What’s New in the Patient Safety World


January 2008   Two Timely Articles On MRSA Interventions


Evanston Northwestern Healthcare’s MRSA Intervention





The December issue of The Joint Commission Journal on Quality and Patient Safety has an article on an award-winning MRSA intervention by Evanston Northwestern Healthcare.



They found a high point prevalence for MRSA colonization and developed and implemented a MRSA control plan based on IHI’s 5 Million Lives Campaign recommendations for MRSA control. A prior ICU-based MRSA surveillance program had had little impact on overall MRSA infection rates but may have been helpful in fostering awareness when they rolled out their universal surveillance process. The article details how they developed the implementation plan and business plans, communication and training plans, and data monitoring. In addition to educating key constituents, other critical factors were development of order sets, ensuring adequate resources for patient isolation, and deciding which test for MRSA to use. Ultimately they chose a PCR test for MRSA because of its sensitivity and rapid turnaround time. One of the keys, however, was ensuring availability of additional laboratory personnel to do all the screening tests promptly. 65% of inpatients identified as MRSA carriers had not been previously known to their infection control program. In the first year of universal surveillance, they found a 13-fold reduction in MRSA transmission and an 80% reduction in MRSA bloodstream infections. The net cost of the intervention was about $15 per admission and their calculation of cost savings of the intervention showed it was at least cost-neutral (their conservatism and modesty kept them from highlighting that the calculated return on investment was almost double the cost invested).



This is another great example of how healthcare facilities are demonstrating that complications once thought to be unavoidable are now being dramatically reduced. Kudos to IHI, Joint Commission, and Evanston Northwestern Healthcare for this lesson that other organizations can learn from.






Peterson LR, Hacek DM, Robicsek A. Case Study: An MRSA Intervention at Evanston Northwestern Healthcare. Joint Commission Journal on Quality and Patient Safety. 2007; 33: 732-738 (http://www.jcrinc.com/fpdf/pubs/pdfs/JQPS-12-07-peterson.pdf)




Pennsylvania Patient Safety Authority Patient Safety Advisory on MRSA


The December 2007 issue of the Pennsylvania Patient Safety Authority’s Patient Safety Advisory also has a timely article on MRSA “Prompt Identification and Effective Communication of Status May Reduce MRSA Infections”. The Pennsylvania Patient Safety Reporting System has had over 1700 reports on MRSA since its inception and they have been able to identify numerous barriers to prompt identification and isolation of cases. They also note data from the Pennsylvania Health Care Cost Containment Council that shows the average cost of hospitalization for a MRSA-infected patient is $87,990 compared to $28,711 for those without MRSA infection (based on 2004 data). In addition, mortality rates are 4 times higher in MRSA-infected patients and average length of stay up to 8 days longer.



The advisory gives numerous examples of delays in identification of MRSA status or implementation of isolation of patients.



The report details the important components of a MRSA prevention/containment program. Active surveillance is a fundamental component. While the Northwestern program above chose universal screening and use of a PCR technique, other hospitals have chosen active screening of high risk patients and used nasal swabs for culture. They note high risk patients are nursing home patients, ICU patients, patients with recent invasive procedures, HIV infection , IV drug abuse, hemodialysis, age over 65, recent or long-term antibiotic use, and previous MRSA infection or colonization. They also note that computer technology can be used to alert staff of patients with current or previous MRSA infection or colonization.



They note that standing orders for MRSA screening on the target population are helpful and discuss the educational or training programs needed for various staff, patients and families. They stress that proper communication of MRSA status to all constituents is critical.



They go on to discuss the CDC-recommended isolation procedures for patients infected with or colonized with MRSA. They conclude with a section on prevention of MRSA transmission by proper hand hygiene programs (good description of the important components of a good hand hygiene program) and important details about use and care of equipment carried by healthcare workers and appropriate cleaning of hospital beds and surrounding patient environment.



This is an excellent and timely article that nicely complements the Northwestern article noted above.







Pennsylvania Patient Safety Authority. Patient Safety Advisory: Prompt Identification and Effective Communication of Status May Reduce MRSA Infections. Pennsylvania Patient Safety Authority Patient Safety Advisory 2007; 4: 124-129








Update: See also our March 25, 2008 Patient Safety Tip of the Week “More on MRSA” for additional comments and discussion on universal screening for MRSA.





In addition to this month’s column above, there are some other important new patient safety issues we’d like to point out. We ended last year with a discussion of heparin flush overdoses and a recommendation that part of your routine patient safety activities is responding to alerts put out by the FDA, ISMP, Joint Commission, your state Department of Health, or other reputable organizations that issue alerts. It turns out that this month was an active one for the FDA MedWatch site for product recalls. Some of the more important ones are below:



Heparin lock flush solution in pre-filled syringes
Ironically (since one of the recommendations to help avoid heparin flush overdoses was to use pre-filled syringes), one of the recalls was for one lot of a pre-filled heparin lock flush solution. AM2 PAT, Inc., and FDA informed healthcare professionals and consumers of a nationwide recall of one lot of Pre-Filled Heparin Lock Flush Solution (5 ml in 12 mL Syringes), Lot # 070926H. The heparin IV flush syringes were found to be contaminated with Serratia marcescens, which have resulted in patient infections in a Chicago area hospital. This type of bacterial infection could present a serious adverse health consequence that could lead to life-threatening injuries and/or death. Consumers and user facilities should immediately stop using the product, quarantine it and return the affected product to the distributor.



Alaris pump recall
Cardinal Health announced a voluntary recall for all Alaris Pump modules, model 8100 (formerly known as Medley Pump module), shipped prior to September 27, 2007 because the units may contain misassembled occluder springs (bent, broken, nested or missing) that occurred during manufacturing. Misassembled springs could lead to overinfusion that could result in serious adverse health consequences or death. Overinfusion may be difficult to detect because the misassembled springs can work intermittently, and there is no warning or notification of an overinfusion. There is a link to the manufacturer's press release and another for a list of the serial numbers for the affected devices.



Bayer Diabetes Care Contour Test Strips (TS)
Bayer Diabetes Care notified healthcare professionals and consumers of a voluntary market recall of test strips (sensors) used exclusively with the Contour TS Blood Glucose Meter because test strips from specific lots could result in blood glucose readings with a positive bias that could demonstrate 5 - 17% higher test results. This issue is unrelated to the Contour TS meter itself and pertains only to certain test strips used with the meter. There is no impact on the performance of strips with other Bayer meters. Healthcare professionals, retailers, patients and other customers who use Contour TS are advised to check the lot number of the test strips in their inventory (affected lot numbers are provided in the manufacturer’s press release and contact Bayer Diabetes Care for information regarding the return and replacement of strips.



Other significant patient safety news items this month:



The December Patient Safety Alert from the Pennsylvania Pateient Safety Authority mentioned above also has some other excellent articles. One is a followup on wrong-site surgery that has valuable lessons learned from both root cause analyses and from on-site observations at hospitals. There is also an article about the safety catches on smart pump infusion devices and several other useful articles.



The New Jersey Patient Safety Initiative: 2006 Summary Report is also available and has good statistics on falls and decubiti. We previously have mentioned some of the good work done collaboratively in New Jersey on falls.




The January 17, 2008 ISMP Newsletter has results of their recent survey on automated dispensing cabinets.












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