Patient safety takes one-two punch
A report from the Office of the Inspector General at the U.S. Department of Health and Human Services and a sentinel alert from the Joint Commission issued in succession this week hit patient safety hard.
The OIG issued its Compendium of Unimplemented Recommendations. The Joint Commission delivered Sentinel Event Alert No. 54, which focuses on the safe use of health information technology.
The March 2015 Compendium from OIG takes on topics such as payment policies and practices, contractor oversight, fraud, grant programs, financial stewardship – and quality of care and safety.
Both the OIG and the Joint Commission findings signify vast room for improvement on the quality of care and patient safety front.
"Many of the recommendations in this compendium have seen some progress," OIG notes. "However, as of March 2015, the date of publication, OIG had reason to believe that more should be achieved."
On the patient safety front, adverse events proved especially intractable.
"Many adverse events that were identified through OIG work were preventable," OIG writes. "This finding confirms the need and opportunity for hospitals to significantly reduce the incidence of events, and AHRQ and CMS share the responsibility for addressing this issue."
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Using a random sample of Medicare beneficiaries discharged from hospitals over one month, OIG found that 13.5 percent experienced adverse events. Also, for 1.5 percent, these adverse events contributed to their deaths. An additional 13.5 percent of beneficiaries in the sample experienced temporary harm as a result of their medical care, bringing the total percentage of beneficiaries experiencing instances of care-related harm to 27 percent.
Physician reviewers determined that 44 percent of adverse and temporary harm events were preventable, OIG notes.
The term "adverse event" describes harm to a patient as a result of medical care. An adverse event can either be preventable or nonpreventable and includes "never events" – events that should never occur in a healthcare setting; hospital-acquired conditions; events that required life-sustaining intervention; and events that caused prolonged hospital stays, permanent harm or death.
[See also: Deaths by medical mistakes hit records.]
OIG's top recommendation to AHRQ and CMS, which was issued in November 2010, was to broaden patient safety efforts to include all types of adverse events. OIG found that AHRQ had fully implemented the recommendation, but CMS had not, though the agency made "considerable strides." OIG would consider the recommendation to CMS fully implemented following further progress toward use of the QAPI – Quality Assessment and Performance Improvement – guidance and implementation of the Partnership for Patients initiative.
The Joint Commission's most recent sentinel alert builds on a previous alert, No. 42, sounded in 2008. It called for taking a broader look at health IT, particularly the socio-technical factors having an impact on its safe use.
Incorrect or miscommunicated information entered into health IT systems may result in adverse events, the Joint Commission points out. In some cases, interfaces built into the technology contribute to the events. The organization obtained examples from ECRI Institute showing several ways adverse events might occur through the use of electronic health records and related technologies:
- A chest X-ray was ordered for the wrong patient when the wrong patient room number was accidentally clicked. The orderer noticed the error right away and promptly discontinued the order, but not in time for the X-ray technician to see that the order was withdrawn. The technician performed the test on the wrong patient.
- A drug was ordered as an intramuscular injection when it was supposed to be administered intravenously. The physician did not choose the appropriate delivery route from the drop-down menu.
- A nurse noted that a patient had a new order for acetaminophen. After speaking with the pharmacist, the nurse determined that the order was placed for the wrong patient. The pharmacist had two patient records open, was interrupted and subsequently entered the order for the wrong person.
In its report, the Joint Commission acknowledges that well-designed and appropriately used EHRs – coupled with strong clinical processes – can improve quality and safety – even reduce adverse events.
It also called for more vigilance.
It urged creating – and maintaining – "a culture of safety, which would include a collective mindfulness focused on identifying, reporting, analyzing and reducing health IT-related hazardous conditions, close calls or errors."
It also advocates for process improvement and interdisciplinary leadership that provides oversight of heath IT planning, implementation and evaluation.
Read the Joint Commission Sentinel Event Alert here.
Read OIG's Compendium of Unimplemented Recommendations here.