Hospitals are charged with the dual task of keeping patients well while also keeping patients safe. The two are inextricably linked, as patient safety concerns often tie directly into patient health concerns — hand hygiene, transitions of care and medication errors are a few such concerns that come to mind.
Retrospectively, 2014 provided some lessons in patient safety issues. The Ebola outbreak shed light on the country's unpreparedness for handling infection outbreaks after two nurses contracted the virus while caring for an infected patient, and meaningful use guidelines are ramping up requirements for patient involvement in their care.
Looking prospectively, these concerns, and many others, will flow into the next calendar year. Some of the patient safety issues are long established, and will remain in the forefront of healthcare's mind for years to come. Here, in no particular order, are 10 important patient safety issues for providers to consider in the upcoming year.
Healthcare-associated infections. HAIs have long plagued healthcare facilities, both clinically and financially. Protocol including hand hygiene and antimicrobial stewardship play directly into the rate and prevalence of HAIs, and all three are continuously deemed patient safety concerns. According to the CDC, one in every 25 patients will contract an HAI during a hospital stay, and treating such infections costs the healthcare industry upwards of $9.8 billion, by some estimates.
Antibiotic resistance. Given current prescribing practices, the lack of new antibiotic development and the speed with which pathogens are developing resistance to certain drugs, a scenario in which antibiotics are rendered useless may be sooner than many realize. The Centers for Disease Control and Prevention estimate 2 million people contract an infection by bacteria that are resistant to antibiotics each year, and 23,000 people die as a direct result of this infection.
Since the 1940s, the beginning of the "Golden Age of Antibiotics," society has leaned on antibiotics as a go-to fix, regardless of whether they could actually cure the ailment at hand. Clinicians also have adopted a preemptive, precautionary attitude, prescribing antibiotics to protect themselves in the event a patient does develop an infection. Antimicrobial stewardship programs can play a key role in transforming antibiotic prescribing practices to reduce both the use of antibiotics and pathogens' ability to develop resistance to such organisms.
Personal protective equipment protocol. 2014 saw the largest Ebola virus outbreak to date. As of Nov. 16, the World Health Organization reported 5,420 deaths in eight countries attributed to the virus. Although the overwhelming majority of the outbreak was contained in West Africa, the United States cared for seven Ebola patients through November; five of whom were travelled back to the country from West Africa and two of whom contracted the virus in the U.S., marking the first Ebola transmissions in the country. The two patients who contracted Ebola in the U.S. were nurses caring for the U.S.'s first imported Ebola patient. It is suggested the virus was contracted through lack of or inadequate PPE protocol, sparking controversy and a reexamination of such guidelines. The WHO and the Centers for Disease Control and Prevention issued guidelines for donning and removing PPE, and hospitals are bolstering their infection control tactics. Additionally, nursing unions such as National Nurses United are going on strike, demanding better protective gear and safety precautions and increased education and training on treating patients with Ebola or other infectious diseases.
Hand hygiene. The first line of defense against infections remains one of the least-used tactics. Despite the relative easiness of washing hands, hand hygiene compliance rates simply remain too low. "Hand hygiene has well-documented ties to patient safety, yet median hand hygiene compliance is still only 40 percent, meaning healthcare workers clean their hands less than half the time they enter patient rooms," says Jason Burnham, associate director of patient care solutions of Halyard Health, a global medical technology company spun-out of Kimberly Clark Health Care.
Mr. Burnham adds financial incentives are pushing healthcare providers to explore different avenues by which to increase hand hygiene. "With CMS penalties for infections adding to the cost of poor quality in 2015, hospitals across the country are exploring electronic monitoring as a way to create rapid improvement and individual accountability where manual audits and observations have not succeeded in improving behavior in this fundamental of patient care."
Hospitals and health systems have implemented hand hygiene intervention and conducted studies to determine when clinicians achieve optimal hand hygiene compliance. But the fact remains that clinicians just aren't washing their hands enough.
Health IT issues. The proliferation of health IT has been both a blessing and a curse in the patient safety sphere. At its core, health IT is meant to quicken processes, aggregate and analyze data and eventually improve outcomes. However, implementation of IT has been rocky, and the scope of technology's reach is shorter than anticipated, creating an environment conducive to human error and patient safety mistakes.
"We believe there is a lot of promise for health IT to improve quality and safety, but new technology generally also brings new problems," says Tejal Gandhi, MD, MPH, president and CEO of the National Patient Safety Foundation. "The job now is to enhance the technology, so we are using it in optimal ways to improve communication within and between teams, improve timeliness of care, and create meaningful data for monitoring and evaluation."
Medication errors. The Institute of Medicine has estimated nearly 1.5 million Americans experience an adverse event due to a medication error each year, costing the health system nearly $3.5 billion in extra costs. The Mayo Clinic suggests medication errors are largely communication errors, be it between patient and provider, provider and pharmacist or pharmacist and patient. This is one arena in which health IT can offer a proven solution. A recent study at Boston Children's Hospital found medication errors fell by 58 percent when an electronic reconciliation tool was implemented. Innovations and adaptations such as electronic tools may begin to help cut down the incidences of this adverse event.
Workforce safety. Clinicians can't treat others if they themselves are not well. The NPSF believes ensuring safety of the workforce and in the workplace is a prerequisite for patient safety. This includes both the physical and psychological safety of healthcare employees. "The Occupational Safety and Health Administration reports that hospitals and health settings are among the most hazardous workplaces in the country, with high rates of injury such as musculoskeletal problems and needlestick injuries," says Dr. Gandhi. "We also know that there are intense pressures in healthcare, and disruptive behaviors, disrespect and even violence against health workers is all too common. We believe these issues have a direct impact on patient safety because workers can only perform at their best when in an environment of physical and psychological safety."
Transitions of care. The healthcare spectrum is a string of transitions, whether it is a physical transfer or just a change of physician. "Our communication around patient care is critical in that we must communicate exact information at each change of care to provide the next caregiver with the necessary information to start care without having to read the chart from the beginning or until the personnel can assess the patient themselves," says Nan Finch, system director of compliance and quality at Arise Austin (Texas) Medical Center.
Health IT has also stepped up to the plate to deliver technologies and solutions to address care transitions, such as remote patient monitoring, wireless data aggregation and analysis and electronic data sharing. As Ms. Finch says, the clearer communication channels are, the better care patients will receive as they move through the healthcare spectrum.
Diagnostic errors. In addition to the severe issues they cause patients, diagnostic errors are both the most common and the most costly form of medical malpractice claims. A 2013 study from Johns Hopkins Medical Center in Baltimore found nearly 8 percent of medical malpractice payouts exceeding $1 million from 2004 to 2010, the majority of which were due to misdiagnoses.
Frank Seidelmann, DO, co-founder, chairman and CMO of Radisphere, a national radiology practice, says diagnostic errors are largely an issue in radiology due to substandard operating models. "To date, there is still no established set of standard best practices that radiologists, patients, health systems and payers can use to gauge the quality of radiology services," Dr. Seidelmann says. "What is needed, at the very least, is a better clinical operating system that ensures routing of images to the right subspecialty and a consistent practice of blinded peer reviews. This will significantly increase quality of care, reduce costs and enable radiologists to practice at the top of their license."
Diagnostic errors were a key issue at NPSF's Patient Safety Awareness Week 2014, adds Dr. Gandhi, saying such errors may be more prevalent than people initially realize. These errors can result from a number of combined forces, including failure to order appropriate tests and a lack of patient engagement. She says it is a complex error, but even missed communications, such as not following up on a test or a patient not realizing how important a test is, could lead to a diagnostic misstep.
Patient engagement. Patients are becoming consumers of healthcare, and the industry has to shift to meet this new demand. By involving patients in their treatment plans and processes, they become allies in their care and can serve as another layer of defense against many safety issues. The more minds tuned into an issue, the better the outcome.
"NPSF has been a strong advocate for increased patient engagement in healthcare at all levels," says Dr. Gandhi. "This is an extremely complex issue with many corresponding challenges — for example, health literacy and ensuring that patients are given materials and information in a way that they can understand it. There needs to be considerable education and training of health professionals, as well as the creation of shared decision making tools. But there is great promise to improving patient safety by having patients more directly involved."
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