BB&T Contributing Editor

CHICAGO – The 22nd annual Joint Commission (Oakbrook Terrace, Illinois) Conference on Quality and Safety, held here in November, drew close to 400 attendees representing just about every state. The attendee list was comprised of risk managers, nursing directors, patient safety officers and other hospital managers entrusted with the responsibility of maintaining patient safety while in their institution.

The Joint Commission embodies the essence of what any self-regulating and self-policing group should entail. Its commitment to collecting data, analyzing it, arriving at solutions to solve the problem, and then training all institutions how to avoid that problem is unparalleled in any industry.

The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 15,000 healthcare or-ganizations and programs in the U.S. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.

Each year the Joint Commission holds a conference to teach leadership and negotiation skills that will help hospitals engage their employees and peers into complying with the patient safety goals. At the same meeting the organization reviews the previous year's progress towards safety goals and introduces the new year's goals for better patient care.

"We want you to be able to provide reasons for each new requirement in order to enable you to get compliance from those who have to enforce them," said Louise Kuhny, RN, senior associate director, standards interpretation at the Joint Commission, who opened the conference with a review of changes in the National Patient Safety Goals (NPSGs) from 2008 to 2009.

"The process for development of NPSGs involves a constant review of sentinel events that have occurred," Kuhny said. Sentinel events (see Table 6 on p. 32) are reviewed by experts in that field, root causes are identified, and then protocols are developed for implementation into institutions that should reduce future risk for occurrence of that event.

Sentinel events are defined as being an event that resulted in unanticipated patient death or major permanent loss of function unrelated to the natural course of the patient's illness or underlying condition.

"It is important that the staff needs to know to report any of these. Sentinel event reports are anonymous, providing only the organization characteristics, with no names. Only the event data and the cause data is requested," Kuhney said.

Sentinel event reporting was established about 10 years ago to be used as a learning tool and to be able to decrease the root causes of the events by applying universal policies and procedures.

Through March 2008, the most cited sentinel events were: wrong-site surgery, inpatient suicide (in 24-hour staffed settings), and operative and post-operative complications. These were followed by medication errors, delay in treatments, and patient falls.

"Of all reported sentinel events, 70% resulted in death," Kuhny said, "with the most common root causes being lack of, or wrong, communication, training, or patient assessment."

Each year new patient safety goals are identified based on sentinel event alerts, with a subset selected that the Joint Commission believes will have the largest effect nationally. The timeline from first identifying a frequently occurring sentinel event to the time a NPSG is endorsed is about 18 months.

"The Joint Commission requests that you actively inform your physicians what new protocols may be coming down the line so that you can achieve better compliance once it is established," Kuhny said. "You should let them know that the sentinel advisory boards consist of nationally recognized experts in safety-clinicians, nurses, systems engineers – and that practicality and cost of implementing evidenced based recommendations is also taken into consideration. Cost benefit analysis is performed before each goal is established and the final result of this process is that certain goals are spotlighted each year.

"Although there are no new goals for 2009, there are new requirements in existing protocols to achieve current goals," she said. The 2009 patient safety goals are listed in Table 7.

In reference to patient identification, "Checking the armband is no longer enough. We need to make a paradigm shift to actively include the patient, or their caregiver, in identifying themselves, their drugs, their procedures," Kuhney said. "Although this will take longer in a time-constrained environment, the decision must be made based on patient safety, not throughput."

Since wrong-site surgery remains the top reported sentinel event, new measures have been included in the universal protocol to combat this from happening. Two critical changes in the protocol regard marking the patient who will be receiving the operative procedure:

1) The site must be marked BEFORE the patient moves to the room where it will take place.

2) The person marking the patient can only be one who is "privileged or permitted to perform the procedure and will actively be involved in the procedure." This will eliminate residents who are not going to take an active part of performing the procedure as well as nurses.

With regard to effectiveness of communication (No. 2 on the list of goals), 23% of hospitals surveyed in 2007 were non-compliant with regards to having a standardized list of abbreviations acronyms, symbols, and dose designations that are NOT to be used. This often occurred when a staff member was using an old form or prescription pad.

In an effort to correct this problem, one hospital created a "Treasure Hunt" for their employees. When any staff member found an old form that still contained abbreviations that were on the "do not use" list, they were rewarded with a gift card.

Some 34% of audited hospitals were non-compliant in the requirement to "measure, assess, take action to improve timeliness of reporting and receipt by responsible licensed caregiver of critical test results and values. "It is up to each hospital to identify, publish and communicate their definition of "critical tests," Kuhny said.

She concluded by stating that much progress has been made, but more is still to be had.

DVT new area of interest

One of the newest areas discovered with a high potential for sentinel events for inpatients is that of being at risk for deep vein thrombosis (DVT) which can lead to pulmonary embolism (PE) – a potentially lethal occurrence that until recently has gone largely unprevented.

Hella Ewing, RN, and Mary Foscue, MD, of Sacred Heart Health System (Pensacola, Florida), presented "Screening and Implementation of a DVT Prophylaxis Program for Medical/Surgical Population in an Acute Care Setting."

They noted that there are about 2 million cases of DVT annually in the U.S., and some 200,000 persons die from pulmonary embolisms – more than from AIDS and breast cancer combined.

DVT is the leading cause of death from childbirth, with pregnant women having a six-fold greater risk of having DVT. Even scarier is the fact that of all DVT patients, only one-third will show any symptoms whatsoever (see Table 8).

"Because it is hard to predict which patents will develop VTE, and often there is no warning that a PE will develop, it is critical that hospitals embrace a DVT prevention plan," Foscoe said. "In 70% to 80% of hospital patients who died of a PE, the diagnosis was not considered prior to death. PE is the most common preventable cause of hospital death."

In their program, all patients are screened for DVT risk at the three possible points of entry: direct admit, ER admission, or transfer from medical patient to surgical patient (see Table 9).

"Rather than utilize a complicated computer-generated risk stratification model, we have adopted the criteria for DVT prophylaxis to be two or more risk factors," Foscoe said. "By adopting this practice, we have found it to be quicker and easier for everyone to determine which patients will be on DVT prophylaxis.

"It is important to incorporate the DVT screening tool into your existing nurse admit history," said Ewing, "as it makes the process simple, adds no new paperwork, and reminds them to do it all at the same time."

They found that by modifying what they were already doing, rather than creating a whole new process that they had much better success with implementation.

The incremental cost of adding this life-saving program was more than offset by a reduction in lawsuits and a reduction in length of stay, they said.