87,000 patient deaths were prevented due to a 17% decrease of hospital-acquired conditions from 2010 to 2014, according to an HHS report released in December 2015. Though this is an inspiring statistic, more can always be done in the journey to a zero patient harm healthcare system.
The team at Becker’s Infection Control & Clinical Quality highlighted the top ten issues they saw as they analyzed the trends and events of 2015.
- Medication Errors. One of the most common inpatient errors is medication errors, but a new study published by Massachusetts General Hospital in October 2015 uncovered nearly half of all surgeries have some form of medication error. Documentation errors, incorrect dosage, mistakes in labeling and neglecting to treat a problem indicated by a patient’s vital signs were the the most frequently cited medication errors. “We definitely have room for improvement in preventing perioperative medication errors, and now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them,” said Karen Nanji, MD, lead author of the study.
- Diagnostic Errors. 6 to 17% of hospital adverse events and about 10% of patient deaths were due to diagnostic errors, according to “Improving Diagnosis in Health Care,” a 2015 report by the Institute of Medicine. Also included in the report were several possible solutions as outlined by IOM to improve this severe patient safety issue. A leading suggestion was enhanced teamwork among healthcare workers.
- Proper Discharge Procedures. A patient’s discharge is a critical moment in their care and safety. This issue is getting more focus now that the Comprehensive Care for Joint Replacement is holding hospitals accountable for 90 days post-discharge if any complications arise.
- Sterilization Problems. Unpleasant as it is to think about, hospitals have cited a resurgence in infections due to reprocessing issues. Following the proper protocol while sterilizing previously used medical scopes, tools and devices is mandatory, yet issues still persist.
- Transparency Issues. “When everyone — physicians, patients, institutions, and the press — is privy to data on performance, physicians will develop a greater sense of accountability to deliver quality care,” Ashish K. Jha, MD, a patient safety researcher at Harvard University’s School of Public Health in Cambridge, Mass., wrote in a post on Harvard Business Review in October. A heightened sense of transparency encourages quality improvement and facilitates discussion around issues that administration may not be aware of.
- Cybersecurity of Medical Devices. Since 2011 cybersecurity of personal medical devices has been on the radar, but recently hospital network security has come into question. Hospital networks carry vulnerable information – patient history, sensitive financial data, and specific health knowledge – that can be easily hacked by the many devices connected to the network. Solutions are currently being developed, but this will be a continuous issue for the foreseeable future.
- Superbugs. As defined by Brian K. Coombes, PhD of McMaster University in Ontario, superbugs are bacteria that cannot be treated with two or more antibiotics. Recently, scientists in China discovered “super” superbugs – bacteria resistant to ALL antibiotics. These superbugs and “super” superbugs are only getting stronger, and a cry for caution and proper antibiotic practices have come onto to the horizon with intensified vigor.
- Sepsis. Sepsis has gotten renewed attention this year because the CMS added the Severe Sepsis and Septic Shock Early Management Bundle to the fiscal year 2016 Inpatient Prospective Payment System Final Rule. Sepsis is the ninth leading cause of disease-related deaths, and hospitals that comply with these new guidelines can significantly lower the mortality rates as well as the costs associated with treating sepsis.
- Hospital Facility Safety. Hospitals are complex building that require complex infrastructure. When this infrastructure is not properly maintained, or installed, patient safety is in jeopardy. In 2015, several organizations from the engineering, construction and healthcare industries created a set of uniform guidelines for the ventilation, heating and air conditioning of operating and procedure rooms to ensure patient safety.
- Workplace Safety. Patient safety begins with workers’ safety. If the healthcare providers feel safe, they are apt to deliver better care to the patient. Deborah Grubbe, a healthcare consultant with DuPont Sustainable Solutions reasoned why: “Because healthcare providers won’t have to focus on their own safety and thinking they’ll get hurt, [they’ll] be able to spend all their energy and alertness in providing good care for the patient.”
These are the top ten issues, in no particular order, of patient safety as recommended by editorial team at Becker’s Infection Control & Clinical Quality. As 2016 progresses, we will continue to keep an eye out for these issues and others that might emerge in order to keep patient harm to a minimum.
Steve Leatherman, firstname.lastname@example.org, brings over thirty-years (30) of broad-based Life Science & Healthcare business management experience to Allen Austin. Located in our Nevada office, Steve’s consulting practice focuses on all aspects of the Life Science and Healthcare industry as well as general management searches for medium and Fortune 500 class enterprises.
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