Perioperative News Update

June/July 2008

PATIENT SAFETY
2009 National Patient Safety Goals announced
The Joint Commission announced its 2009 National Patient Safety Goals on June 17. Major changes from the 2008 goals include three new requirements related to preventing health-care associated infections due to multiple drug-resistant organisms (MDROs), central line-associated bloodstream infections and surgical site infections.

Building on an existing goal to reduce the risk of healthcare-associated infections, these new requirements are designed to help facilities recognize that patients continue to acquire preventable infections at an alarming rate within hospitals, according to a news release from The Joint Commission. These new infection-related requirements have a one-year phase in period that includes defined milestones, with full implementation expected by January 1, 2010.

Other changes to the National Patient Safety Goals include a requirement to eliminate transfusion errors related to patient misidentification in hospitals, critical access hospitals, ambulatory care facilities and office-based surgery practices. New requirements for several programs focus on engaging patients in their care of infection control, prevention of surgical adverse events and the patient identification process.

Applying to more than 15,000 Joint Commission-accredited and -certified healthcare organizations and programs, The Joint Commission’s National Patient Safety Goals promote improvements in patient safety by providing healthcare organizations with solutions to persistent safety programs. Read the complete 2009 National Patient Safety Goals at www.jointcommission.org.

INFECTION CONTROL
Poll finds increased MRSA prevention measures, need for staff, technology to control MRSA infection
While more than three out of four infection prevention and control professionals said they have implemented additional measures to prevent the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in the last year, more than half said their institutions are not doing as much as they could and should be doing to prevent the spread of MRSA. That’s according to 2,041 infection control professionals across the country who responded April 25-May 15, 2008 to an online survey conducted by the Association for Professionals in Infection Control and Epidemiology (APIC).

Of those respondents who said their facility should be doing more to control the spread of MRSA, the most popular needs listed included additional staff and healthcare-associated infection (HAI) surveillance technology.

Respondents to this May 2008 APIC Pace of Progress Poll also answered that institutions who have adopted new interventions are using a group of approaches to prevent the transmission of MRSA, including:

staff education
more aggressive hand hygiene programs
stricter use of contact precautions for patients who test positive for MRSA
more emphasis on housekeeping and cleaning equipment
maintaining a tracking system to flag patients previously identified as having MRSA
patient/client education
better HAI surveillance technology
additional staff or an increase in hours dedicated to infection control and universal patient screening

“It’s good news that healthcare providers are adopting a multi-faceted approach,” said APIC’s 2008 President Janet E. Frain, RN, CIC, CPHQ, CPHRM, in a June 17 APIC news release. For more information about this survey or to access APIC’s guidelines for the elimination of MRSA transmission, visit www.apic.org.

QUALITY
Low risk patients may hold keys to reducing preventable deaths
A focus on what goes wrong in uncomplicated cases may be a good way to improve patient care. That’s according to a study published in the June issue of Circulation (circ.ahajournals.org) that looked at ways high-ranking hospitals can still find room for improvement.

Study authors reviewed coronary artery bypass graft (CABG) deaths in 347 randomly selected patients from Ontario hospitals between 1998 to 2003 to determine if any of the deaths may have been prevented. The study also looked at whether the estimated rate of preventable death correlated with the overall bypass mortality rate at each hospital.

Preventable deaths were found across all patient risk categories with the highest rate among those with lowest preoperative risk. Also, authors found that most of the preventable deaths were related to problems during surgery or while patients were recovering in intensive care.

“We hope that surgeons and physicians in other areas of medicine can learn from our experience and conduct their own detailed adverse event audits so that we can have the best possible outcomes for all types of patients in our hospitals,” said Chris Feindel, MD, a senior cardiac surgeon at University Health Network in Toronto and a co-author of the study, “The Relationship between preventability of death after CABG surgery and all cause risk-adjusted mortality rates.”

GRANTS
Patient Safety research grants available
Proposals to identify, develop and/or test local interventions for improving patient safety, as well as studies on the cost-effectiveness of risk-reducing strategies are invited for small research grant opportunities offered by the World Health Organization.

The WHO World Alliance for Patient Safety is offering the grants to stimulate research in patient safety worldwide. The deadline to submit applications is Sept. 30, 2008. For more information and to download the application form and other documents, visit www.who.int/patientsafety/research/grants.

Correction
In the June issue of AORN Connections, the story on Safe Sedation included incorrect medication information in the opening description of a procedural sedation scenario. The medication named in the story to relieve chronic pain was oxytocin. The correct medication used in this scenario is oxycontin. AORN Connections apologizes for the error.

May 2008

QUALITY
FDA and CMS announce efforts to improve product quality, safety
The U.S. Food and Drug Administration (FDA) launched the Sentinel Initiative on May 22 with the goal of creating and implementing the Sentinel System—a national, integrated, electronic system for monitoring medical product safety.

WORKPLACE SAFETY
CSPS statement on violence in the workplace The Council on Surgical and Perioperative Safety (CSPS) approved a statement on violence in the workplace, stating that “violence or the threat of violence in the workplace must not be tolerated under any circumstances.” The statement also says, the “creation of a violence-free culture of mutual respect, dignity and fairness among individuals and professional disciplines is essential for the teamwork and communication necessary for patient safety.” The statement includes definitions for related terminology, including workplace violence, intimidation, threat and sexual harassment. Additionally, risk factors for violence and details on the council’s position against violence in the workplace are also included in the statement.

CSPS also recommends that all healthcare organizations establish a health and safety committee to monitor, address and evaluate violence through a comprehensive workplace safety violence program. Learn more about these recommendations and read the full statement.

CSPS is an incorporated, multidisciplinary coalition of professional organizations whose members are involved in the care of surgical patients. CSPS member organizations include AORN, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the American College of Surgeons, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses and the Association of Surgical Technologists. Learn more about the CSPS.

MEDICATION SAFETY
Joint Commission releases alert on preventing pediatric medication errors
OAKBROOK TERRACE, ILL. – The Joint Commission released a Sentinel Event Alert in April advising further research into the issue of preventing pediatric medication errors.

The alert is based on information in The Joint Commission’s own voluntary database and several studies that show a high error rate among pediatric patients. The Joint Commission outlines reasons why children are more prone to medication errors, along with several risk reduction strategies.

“Children are in general much more prone to medication errors and the resulting harm,” said Peter B. Angood, MD, co-director for The Joint Commission International Center for Patient Safety and vice president for The Joint Commission in a podcast. “A few of those reasons are related to the fact that medications used in pediatric populations are primarily still formulated and packaged for adult populations. Therefore there is a need to alter these medication dosages, and that creates a significant probability of an error occurring while the calculations are being done to adjust for the pediatric population.”

Error rates among the pediatric inpatient population were reported to be about three times as high among hospitalized adult populations. About 22% of those pediatric medication errors were classified as being preventable.

Angood said that hospital settings were prone to error because of a primary focus on adults. Emergency rooms in particular are risk-prone if they do not have areas focused on children. Another factor is that younger patients cannot always communicate if something is wrong.

Risk reduction strategies outlined by the April Sentinel Event Alert included the effective standardization and identification of medications, processes for drug administration, pharmacist oversight and the judicious use of technology.

The Joint Commission Sentinel Event Alerts identify specific events, explain common underlying causes and provide suggestions to prevent further occurrence.

REIMBURSEMENT
CIGNA to adjust hospital reimbursement policy
BLOOMFIELD, Conn. – Insurance giant CIGNA HealthCare is the latest group to establish a policy to cease payments for so-called “never events” and avoidable hospital conditions.

Further aligning its policy with the Centers for Medicare and Medicaid Services (CMS), CIGNA will stop payment for such errors beginning Oct. 1. CIGNA defines never events as surgical procedures performed on the wrong site, wrong side, wrong body part or wrong person. As with CMS, CIGNA identifies avoidable hospital conditions that are potentially not reimbursable, such as objects left inside a patient during surgery, pressure ulcers, hospital-acquired injuries and several other mistakes.

According to a press release, CIGNA states that its policy is designed to avoid member liability for any payment denials to participating facilities. The initiative is also in line with national quality initiatives CIGNA participates in, such as the National Quality Forum and the Leapfrog Group. The healthcare company plans to give greater weight to never events and avoidable hospital conditions as part of the new policy.

HEALTHCARE IT
Electronic record-keeping moves forward
While Federal officials urged an electronic record-keeping plan in New Jersey, SSM Healthcare in St. Louis launched a new system in the Midwest. The concept of electronic record-keeping is apparently gaining momentum. Federal officials promoted a five-year demonstration program in New Jersey in April that could have as many as 1,200 primary care physicians across the United States receiving financial incentives for the adoption of new technology. During a stop in Newark, Tevi Troy, deputy secretary of the Department of Health and Human Services, discussed the initiative, for which 12 communities nationwide would be selected to participate in the Electronic Health Record demonstration project.

Meanwhile, SSM Healthcare in Missouri worked on the launch of the region’s first integrated electronic medical records system. The three-year, $330 million project aims to connect SSM’s facilities with a goal of improving patient safety and easing administrative duties.

In April, AORN announced its own electronic system, which is under development. Learn more about the Standardized Perioperative Record and Data Repository System in the May issue of AORN Management Connections.

April 2008

INFECTION CONTROL
APIC launches national C. difficile prevalence study
WASHINGTON – The Association for Professionals in Infection Control and Epidemiology (APIC) announced March 20 a national prevalence study of Clostridium difficile-associated disease.

The APIC Research Foundation C. difficile Prevalence Study will take place from May 1 to May 23 as part of a detailed strategy to combat the disease. The association has invited more than 5,000 healthcare facilities to participate by providing a “one-day snapshot” of C. difficile infections.

A goal of the study is to provide the first national estimate of C. difficile infection in U.S. facilities, said Kathy L. Warye, CEO of APIC. When the study is complete the association plans to develop education about the infection, including a Guide to the Elimination of C. difficile, strategies for controlling transmission and a Webinar series.

More information is available at www.apic.org.

AMBULATORY
Nevada's ambulatory surgical centers inspected for unsafe practices
Federal investigators are inspecting all 50 of Nevada's ambulatory surgical centers out of concerns of a widespread hepatitis C outbreak.

The statewide inspection follows the discovery of unsafe practices at a Las Vegas gastroenterology center that led to at least six cases of hepatitis C. Officials suspended Endoscopy Center of Southern Nevada's business license Feb 29., after learning the center had been reusing syringes and vials for anesthesia. More than 40,000 patients from that center alone could have been exposed.

Investigators were given 30 days to inspect all of the state's ambulatory surgical centers. Julie Gerberding, head of the Centers for Disease Control and Prevention told the Associated Press the initial incident "could represent the tip of an iceberg" concerning unsafe practices.

Stay tuned for more on this story in your April issue of AORN Management Connections.

WORKPLACE SAFETY
AORN supports the Center for American Nurses call for an end to lateral violence and bullying in nursing work environments
Nurse-to-nurse aggression, also known in nursing as lateral or horizontal violence, should not be tolerated in professional practice environments, according to a new position statement, Lateral Violence and Bullying in the Workplace, released in February by the Center for American Nurses. AORN supports this new position statement, which is consistent with current research on lateral violence.

The Center for American Nurses new position statement on lateral violence and bullying calls on all healthcare organizations to "implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior."

Lateral violence may be verbal or non-verbal and occurs most commonly as non-verbal innuendo, verbal affront, undermining, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences.

"These disruptive behaviors are toxic to the nursing profession and have a negative impact on retention of quality staff," according to the position statement, which includes recommended strategies and a template for a zero tolerance policy and procedure to eliminate lateral violence and bullying in nursing work environments.

March 2008

MEDICATION ERRORS
Report indicates look-alike and sound-alike drugs lead to thousands of medication errors nationwide
A 2008 MEDMARX data report from U.S. Pharmacopeia (USP) reveals that more than 1,470 commonly used drugs are involved in errors linked to drug names that look or sound alike. From this data, USP compiled a list of 3,170 pairs of medication names that look and/or sound alike, nearly double the 1,750 pairs that were identified in USP’s previous report on this topic in 2004.

According to findings in the MEDMARX report, 1.4% of the errors resulted in patient harm, including seven errors that may have caused or contributed to patient deaths. Due to widespread underreporting of incidents, the study’s authors believe that the number of adverse events resulting from look-alike/sound-alike errors is understated, according to a January 29 news release from USP.

“This report brings a new dimension to USP’s list of look-alike and/or sound-alike drug names by providing additional evidence about the many ways in which easily confused names can lead directly to medication errors,” said Diane Cousins, R.PH., USP’s vice president of healthcare quality and information and co-author of the MEDMARX report.

In response to the report findings USP is calling on prescribers and pharmacists to include an indication for use on prescriptions. "Indications for use" is a phrase that signals why the patient is taking the drug, such as for cough, infection or rash. To prevent medication errors USP suggests that the indication-for-use information be conveyed at several points throughout the healthcare continuum.

For the report USP reviewed more that 26,000 records submitted to the MEDMARX database from 2003 to 2006. To learn more visit U.S. Pharmacopeia.

INFECTION CONTROL
APIC calls for increased HAI prevention measures
As antibiotic-resistant infections continue to spread, healthcare institutions need to increase efforts to prevent healthcare-associated infections (HAIs), according to Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC), in a statement released February 13.

“APIC is concerned with the increased rate of antibiotic-resistant infections – as high as 70 percent according to recent reports. New strains of [methycillin-resistant Staphylococcus aureus] MRSA, such as the pUSA03-positive strain, provide evidence that the very nature of these organisms is changing – producing infections that are increasingly resistant to our strongest antibiotics,” Warye said in the statement.

APIC promotes a culture of “zero tolerance” toward non-compliance with measures proven to prevent HAIs, including proper hand hygiene, barrier precautions such as use of gloves and gowns, and equipment cleaning and decontamination. APIC also urges consumers and health professionals to exercise the prudent use of antibiotics.

Warye further stated that “reducing the rate of HAIs will require adequately resourced infection prevention departments within healthcare facilities. To ensure the safety of patients, APIC stands ready to partner with healthcare professionals, policy makers and consumer groups to provide support and education in this important endeavor.” To learn more visit APIC.

RECALL
Certain fentanyl patches recalled in the US
Following concerns that certain defective fentanyl patches may lead to serious adverse events, two separate voluntary recalls have been announced.

On Feb. 17 Actavis Inc. announced a nationwide recall of certain lots of Fentanyl transdermal system CII Patches sold in the US and labeled with an Abrika or Actavis label. The product may have a fold-over defect which can cause the patch to leak and expose patients or caregivers directly to the fentanyl gel. The lots covered by this recall include doses of 25, 50, 75 and 100 mcg/hr.

On Feb. 12 PriCara and Sandoz Inc. announced a nationwide recall of all lots of 25 mcg/hr Duragesic (fentanyl transdermal system) CII patches sold in the United States. The product is being recalled because the patches may have a cut along one side of the drug reservoir within the patch, which may result in the possible release of fentanyl gel that may expose patients or caregivers directly to fentanyl gel on the skin. These recalled patches have expiration dates on or before December 2009 and are all manufactured by ALZA Corporation, an affiliate of PriCara.

Fentanyl is a potent opioid medication. Exposure to the gel may lead to serious adverse events, including respiratory depression and possible overdose, which may be fatal. To learn more visit FDA MedWatch.

STUDY
New endoscopic technique for lung cancer staging
Using two endoscopes together instead of one to stage lung cancer is more precise and less invasive than the surgical method most commonly used, researchers at Mayo Clinic in Jacksonville, Fla., report in the Feb. 6 issue of the Journal of the American Medical Association.

The new technique uses two small flexible tubes: one inserted into the patient’s esophagus to access lymph nodes in the back of the lungs and the other placed into the trachea to reach nodes at the front and sides of the lungs. In a group of 138 patients this combination technique was 93% accurate in finding malignant lymph nodes, according to study findings. The study’s lead investigator Michael Wallace, MD, MPH, a gastroenterologist, and study co-author Jorge Pascual, MD, a pulmonologist, both pioneered the technique.

“Both scopes together found more malignant lymph nodes than did the use of a single endoscope. Doing both procedures at once takes little time, requires only a mild sedative, and patients go home the same day,” said Wallace in a Feb. 5 news release. The method is now used routinely at Mayo Clinic Jacksonville to stage lung caner patients. Read the full news release.