately 1,000 deaths a year. She added that adding one patient to a nurse’s workload increases the odds to readmission for heart attack by 9 percent, heart failure by 7 percent and pneumonia by 6 percent. Patients on an understaffed unit have a 6 percent higher mortality rate.

She said legislation to establish a safe nurse-to-patient ratio is in the works and that though some states have instituted such practices, they are not well-monitored. She noted that nurses will gather in Washington, D.C., May 4-5 in support of legislation for better nurse-to-patient ratios.

A Massachusetts Nurses Association survey from 2015 found that 50 percent of the nurses in the survey reported injury and harm to patients due to understaffing; 61 percent reported medication errors due to unsafe patient assignment; 61 percent reported complications for patients due to unsafe staffing assignments; 81 percent report RNs don’t have enough time to educate patients and provide adequate discharge planning and 86 percent report RNs don’t have time to properly comfort and care for patients and families due to unsafe staffing assignments.

Operating room safety

Dr. Mark S. Davis, an operating room safety consultant and author of Irresponsible: What Surgeons Won’t Tell You and How to Protect Yourself, said there are hidden risks to surgeries that put you at risk of contracting HIV or hepatitis C because many surgeons don’t adhere to basic safety standards.

“This risk does not appear on a surgical consent form and is not discussed pre-operatively with the patients,” he said.

He said surgeons and assistants are “injured with needles, scalpels and other sharp objects at an astonishing 1,000 times a day” and are exposed to the blood of potentially infected patients because many people are infected with HIV or hepatitis C and don’t know it.

Davis said that surgeons usually fail to report their injuries and that this puts their future patients at risk because if they are infected and don’t know it (and might not know it for years), they can then transmit the infection to a healthy surgical patient during a procedure if they cut themselves and then bleed into the patient.

Davis said most exposures are preventable if physicians would use safety devices to prevent sharps injuries, like safety designed injection equipment, safety scalpels and blunt tipped suture needles. Federal law requires surgeons to use them, but there is a clause in the law that says surgeons may chose to not use them if “in their opinion, they interfere with patient care.”

“Well the truth is, they rarely interfere with patient care. I have a lot of experience with them, yet only 5 to 10 percent of surgeons use these devices,” Davis said.

He said surgeons don’t use them because of the poor enforcement of the federal regulations that requires them; because facilities don’t enforce their use; and a general resistant to change.

“The only solution left in my mind is consumer pressure,” he said.

Davis stressed the importance of bringing someone with you to your appointments to ask questions and assure understanding and said there are some questions that “you can and must ask” the surgeon before you schedule any surgery to protect you from this hidden risk:

1. Do you use blunt tipped suture needles to close your incisions?
2. Do you use a neutral zone for passing sharps?
3. Do you double glove?
4. Do you and your team all use protective eyewear?
5. Do you use safety scalpels?

“As a consumer of health care, you have the power to protect yourself and you must use that power,” he said.

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