Untitled Document

Scope of the Problem

50,000 Vegas Patients Exposed to Hep C
Nurse anesthetists ordered to reuse syringes!*

1.7 errors per patient day in ICU?*

100,000 Americans die each year as a result of potentially preventable, in-hospital medical errors. *

'Medical error' is one of the most significant preventable national safety issues. Unfortunately, the U.S. government lacks the infrastructure to systematically track patient injury associated with our healthcare industry. There is no single national agency empowered to set standards and compel compliance. There are agencies to enforce regulations pertaining to: worker safety, nuclear energy, aviation, etc. However, there is no agency empowered to protect our most vulnerable citizen; the patient.

The need for change is evident. HealthGrades, Inc. provides a number of valuable consumer services including an annual patient safety report card for the industry. The Fourth Annual HealthGrades Patient Safety in American Hospitals examined 40 million Medicare hospitalizations from 2003 to 2005. The study found 1.6 million patient safety incidents in the patient records. The number of unreported incidents is unfathomable. It is estimated that the recorded incidents increased the cost of treatment by $8.6 billion. The study also found that patients who experienced a patient safety incident had a 25% chance of dying during their hospitalization. Of "the 284,798 deaths that occurred among patients who developed one or more patient safety incidents, 247,662 were potentially preventable."

The Fifth Annual Patient Safety in American Hospitals Study, provided some evidence of improvement. The records of 41 million Medicare hospitalizations were examined and only 1.12 million patient safety incidents were identified. Preventable hospital associated deaths of Medicare patients were only 238,337 from 2004 to 2006.

The 6th, 7th and 8th Annual Patient Safety in American Hospitals studies are based on a reduced number of indicators. HealthGrades warns readers that the prior Annual Patient Safety in American Hospital Study data are not comparable year over year. The Eighth Annual Patient Safety in American Hospitals study further reduced the indicators to 13 of 20. HealthGrades admits that these studies capture only a fraction of recordable patient safety events and deaths. Obviously Medicare patients are still endangered by the medical care industry. This is evident from the fact that a Medicare patient has a one in ten chance of dying if she/he experiences only one of the 13 currently tabulated patient safety events during an American hospitalization.

Chart of 6th, 7th and 8th Annual HealthGrades Patient Safety Hospitals Study
6th Annual 2005-2007		7th Annual 2006-2008		8th Annual 2007-2009
Medicare patient safety events	913,215	Medicare patient safety events	958,202	Medicare patient safety events	708,642
Medicare deaths	97,755	Medicare deaths	99,180	Medicare deaths	79,670
Avoidable Medicare deaths	22,771	Avoidable Medicare deaths	22,590	Avoidable Medicare deaths	20,688

While the HealthGrades trends remain dismal, a 2011 study by Lipitz-Snyderman; Needham; Colantuoni et al. has demonstrated that any hospital can significantly improve patient safety if it will commit the resources. The researchers found that 60 percent of the 80 participating ICUs went 1 year or more without a central line-associated bloodstream infection, and 26 percent achieved 2 years or more. Smaller hospitals sustained zero infections longer than larger hospitals. The participating hospitals employed the multi-phase Keystone ICU Improvement program. The Keystone program focuses on: evidence based learning, unit goal directed expert teams, team communication, goal implementation, etc. A keystone model could include the following elements:

"Comprehensive Unit-based Safety Program (CUSP)" forms an organizational framework for improvements
- Evaluate care unit's patient safety culture.
- Provide safety science education.
- Identify and correct acute safety issues
- Identify a project team to include: physician leader, nurse leader, staff nurse, pharmacist, senior executive.
- Learn from one preventable error per month.
- Re-evaluate unit's patient safety culture.
Identify Daily Goals
- Provide team training and communication strategies.
- Physician lead interdisciplinary rounds.
- A goal sheet providing clear expectations to guide care.
Eliminate Bloodstream Infection using BSI Bundle
- Educate staff on bloodstream infection control practices.
- Create a central-line cart that contains all equipment needed to comply with evidence-based guidelines for central-line insertion.
- Institute a policy that requires nurses to assist in central-line insertion.
- Require use of a checklist to ensure compliance with evidence-based guidelines for central-line insertion.
- Provide regular feedback to staff on infection rates.

Nursing provides the vast majority of direct patient care. Therefore, whether it is transmission of nosocomial infection, medication error, wrong-site surgery, failure to protect, etc.; nursing was probably involved at some point. Nursing must act to establish safe patient care as its singular purpose.