• Pressure: The longer pressure is sustained, the more likely is local tissue ischemia, edema, and tissue death. • Pressure scale risk scores: The higher the score on a pressure scale score, the greater the risk of pressure ulcer development. • Vasoactive medications: Vasoactive medications given to improve blood pressure increase vasoconstriction. This may decrease perfusion of skin tissue. Venous Thromboembolism (VTE): VTE includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). According to the CDC, VTE is a leading preventable cause of hospital death. 50 VTE may affect as many as 900,000 people each year in the US, and be responsible for between 60,000 and 100,000 deaths. 50 Approximately 5% to 8% of the US population has one of several genetic risk factors, known as inherited thrombophilias in which a genetic defect can be identified that increases the risk for thrombosis. 50 Risk factors for VTE include 51 • Birth control pills or hormone therapy. • Blood-clotting disorders. • Some malignancies. • Increasing age. • Overweight or obese. • Personal or family history of DVT or PE. • Pregnancy and the postpartum period. • Smoking. • Vein disease(s). Strategies for the prevention of DVT include 51, 52 • Administrating anticoagulant therapy as indicated. • Promoting early movement and physical therapy. • Facilitating position change in patients who have difficulty moving themselves. • Applying compression stockings or pneumatic compression devices as ordered and indicated. • Teaching patients and families about the importance of early movement and position change. MEDICAL ERROR REDUCTION The following Congressional actions and ACA policies were developed with the objective of reducing medical error: • In 2011, the Centers for Medicare and Medicare Services (CMS) launched the Hospital Patient Safety initiative, which piloted new surveyor tools for assessing compliance with federal regulations. 53 • Under the Hospital Inpatient Quality Reporting (HIQR) program, CMS reimburses hospitals that successfully report designated quality measures a higher annual update, while failure to report the measures results in a payment reduction. CMS publicly reports the data on its “Hospital Compare” website. • The Deficit Reduction Act of 2005 required CMS to select at least two hospital-acquired conditions for which hospitals would not be paid higher Medicare reimbursement. Since 2008, CMS has maintained a list of hospital-acquired
conditions that includes catheter-associated UTIs, falls and trauma, late-stage pressure ulcers, surgical site infections, and DVT. 54 Under the Patient Protection and Affordable Care Act of 2009, starting in 2011, CMS applied this payment policy to the Medicaid program to encourage hospitals to actively prevent these conditions. • The Patient Safety and Quality Improvement Act of 2005 established Patient Safety Organizations under supervision of the AHRQ. Patient Safety Organizations receives reports of patient safety events from healthcare providers and provides analyses of these events. 53 They operate under federal privacy protections to encourage providers to report medical errors and to work with healthcare systems to resolve systemic issues. • The Patient Safety and Quality Improvement Act of 2005 authorized AHRQ to promulgate “Common Formats” so that hospitals can report adverse events in a uniform, unambiguous manner. 54 The goal of Common Formats is to allow for the “apples to apples” comparison of medical errors across multiple hospital systems. • The Patient Protection and Affordable Care Act also authorized three pay-for- performance programs that adjust Medicare payments to hospitals based on the quality of care delivered. The Hospital Readmission Reduction Program began in October 2012 and penalizes hospitals with higher-than- expected readmissions for beneficiaries initially admitted for selected conditions. The Value Based Purchasing Program began in October 2012 and provides penalties, as well as incentive payments, based on hospitals’ performance on quality measures, including reducing surgical site infections. 53 • The Hospital-Acquired Condition Reduction Program reduces payments to hospitals that are in the top quartile for hospital-acquired conditions; the program started on October 1, 2014. 53 CMS has adopted AHRQ safety indicators encompassing pressure ulcer rate and DVT rate, among others, as well as measures from the CDC, such as central line- associated bloodstream infection and CAUTIs. • The Office of the National Coordinator is developing a system for reporting medical errors, similar to the method of Common Formats established by AHRQ, allowing hospitals to more easily and accurately collect data on errors, including critical information about where and when they occur. FUTURE EFFORTS TO ENSURE PATIENT SAFETY Since the launch of To Err is Human in 1999, a campaign to improve patient safety and reduce adverse events, improvements have been made in specific areas of care. However, much work needs to be done to continue to ensure patient safety in all healthcare settings.
In 2015, the National Patient Safety Foundation described eight recommendations to continue improvements for patient safety. These recommendations are as follows: 55 •
Ensure that leaders establish and sustain a safety culture. Safety should be engrained in the culture of healthcare facilities and promoted by leadership. Create centralized and coordinated oversight of patient safety. Patient safety should be coordinated and monitored by safety and national organizations. Create a common set of safety metrics that reflect meaningful outcomes. Standardized metrics that identify and measure risks should be used. Increase funding for research in patient safety and implementation science. Research should be utilized to understand risks and how to best mitigate those risks. Address safety across the entire care continuum. Safety should be ensured in all healthcare settings, Support the healthcare workforce. Provide support to all healthcare staff. Partner with patients and families for the safest care. Communicate information and actively involve patient and families in their care. Ensure that technology is safe and optimized to improve patient safety. It is crucial to utilize benefits and minimize unintended hazards of health IT.
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The Role of Information Technology Although the appropriate use of information technology can help to reduce errors, challenges exist. Electronic medical records, electronic prescribing, bar coding of medications, and decision support systems have been shown to be effective. However, many hospitals/organizations have been slow to invest in these technologies. 1 In addition, it has been reported that at least 50% of patient EHRs contain an error, many of which are related to medications. 8 Overburdened providers may import inaccurate medication lists, propagate other erroneous information electronically by copying and pasting older parts of the record, or enter erroneous examination findings. EHRs may also lack critical information (errors of omission) because of limited interoperability among healthcare sites. Among primary care physicians sharing notes with patients, 26% anticipated that patients would find nontrivial errors that could therefore lead to medication errors, wasteful duplication, unnecessary or incorrect treatment, and delayed diagnoses. Despite these problems, systems for checking the accuracy of notes are almost nonexistent. 8 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDIES 1 & 2 ON PAGE 115.
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