Who should make medical decisions for children, when should a surgeon hang up their scalpel, and where do we draw the line between just culture and accountability?
Diagnosis: Crisis
Before the pandemic, more than half of frontline clinicians were experiencing burnout, and physician suicide rates were more than double the general population. COVID-19 is bringing this long-simmering crisis to a boil, as doctors, nurses, and other healthcare professionals give their all for their patients. Is there anything we can do to care for our caregivers? What can they do to take better care of themselves? Therapist and best- selling author SaraKay Smullens and Dr. Stanton N. Smullens, chair of the Patient Safety Authority, answer these questions and more. They offer actionable self-care strategies we can all use to manage burnout and depression in our lives during these difficult times and in the uncertain days to come. “We know there will be other viruses in the future,” says Dr. Smullens, “and we know that each of us is stronger working together, providing care for one another, than we could ever be as individuals.”
Perspectives — How Hospice Saved My Mother’s Life
Hospice. The term likely conjures the image of someone with little or no chance of recovery from a terminal condition or disease. But for Ann Green, the word sparks hope—for her mother, hospice care wasn’t an ending but a beginning. It was a path beyond her illness to a new life filled with joy and fulfillment. After breaking her hip twice, Ann’s mom was diagnosed with late-stage dementia and began a slow spiral into rehabilitation and recurring infections. Since Ann and her sister couldn’t give their mother the ongoing care and attention she needed, a social worker suggested hospice to make her more comfortable. It was a scary step, but it was the right one as it turned out. “Hospice and its kindnesses—its ability to address pain, anxiety, and discomfort over ‘curative’ treatments—improved Mom’s life and extended it,” Ann says. And four years later, her mother is not only still alive, but also thriving, now in a nursing home. “We are amazed and grateful that we have continued to have time together.”
Patient Safety vs. COVID-19
Even as COVID-19 rages around the world, it is important not to overlook another global healthcare crisis without a cure: preventable medical errors. The pandemic has claimed hundreds of thousands of lives to date, and medical errors are responsible for 100,000–300,000 patient deaths each year in the United States alone—but the combination of the two could have dire repercussions long into the future for patients everywhere. William Wenner, MD, JD, MP, points out that the ongoing state of emergency, which places enormous stresses on an already fraught healthcare system, is compromising the quality of care, and when we’re past it we will need to work hard to regain the lost momentum in improving patient safety. The key, Wenner says, lies in restoring proper oversight of healthcare and reengaging patients and families at the center of their care: “The safeguards that existed prior to the pandemic must be restored and strengthened.”
The ABCs of HPV and LGBTQ
How much do you know about human papillomavirus (HPV)? HPV infections typically show no symptoms and resolve on their own, but some untreated infections can cause other medical conditions—even cancer. Though most often associated with females, anyone can contract it, and around 79 million Americans are infected with HPV each year. It is the most common sexually transmitted disease, and members of the LBGTQ community are particularly at risk. The good news is we have a vaccine to prevent HPV infections; however, less than 10% of men get vaccinated for it. Hear from five members of the LGBTQ community about what they know about HPV vaccination, and learn the facts for yourself.
Patient Safety Initiatives — Making A List, Checking It Twice
We all make lists so we don’t forget anything important, whether it’s for grocery shopping, things we need to do, or even holiday gift giving. So why not do the same for something really important, like protecting patients? One organization did just that when they adopted the “Medication Management During Transitions of Care Checklist”—one of many handoff communications checklists developed by the Patient Safety Movement Foundation—to help prevent medical errors during care transitions. The Centers for Medicare & Medicaid Services (CMS) defines transition of care as “the movement of a patient from one setting to another.” Each handoff poses a risk to the patient due to changes in their care team, health status, and medications. But a list of reminders for healthcare staff, such as “Ensure collaboration between pharmacist, nursing, and care management” and “Ensure patient can access medications,” with itemized tasks for each, can go a long way to maintaining continuity of care and improving the safety of patients. Find out more about implementing a similar solution at your institution.
An Abstract Look at Patient Safety
Our annual conference, the Pennsylvania Patient Safety Summit (P2S2), may have been canceled due to the pandemic, but that doesn’t mean you have to miss out completely. Here are summaries of four quality improvement projects that would have been displayed as academic posters: “Walking Out”: VTE on an Orthopaedic Unit, Reducing Complications Through the Implementation of ProvenRecovery™, MOVES Program for Hospitalized Patients, and Safety Reporting Across the Care Continuum.
Research — One Less Reason Not to Vaccinate
Vaccines prevent 3 million deaths worldwide every year, but errors made in admin- istering those vaccines can harm patients. To help mitigate this risk, a federally qual- ified health center completed a root cause analysis and identified some common causes of vaccine errors, such as selecting the wrong vaccine, rushing through the process, and improper vaccine storage. Armed with this information about systems and human factors issues, they improved their process to eliminate them, which included education and competency training for staff—successes which any orga- nization can replicate in their own facility. Despite the overwhelming benefit that vaccines offer, some children remain vulnerable to vaccine-preventable illness for several reasons; however, by committing to improving patient safety and following these steps, vaccine-related errors need not be one of them.
Data Analysis — COVID-19–Related Patient Safety Events
Infection is only one way COVID-19 causes harm. Six months into the crisis, here’s what we know about how it has been affecting patient safety, based on reports from 71 healthcare facilities throughout Pennsylvania. Looking at 343 events in the Pennsylvania Patient Safety Reporting System (PA-PSRS), one of the largest event reporting databases in the world, most events involved the emergency department, a medical or surgical unit, or the intensive care unit, and were commonly associated with errors in laboratory testing, process or protocol, and integrity of isolation. Fa- miliarizing yourself with the data and knowing the facts are important in developing best practices to protect your patients during the pandemic.
Some Drugs Shouldn’t Be in Hospitals
Do your protocols for treating patients who are unresponsive, tachycardic, or have slurred speech include checking for illicit substance abuse? If not, you may want to reconsider. Researchers recently examined the understudied topic of patients’ substance use and possession while in hospital, by analyzing events reported by 38 acute care hospitals in Pennsylvania. Their findings suggest that hospitals need to increase their use of substance use disorder screening tools, pharmacotherapy, and referring patients to treatment, in order to proactively reduce the likelihood of in-hospital substance use. The first step is understanding the benefits, disadvantag- es, and challenges of preventing and deterring it. Read on to find out how.
The Truth Is Hard to Swallow—But a Tooth Isn’t
Quick, what condition affects three times as many men as women and can cause severe chest pain and trouble breathing? Swallowed dentures. More than 100 mil- lion Americans are at risk for denture impaction, in which permanent or temporary dentures become dislodged, swallowed, and stuck in the gastrointestinal tract. This happens much more often than you might expect—so all patients with replacement teeth, as well as their caregivers and healthcare providers, should be aware of the risk of denture impaction. Read this first-ever study of patient safety events related to denture impaction reported by acute care facilities to learn the signs and how to prevent it.
The Year in Review
In conjunction with the Patient Safety Authority 2019 Annual Report, we published two articles in Patient Safety analyzing 2019 data from the Pennsylvania Patient Safe- ty Reporting System (PA-PSRS), the nation’s largest event reporting database. In “2019 Pennsylvania Patient Safety Reporting” PSA data analysts take a close look at the 293,400 incidents and serious events reported by acute care facilities last year, while “Healthcare-Associated Infection in the Long-Term Care Setting” examines 28,310 HAI reports from long-term care facilities in 2019. They supplement the data overview in the annual report with a comprehensive review and analysis of events reported in 2019, as well as insights into patient safety in Pennsylvania and how we may continue to improve it together.
