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    Healthcare Risk Management Solutions for Top Reported Sentinel Events

    Healthcare Risk Management (HRM) Week, June 18-22, 2012, is ASHRM’s annual campaign to raise awareness about the critical role risk management and patient safety professionals play in helping to eliminate preventable serious safety events. Throughout HRM Week, ASHRM is offering solutions that risk managers and patient safety experts can employ to help prevent some of the most common serious safety events, many of which are aligned with the Hospital Engagement Network (HEN) Initiative. Keep reading to explore solutions for the top-reported sentinel events and help your organization in "Getting to Zero™ through the Power of One".


    Tip 5: Sign Out Wrong-site Surgeries
    The HEN initiative lists Preventable Readmissions as a core area of focus for preventing serious safety events. Eliminating wrong-site surgeries will help prevent patients from being readmitted to the hospital to undergo the surgery on the correct site.

    Wrong-site surgeries occur approximately 40 times each week at hospitals across the nation, according to The Joint Commission Center for Transforming Healthcare. Examples of wrong-site surgeries include invasive procedures on the wrong patient, wrong procedures on the correct patient, and correct procedures on the wrong side of the patient. All physicians and facilities that perform invasive procedures are at some degree of risk. Research has found that the cause of these events is usually not a single, large factor, but rather a combination of smaller factors, such as communication and procedure breakdowns. Hospitals or healthcare providers most at risk include:

    • Facilities with problems in the scheduling and preoperative/holding processes
    • Providers/facilities with ineffective communication methods
    • Facilities where distractions routinely occur in the operating room
    • Facilities/providers that perform pre-surgery "time-outs" without full participation by all key people in the operating room

    Solutions
    A simple solution for preventing wrong-site surgeries involves surgeons signing their initials to the patient’s operative site using a permanent marking pen. The patient should confirm the operative site as the surgeon marks it. Members of the operative team also need to verify the site.

    Other solutions for preventing wrong-site surgeries include:

    • Ensure that copies of the operative permit/informed consent form state the correct surgery.
    • Have the surgeon verify that X-rays and medical records are for the correct patient as well as confirm the identity of the patient before beginning the procedure.

    For the complete checklist provided by the American Academy of Orthopaedic Surgeons, Click Here...

    ASHRM’s Risk Management Pearls for Policies and Procedures offers more preventive strategies. Click Here for more information.

    Tip 4: Count to Protect Against Foreign Bodies Left In Patients After Surgery
    The HEN initiative lists both Preventable Readmissions and Surgical Site Infections as core areas of focus for preventing serious safety events. Removing all foreign bodies from patients prior to finishing surgery will eliminate the need for patients to undergo a second surgery to remove the objects, and also lesson their risk of a surgical site infection.

    The items most commonly left inside a patient’s body after surgery include gauze, sponges, towels, scissors and needles, according to The Doctors Company. While pointed items like scissors pose obvious hazardous such as organ puncture wounds, even the more “harmless” items such as sponges may cause infections, pain and blockage of organ functions. Of course, patients face the risks of a second surgery to remove the item. Facilities and providers most at risk of leaving foreign items inside patients are those that are lax on documenting items placed in the body during surgery and counting these items accurately pre and post-operatively.

    Solutions
    The Doctors Company recommends adopting the following four preventive measures:

    • Perform procedures in facilities with established written protocols for counting sponges, sharps and instruments that meet Association of Operating Room Nurses (AORN) standards and/or are accredited by The Joint Commission
    • Make certain that counts are performed and reported to surgeons as correct, both at the beginning and at the conclusion of every surgical procedure
    • Include one phrase—without fail—in every operation report: The sponge and needle counts were reported to be correct
    • Maintain a healthy level of suspicion that complicated wound healing might be caused by a retained foreign body

    ASHRM’s Risk Management Pearls for Policies and Procedures offers more preventive strategies. Click Here for more information.

    Tip 3: Death or Injury of Patient in Restraints
    The HEN initiative lists Injuries from Patient Falls and Immobility (due to restraints or other limitations) as a core area of focus for improving patient safety.

    Commonly used physical restraint devices include safety vests and jackets, lap and wheelchair belts, and fabric body holders. Used correctly, these devices can keep patients from falling or from harming themselves or their caregivers. However, improper use of these devices can lead to injuries or even death due to strangulation or broken bones. The U.S. Food and Drug Administration estimates that at least 100 deaths occur each year from the improper use of restraints. Most reported deaths and injuries have involved elderly patients living in nursing homes who were left unattended while restrained. Healthcare facilities most at risk of restraint injuries or deaths are those that fail to develop and/or follow specific policies and procedures regarding restraint use.

    Solutions
    The Center for Medicare and Medicaid Services “Hospital Conditions of Participation Section on Patient Rights” (CFR482.13) focuses principally on ensuring the physical safety of patients during a restraint or seclusion episode. These rules include the following basic tenets:

    • Restraint and seclusion are safety interventions of last resort, to be used only when an individual poses an imminent danger to someone’s safety
    • Restraint and seclusion may be ordered only by a physician or a licensed independent practitioner (such as a physician’s assistant or nurse practitioner who is licensed to deliver medical services without oversight)
    • Orders must be time-limited— four hours maximum for adults, two hours for adolescents ages 9-17, and one hour for children under age 9—and the intervention must be ended as soon as it is safe to do so
    • Certain risky practices, such as “basket holds” and applying back pressure to a person who is prone, are prohibited
    • A physician or licensed independent practitioner must conduct a face-to-face assessment of the individual as soon as possible, which cannot exceed one hour
    • Appropriately trained staff must continually assess, monitor and re-evaluate individuals who are restrained or secluded
    • Debriefings with the individual and staff must occur as soon as possible after each use of restraint or seclusion

    ASHRM’s Risk Management Pearls for Policies and Procedures offers more preventive strategies. Click Here for more information.

    Tip 2: Report and Apologize for Medical Errors
    The HEN initiative lists medical errors such as Adverse Drug Events, Pressure Ulcers and Surgical Site Infections as core areas of focus for improving patient safety.

    As the practice of medicine is a complicated art, there are numerous challenges and opportunities for improvement. Some of the most frequently reported medical errors include:

    • Pressure ulcers
    • Postoperative infections
    • Hemorrhage complications occurring during, or shortly after, a procedure
    • Accidental puncture or laceration during a procedure
    • Mechanical complication of a device, implant or graft
    • Adverse effect of a medication

    There are as numerous reasons for the errors as there are types of errors. Faulty system and process designs can be at fault, such as poor communication methods, disconnected reporting systems and reliance on automated systems to prevent errors. Variations in healthcare provider training and experience may also be to blame. Finally, human factors such as fatigue, depression and burnout play a large role in medical errors. Whatever the error or the reason, providers must be open about reporting these errors and disclosing all details to patients and their families as well as apologizing to patients that the error occurred.

    Solutions
    According to a column published in USA Today, there's no panacea for eliminating mistakes, but a starting point is clearly communication. Better doctor-patient exchanges improve medical care. A well-designed system also can help prevent medical errors. For example, a seemingly simple task of dispensing a drug at a hospital is actually a complex process that requires five interdependent steps: ordering, transcribing, dispensing, delivering and administering. A poorly designed system can lead to an error in any of those steps which can lead to a serious adverse outcome or death of a patient.

    Additional steps to reduce or prevent future medical errors include:

    • Implementing a patient’s informed consent policy
    • Getting a second opinion from another independent practitioner with similar qualifications
    • Voluntary reporting of errors
    • Root cause analysis to determine the cause of the error and to develop actions to prevent a similar event from occurring in the future

    ASHRM’s Risk Management Pearls for Disclosure offers organizational scenarios and strategies for implementing and enhancing the practice of disclosure. Click Here for more information.

    Tip 1: Screen Out Patient Suicides
    Nearly 1,500 suicides take place annually in U.S. inpatient hospital units, according to The Joint Commission. The majority of these cases (about 75 percent) involve hanging. The second most common cause of patient suicide is jumping from a roof or window (20 percent). Most patients who commit suicide are admitted for psychiatric disorders, but several are medical patients. Patients who are at greatest risk of committing suicide include those who are/have:

    • Male
    • Single status
    • Unemployed
    • Suffered a recent loss
    • Displayed previous suicidal behavior
    • Family history of suicide
    • Poor physical health
    • History of violence or impulsivity
    • Lack of social support
    • Feelings of hopelessness
    • History of substance abuse
    • History of depression

    Solutions
    According to an article published in the April 2010 issue of The Joint Commission Perspective on Patient Safety there are three umbrella actions to take to prevent patient suicides: be direct, listen and observe, and safeguard the environment.

    Be Direct
    The most simple, and perhaps effective, thing a healthcare worker can do to determine whether patients are at risk of committing suicide is to ask them directly.

    Listen and Observe
    Ask follow-up questions, listen carefully to the patient, watch the patient’s actions, and do not judge or criticize the person.

    Safeguard the Environment
    A healthcare worker should stay with the patient at all times, or check on the patient every 5, 15, or 30 minutes, depending on the patient’s condition. Hospital rooms should be designed to minimize suicide risk by containing no curtains, towels or sheets patients can use to hang themselves.

    ASHRM’s Risk Management Pearls for Policies and Procedures offers more preventive strategies. Click Here for more information.


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