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What’s New in the
Patient Safety World
December 2020
· Joint
Commission 2021 National Patient Safety Goals
· Guidelines
for Opioid Prescribing in Children and Adolescents After Surgery
· ISMP
Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines
· Do
You Have These Infection Control Vulnerabilities?
Joint Commission
2021 National Patient Safety Goals
The Joint Commission
has announced its 2021 National Patient Safety Goals (TJC
2020). The NPSG’s for hospitals
are:
Goal 1. Improve the
accuracy of patient identification.
· NPSG.01.01.01 Use at least two ways to
identify patients. For example, use the patient’s name and date of birth. This
is done to make sure that each patient gets the correct medicine and treatment
Goal 2. Improve the effectiveness of communication among caregivers.
· NPSG.02.03.01 Get important test results to
the right staff person on time
Goal 3. Improve the
safety of using medications.
· NPSG.03.04.01 Before a procedure, label
medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and
supplies are set up.
· NPSG.03.05.01 Take extra care with patients
who take medicines to thin their blood.
· NPSG.03.06.01 Record and pass along correct
information about a patient’s medicines. Find out what medicines the patient is
taking. Compare those medicines to new medicines given to the patient. Give the
patient written information about the medicines they need to take. Tell the
patient it is important to bring their up-to-date list of medicines every time
they visit a doctor.
Goal 6. Reduce patient harm associated with clinical alarm systems.
· NPSG.06.01.01 Make improvements to ensure
that alarms on medical equipment are heard and responded to on time.
Goal 7. Reduce the risk of healthcare–associated infections.
· NPSG.07.01.01 Use the hand cleaning
guidelines from the Centers for Disease Control and Prevention or the World
Health Organization. Set goals for improving hand cleaning. Use the goals to
improve hand cleaning.
Goal 15. The hospital identifies safety risks inherent in its
patient population.
· NPSG.15.01.01 Reduce the risk for suicide.
Universal Protocol. Introduction to the Universal Protocol for Preventing Wrong
Site, Wrong Procedure, and Wrong Person Surgery™
· UP.01.01.01 Make sure that the correct
surgery is done on the correct patient and at the correct place on the
patient’s body.
· UP.01.02.01 Mark the correct place on the
patient’s body where the surgery is to be done.
·
UP.01.03.01
Pause before the surgery to make sure that a mistake is not being made
You can access the NPSG’s for other venues at the Joint
Commission’s NPSG
website.
We’ll comment on the Elements of
Performance for just a few of these NPSG’s.
Element(s) of Performance for NPSG.07.01.011 really focus on
hand hygiene They require you implement a program following either the current
CDC or WHO hand hygiene guidelines, that you set goals for compliance, and you
actually improve compliance based on those goals.
Element(s) of Performance for NPSG.02.03.01
1. Develop written procedures for managing the critical
results of tests and diagnostic procedures that address the following:
- The definition of critical results of tests and diagnostiic procedures
- By whom and to whom critical results of tests and diagnosstic procedures are
reported
- The acceptable length of time between the availability annd reporting of
critical results of tests and diagnostic procedures
2. Implement the procedures for managing the critical
results of tests and diagnostic procedures.
3. Evaluate the timeliness of reporting the critical results
of tests and diagnostic procedures.
We refer you to our many columns on “communicating
significant results” listed below.
See also our other
columns on communicating significant results:
- May 1,
2007 “The
Missed Cancer”
- February
12, 2008 “More
on Tracking Test Results”
- October
13, 2009 “Slipping
Through the Cracks”
- July
2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- March
9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- March 1, 2011 “Tests Pending at Discharge”
- August 21, 2012 “More on Missed Followup
of Tests in Hospital”
- October
2, 2012 “Test
Results: Everyone’s Worst Nightmare”
- March
12, 2013 “More
on Communicating Test Results”
- October 2013 “New AHRQ Toolkit: Improving Your Office
Testing Process”
- January 2014 “Email Alerts for Pending Test Results”
- July 2015 “Technology to Avoid Delays in Follow-up
of Significant Results”
- November 17, 2015 “Patient
Perspectives on Communication of Test Results”
- December 20, 2016 “End-of-Rotation
Transitions and Mortality”
- September 2018 “ECRI
Institute Partnership: Closing the Loop”
- September 24, 2019 “EHR-related Malpractice
Claims”
- November 26, 2019 “Pennsylvania Law on
Notifying Patients of Test Results”
- January 2020 “The Joint Commission on
Closing the Loop”
- September 8, 2020 “Follow Up on Tests
Pending at Discharge”
References:
The Joint Commission. National Patient Safety Goals
Effective January 2021 for the Hospital Program. The Joint Commission 2020
The Joint Commission. 2021 National Patient Safety Goals.
The Joint Commission 2020
https://www.jointcommission.org/standards/national-patient-safety-goals/
Print “December 2020 Joint Commission 2021
National Patient Safety Goals”
Guidelines for
Opioid Prescribing in Children and Adolescents After Surgery
The first-ever guidelines for opioid prescribing in children after surgery were just published in JAMA Surgery Kelley-Quon 2020
The guideline emphasizes
use of enteral non-opioid regimens as first line therapy for pain
post-operatively but also recommends use of perioperative intravenous non-opioids
like ketorolac and acetaminophen.
The guidelines also endorse
the FDA guidelines regarding limited use of codeine and tramadol for children
younger than 18 years. Our extensive columns on the dangers of codeine (and
tramadol) use in children are listed below.
The guideline
emphasizes that caregivers and children be educated about expectations and
methods of pain management both before the day of surgery and again perioperatively.
Pain management messaging should be consistent from all members of the
perioperative team. Education should be in plain, nonmedical language,
regardless of health literacy level, and delivered in the language most
familiar to the family.
If opioids are
prescribed, perioperative education should include instruction regarding
possible adverse drug events, seriousness of adverse drug events, and what to
do if they occur.
It is also recommended
to educate caregivers and older children to store opioids in a secure location
and properly dispose of unused medication. The guideline recommends health care
entities caring for pediatric patients should consider providing infrastructure
and means for safe opioid disposal. That infrastructure might include a local
drug disposal box in the health care facility or home disposal mechanisms, such
as drug deactivation compounds.
Disposal of unused opioids is such an important issue, yet options have been poorly understood. The FDA recommends that such unused opioids be returned to the healthcare facility (or other designated site) but, if that is not possible, they be flushed down the toilet. The FDA has a section on disposal of unused medicines
Prior to the intervention, 52% did not dispose of their narcotics. After the education and disposal bag were given, this rate increased to 93.5% .
It’s important to recognize that non-opioid pain regimens can adequately
and more safety control pain after surgery in most cases. But sometimes opioids
may be needed. Many studies have shown that we tend to prescribe far more
opioid pills than needed when patients are discharged post-surgery. Even with efforts
to limit such over-prescribing (at the hospital level, specialty society level,
or state health department level), it is inevitable that some patients will be
left with opioids that are no longer needed. It’s
critical that we not only educate patients and caregivers on proper disposal
but give them the tools or infrastructure needed to accomplish safe disposal.
Some of our previous columns
on opioid safety issues in children:
- September 2012 “FDA Warning on Codeine Use in Children
Following Tonsillectomy”
- March 2013 “Further Warning on Codeine in Children
Following Tonsillectomy”
- May 2014 “Pediatric Codeine Prescriptions in the
ER”
- November 2015 “FDA
Safety Communication on Tramadol in Children”
- January 2016 “FDA
Gets Even Tougher on Codeine in Kids”
- October 2016 “Another
Codeine Warning for Children”
- May 2017 “FDA
Finally Restricts Codeine in Kids; Tramadol, Too”
- February 2018 “FDA
Warning on Cough Meds”
References:
https://jamanetwork.com/journals/jamasurgery/article-abstract/2772855
https://jamanetwork.com/journals/jamasurgery/fullarticle/2729448
Print “December 2020 Guidelines for Opioid
Prescribing in Children and Adolescents After Surgery”
ISMP Warns of Vaccine
Errors as We Gear Up for COVID-19 Vaccines
As the world waits with bated breath for mass vaccinations
to protect against the COVID-19 coronavirus, ISMP (Institute for Safe
Medication Practices) reminds us of the many types of errors that might occur
related to vaccinations (ISMP
2020). We discussed some of these in our November 19, 2019 Patient Safety
Tip of the Week “An
Astonishing Gap in Medication Safety”. In that column we noted cases where
insulin or neuromuscular blocking agents (NMBA’s) were erroneously given instead
of intended vaccines, usually with disastrous results. We did discuss some of
the root causes and important lessons learned and recommendations for what you
should be asking at your organization or facility.
ISMP (ISMP
2020) discusses factors in the following categories related to adverse
vaccination-related events:
- Look-alike names, labels, packaging
- Unsegregated storage in a refrigerator
- Mixing errors or omissions with 2-component vaccines
- Miscommunication
- Not checking/documenting administration in the immunization
information system (IIS)
- Lack of usual procedures/technologies during mass immunizations
- Temperature excursions and expired vaccines
ISMP then provides solid recommendations on planning vaccination
campaigns, safe vaccine storage, staffing and training, safe vaccine dispensing.
safe vaccine administration, patient education, and reporting adverse vaccine
events.
References:
ISMP (Institute for Safe Medication Practices). Learning
from Influenza Vaccine Errors to Prepare for COVID-19 Vaccination Campaigns.
ISMP Medication Safety Alert! Acute Care Edition 2020; 25(23): November 19,
2020
Print “December 2020 ISMP Warns of Vaccine Errors
as We Gear Up for COVID-19 Vaccines”
Do You Have These
Infection Control Vulnerabilities?
A recent article
from Health Europa has some valuable lessons in infection control for everyone.
Karolinska University Hospital, affiliated with the world-renowned Karolinska
Institute in Sweden, agreed to participate in a study to identify its key areas
of risk and reduce the spread of infection Health
Europa 2020. Researchers there did bacterial screenings and had 2 individuals (a
doctor or nurse plus a second person with another background, such as an
industrial designer or psychologist) do direct observation by following a
patient through the ward for four hours.
Risk factors
identified by the observers could be specific to individual wards or common to
all the screened wards:
- Parents and siblings on pediatric wards could pose risk for spread
of infection
- Urinary catheters on the urology ward
- Incubators in the neonatology unit
- Breathing apparatus on the thoracic ward
- Immunocompromised or immunosuppressed patients on the hematology
ward
- Incorrect cleaning processes: cleaning staff did not use hand sanitizer
or change their gloves between tasks. Some furniture was difficult to
move, meaning that staff were unable or unwilling to clean under or behind
cumbersome items. Cleaning staff did not appear to have been fully briefed
as to which cleaning tasks were their responsibility and which tasks fell
under the purview of hospital staff, meaning some surfaces may not have
been cleaned at all by either team
- Lack of compliance with necessary infection control processes: staff
were observed wearing the same plastic apron while making beds, dressing
wounds, and feeding patients, leading to a heightened risk of infection
spread
- Widespread overuse, underuse, and misuse of protective gloves
- Patients, their family members and
caregivers were not informed about the importance of good hygiene or how
to establish an effective hygiene routine
- Surfaces in patients’ rooms were described as ‘packed’ with items:
patients’ personal toiletries, specimen bottles, medicine cups and
glasses. Rather than moving these items to clean – or, where relevant,
disposing of them – cleaners simply cleaned around them
- The structure of containers dispensing single-use plastic gloves and
aprons made it difficult for users to take a single apron or pair of
gloves without getting extras – users would simply push the extra items
back into the boxes, thus compounding the issue for the next user and
compromising the hygienic integrity of the aprons and gloves which had
been touched
- Textile draperies were rarely laundered
- Urinary catheter tubes were left on the floor
- Unprotected input ports contaminated with aggregate substances could
be placed near patients’ mouths or near babies’ nappies
- Staff operating patient transports were insufficiently trained on
basic hygiene and disinfection routines
Results of
bacteriologic screenings correlated inversely with the degree of compliance
with basic hygiene routines. Wards with the highest levels of compliance had the
lowest number of surface bacteria, while the highest number of bacteria were
found in the wards with the lowest rates of compliance.
So, what did the
hospital do? It switched its cleaning services contract to a new company and
mandated that its new cleaning contract staff must be trained in the
fundamentals of infection prevention and control, antibacterial measures, and
the necessary standards of hygiene within healthcare environments. It updated cleaning
routines and established checklists to ensure each cleaning task was
documented. Hospital staff were detailed to clean the ‘near-patient
environment’ – the equipment used near the patient and while caring for the
patient, such as the bed, bedside table, bedside lamp
and wheelchair. The hospital’s personnel and the cleaning operatives were
trained or retrained in basic infection control cleaning and disinfection
processes. The fabric drapes, which had represented a significant vector of
infection, were replaced with screens which were less bacteria-retentive and
substantially easier to clean.
The hospital continued
to take monthly culture samples at the sites in each ward which had initially
been identified as having a high bacterial load. A second observational study
conducted nine months after the first found that compliance with basic clinical
hygiene routines had risen by an average of 16 percentage points. Hospital
management found that making staff aware of the initial screening results had
rendered them more motivated to improve their compliance with hygiene
regulations, leading to positive trends in all the wards which were observed.
Our bet is that
Karolinska University Hospital is not alone in having these infection control
vulnerabilities. In fact, most of them probably exist at many hospitals.
Combining the screening cultures with direct observational methods is likely to
help any hospital identify such risk factors. We’d
also bet that you’ll find even more if you extend your observation to following
patients on intrahospital transports.
References:
Print “December 2020 Do You Have These Infection
Control Vulnerabilities?”
Print “December
2020 What's New in the Patient Safety World (full column)”
Print “December 2020 Joint Commission 2021
National Patient Safety Goals”
Print “December 2020 Guidelines for Opioid
Prescribing in Children and Adolescents After Surgery”
Print “December 2020 ISMP Warns of Vaccine Errors
as We Gear Up for COVID-19 Vaccines”
Print “December 2020 Do You Have These Infection
Control Vulnerabilities?”
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version”
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