WHAT YOU NEED TO KNOW

​​​Our quarterly special editions feature articles, stories, interviews, and more from our journal, Patient Safety. In this issue you will read about creating a National Action Plan for Patient Safety, living life after being infected with COVID-19, innovative ways to prevent falls, and how to mitigate spreading respiratory infections like influenza and pneumonia.

​On September 14, the Institute for Healthcare Improvement (IHI) released Safer Together: A National Action Plan to Advance Patient Safety, a guiding document to help healthcare leaders, organizations, and associations make significant progress toward safer care and reduced harm for patients. We spoke with Dr. Tejal Gandhi and Dr. Jeff Brady, co- chairs of the IHI’s National Steering Committee for Patient Safety, about the background of the National Action Plan and its goal of changing the patient safety landscape. “We want to engage every stakeholder, whether it’s a small practice, a hospital, a health system, patients and families, or other associations or government agencies—whoever it is who’s working in patient safety or affected by patient safety,” Dr. Gandhi says. “We think that they can see themselves in this plan and see recommendations they can actively impact. We hope this is the beginning of the next phase of patient safety.”

 

Surviving a bout of COVID-19 doesn’t necessarily mean life goes back to normal once you’re better. Many people who have been infected with the virus and hospitalized for a long time find that when they return home, their “new normal” includes a range of ongoing symptoms that fundamentally change what they can do and how they live. New Yorker Neil Sidrane is one of these lucky/unlucky survivors. Before he got sick in early April, he would golf several times a week, but after COVID-19, he suffered from severe fatigue that meant even walking a short distance—a lap around his living room or a trip to the mailbox—wore him out. “Imagine staying up for 48 hours straight then running a marathon. And throw shortness of breath on top of it,” he says. Getting back to the golf course was his goal for recovery, which he finally achieved after more than a month of taking baby steps to build up his energy. “‘Recovered doesn’t mean you’re back to your old self, it just means you’re through the worst of it,” he cautions. “Even now, months later, I’ll still occasionally skip a breath.”

Meet Danielle Miller, a high school junior from Enola, Pennsylvania. While most 16-year-olds are focused on prom, social media, and the latest Netflix series, Miller’s interests lie in something bigger. “I want to contribute to the world that’s given me so much,” she says. “Either a career in science or medicine. I’d like to find a way to make a difference.” And she’s already well on her way to meeting that goal. For last year’s Capitol Area Science and Engineering Fair (CASEF), she tackled the danger of surgical fires, a nearly twice-daily occurrence in the United States. After conducting a thorough literature review, Miller decided to examine relative humidity and oxygen levels within the operating suite to determine if implementing environmental changes would reduce the likelihood of a fire. For her research, CASEF named her a “Senior Division Grand Champion.” But she isn’t done working on the problem of surgical fires just yet. “What I found in the first experiment was the negative impact caused by excess oxygen. For phase 2, I’m going to explore ways to control those levels and maybe pursue a patent.”

When tallying the devastation caused by COVID-19, the hundreds of thousands of lives lost is only the beginning. A report from the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) highlights another danger arising from pandemics: increases in domestic violence (DV) and intimate partner violence (IPV), and increased demand for emergency shelter. Periods of lockdown and isolation heighten risk and vulnerability of victims, who are disproportionately women, and delay response due to restrictions. This means their only hope for help and intervention may be interactions with healthcare personnel at clinics, the emergency department, and urgent care. That makes it especially important that those involved with patient care be aware of the signs of DV and IPV, follow their instincts, and know what to do to try to remove a victim from the influence of an abusive partner. It’s important to act quickly, but it’s also vital to exercise discretion, to avoid worsening the situation for the patient or staff if the perpetrator of abuse becomes aware that law enforcement is on the way.

 

Nasogastric tubes (NGT)—special tubes that carry food and medicine to the stomach through the nose—provide patients with nutrition, hydration, medication, and gastric decompression. But if they are placed incorrectly, they can do grievous harm instead, which also can result in costly lawsuits and fines, and a damaged reputation for the hospital. In fact, NGT misplacement is considered a “never event,” which according to the National Quality Forum is an error in medical care that is clearly identifiable, preventable, and serious in consequences for the patient, which suggest a problem in a healthcare facility’s safety and credibility. Inspired by the story of Deahna Visscher, who lost her 10-day-old son in 2016 when an NGT was inadvertently placed into his lung, the Patient Safety Movement Foundation created Actionable Patient Safety Solutions (APSS) #15, which provides best practices for NGT placement and verification, such as using safe equipment and keeping staff educated about changes in the products used and training them in NGT placement. Following the APSS recommendations could help avoid harm to both your patients and your facility.

Falls are among the most pervasive and difficult-to-eliminate patient safety challenges no matter where you are in the world. In the United States alone, injuries from falls send 3 million older Americans to the emergency department each year and result in more than 800,000 hospitalizations. While this is a universal problem across the globe, some countries have come up with interesting and innovative ways to prevent falls and reduce injuries from falls. Researchers in China have introduced tai chi exercises among patients with Parkinson’s disease, which demonstrated improved balance and fewer falls. Australians found a way to reinforce fall prevention messag- ing for dementia patients through silent videos that emphasize visual instruction like body language, graphics, and scenes that evoke emotional responses. And in the Unit- ed Kingdom, portable nursing stations—think a computer desk on wheels—parked outside patient rooms improved nurses’ contact with their patients and enabled them to intervene in high-risk situations. This article takes you on a trip around the world, sharing success stories from the United States, Brazil, Wales, Egypt, Spain, South Ko- rea, and other countries that you may be able to replicate at home.

Millions of children inflict harm upon themselves—every year. Termed nonsuicidal self-injury (NSSI), this behavior involves the direct, deliberate destruction of one’s own body tissue to inflict harm or pain, without intending to commit suicide. NSSI commonly manifests as cutting, scratching, biting, hitting, and head banging—in- cluding even eating disorders and body piercing—often in response to interactions with family, peers, and healthcare providers. Researchers recently examined data from Pennsylvania inpatient psychiatric hospitals and units to understand why NSSI is so prevalent in these clinical settings, particularly among girls age 13 and older. Although most patients only suffer minor injuries, NSSI may be linked to future suicidal behaviors, and children and adolescents may accidentally harm themselves more than they meant to. As such, this is an important issue in patient safety, and screening patients at risk for NSSI, as well as further research on prevention strate- gies, could help prevent serious harm later in life.

COVID-19 is on everyone’s mind, but as we move into flu season, we also need to consider influenza and pneumonia. Researchers looked at how failures in processes to diagnose and treat respiratory infections can increase risk of spreading them among staff and patients, by analyzing 338 events related to viruses and bacteria spread through respiratory droplets reported by Pennsylvania hospitals in 2019. They discovered that more than half of these events (54.9%) were associated with processes for testing and handling lab specimens, while the remainder involved isolation proce- dures (29.7%) and treatment (15.4%). Implementing some risk-reduction strategies, such as evaluating specimen collection and testing and other processes, could help mitigate the spread of respiratory illnesses in the hospital and improve care for the estimated 21 million patients who seek medical treatment for respiratory infections each year. Read on to find out how to improve everyone’s safety at your facility.

Food. Medication. Dentures. Plastic. These are just some of the things patients can choke on. Thousands of Americans die each year from accidental choking. What can we do? Researchers dived into 15 years of data in the Pennsylvania Patient Safety Reporting System database in search of the answer. They identified 545 events related to accidental choking on food, beverages, medications, and other foreign bodies reported from 2004 to 2019, which revealed a wealth of information about the causes. The food that caused the most trouble? Meat or fish. More than half of the patients involved were female (56%), and the median patient age was 70. And the most common lifesaving measures for choking victims were the Heimlich maneuver (abdominal thrusts), suctioning, back blows, and finger sweeps. Understanding the factors that contribute to accidental choking—including demographics and co- morbidities like cancer and tooth loss—provides opportunities to minimize risk and prevent choking in hospital settings and the community at large, such as strategies to help patients swallow medication or hard or dry food products.

 

Peter Bossow, Jr. might still be alive today if someone had told him about a tumor noted on his CT scan four years before it showed up again on an X-ray—much larger, and far too late to save him. Florence McLafferty didn’t learn about abnormal findings in a pelvic ultrasound until two years after the scan, when her cancer had become in- operable. Peter and Florence left behind grieving families who never should have lost their loved ones, but there is one silver lining: their stories helped inspire lawmakers to pass legislation that will hopefully prevent similar heartbreak for other patients and their families. One of these lawmakers was Marguerite Quinn, who introduced a bill in 2007 to communicate significant abnormal test results directly to patients. More than 10 years later, the bill finally passed into law as the Patient Test Result In- formation Act, Pennsylvania Act 112 of 2018. Learn more about this important law and how it protects patients by engaging and empowering patients in their own care.​