Patient Safety
"The Electronic Health Record (EHR) is a secure, real-time, point-of-care, patient-centric information resource for clinicians." EHR has these attributes:
Two goals of centralizing all these functions in EHR are to reduce medication errors and to increase patient safety. Two of the ways EHR promises to reduce medical errors is by eliminating illegible handwriting and catching potentially harmful drug interactions. But as of 2004, E H R was largely a dream: only 10% of health care organizations in the US had installed such a comprehensive system.
Evidence-based medicine (EBM) is a movement (particularly since 1972) which says medical decisions should be based on the results of scientific studies, preferably "randomized, double-blind, placebo-controlled trials involving a homogeneous patient population and medical condition." The concept has been criticized because certain populations (women and racial minorities, for instance) are not researched as thoroughly as others; there are therefore fewer studies to derive decisions from for these people. Further, EBM is expensive and funding decisions may favor one disease or population over another, leaving others underrepresented for EBM decisions. Managed health care systems have already denied treatments based on lack of studies and thus an inability to apply EBM.
The IMO (Committee on Quality of Health Care in America, Institute of Medicine) appealed to Congress to set up a mandatory national reporting system to track errors. But pressure from the hospital industry dissuaded Congress and the recommendation fell flat.
In July 2005, the Patient Safety and Quality Improvement Act of 2005, a federal law, was passed. Though the bill appeared to be toting the IOM's finding and recommendations, it is believed by some to have completely missed the committee's point and sidestepped its objective. The new federal law made medical error reporting voluntary and without penalty, while the IOM's plan for reducing medical errors called for mandatory reporting.
At least 20 states have mandatory medical error reporting but state officials say state laws are being ignored and underreporting prevails.
Fear of malpractice or gross negligence suits, shame, embarrassment and intimidation by superiors are main reasons for failure to report medical errors. Using the success of a University of Michigan Hospital System program as a model suggests states with liability protection for disclosing errors may have increased error reporting.
Currently, many states hold inadmissible in court the reports of medical error by health care providers. The provider may even apologize to patients and their families without their words ever making to court.
Even when human error is not at fault, health providers are reluctant to report. Death as a result of the failure of a medical device is supposed to be reported to the FDA. Doctor Susan Gardner, deputy director of the Office of Surveillance and Biometrics of the FDA, said "Guess what? They don't report."
A case study of two U.S. hospitals suggests that between 26% and 60% of patients do not understand some elements of their care. These elements included: medication directions, a standard informed consent and basic health care materials.
This is a common problem for the elderly, those for whom English is a second language and those whose current literacy skills fall below average communication levels.
Ways of bridging these communication gaps are the use of videos, pictures, translators, and simple to understand brochures.
Influenced by a Committee on Quality of Health Care in America Institute of Medicine report on patient illiteracy and the impact on medical cost, a coalition of national organizations called The Partnership for Clear Health Communication (PCHC) created a program called Ask Me 3. Ask Me 3 instructs patients to ask three questions concerning their health care:
The PCHD recommends health care providers follow certain communication guidelines to assist in the patient/health care provider communication.
One thing a many nurses fail to do is initiate patient education, either assuming the nurse from the previous shift had already done so or that it's the doctor's responsibility.
One nurse explains her initiation of a "teach back" method: "I tell the patient, 'Someone has probably already explained this to you but I would like to go over it again and I need you to ask me some questions about it.' I don't let that patient go until I know for certain they understand everything they need to know about their health care."
Pay for performance is exactly what it sounds like: a health care provider is paid according the quality of their work.
In the United Kingdom, this program is already underway and has seen improvements in patient care. In the U.K. there are 146 quality indicators, covering clinical care for 10 chronic diseases, organization of care, and patient experience.
How this would play out in the U.S. is currently unknown. The insurance structures of the two countries are quite different. The UK's nationalized medicine has a long term stake in patient well-being whereas private insurance may be blindsided by more immediate gains in cost reduction.
Decisions made by health care workers should be done with sole intent in establishing the well being of the patient. A nurse related the following example: "A patient came into labor and delivery. She was 33 weeks pregnant. Fetal heart tones were not reactive or reassuring--64--69--63. I was not told until an hour and a half into the shift that I was to be charge nurse. There was no secretary, only a traveler (temporary nurse who works different hospitals), a scrub tech who was on call, and a registry nurse. It was my responsibility to make a determination in favor of the patient. I had to call the doctor at home and tell her to come in immediately. Sure, we could have continued to monitor the patient and wait to call the doctor in at a more crucial moment, but I had to determine what was in the best interest of the patient. Nurses are patient advocates, not doctor advocates."
The federal Centers for Disease Control have determined that hospital patients pick up infections at the rate of 2 million per year. Ninety thousand of those die. It has also been determined by the CDC that half of the infections could have been prevented through proper hand washing.
Johns Hopkins researchers conducted tests involving patient infection and catheters. The research encompassed over 100 intensive care units from local Michigan hospitals. The test was simple: the teams of doctors and nurses were required to adhere to rigorous hand washing, thoroughly cleaning patient skin at the catheter insertion site, avoiding the groin area as a site for catheter insertion, removing catheters as soon as possible and wearing sterile masks, gown and gloves.
After a year and a half, catheter-related bloodstream infections were reduced by 66%.
Hand washing is the exception rather than the rule according to People's Medical Society. Their studies also reveal that hand washing is related to status. Nurse's aides are more likely to wash their hands than doctors. "There is no evidence that hospitals are doing anything about this problem," say People's Medical Society. "This is one of the most common errors and one of the biggest problems confronting patients. And there's no pressure on hospitals to institute vigorous hand washing programs."
In short, hand washing is "the single most effective technique for preventing the spread of communicable disease."
The proper way to wash hands includes:
This procedure would not apply to surgeons as surgery requires a more extensive hand washing ritual.
The treatment table should be sanitized between patients with a washable or disposable barrier place over it. Everything set up for the previous person whether used or intended to be used should be removed from the treatment area before the next person is admitted into the area to prevent accidental reuse.
If applicator wands are used, they should be sterilized or discarded after use.
Any tools used directly on clients must be sanitized or sterilized after each use or discarded.
There should always be a sanitary setup. The author visited a doctor whose nurse did not do a sanitary setup. Instead the nurse set the syringe and cotton that was going to be used for withdrawing blood directly on the exam table, not even on the paper sheet but directly on the vinyl. Yikes! All health related industries should have a sanitary setup, including massage therapist, estheticians and others.
Gloves must be worn if there is a chance that the wearer will encounter bodily fluids. After use, gloves must be removed immediately. The touching of any non-contaminated item or environmental surface post-use must not occur.
Activities with the potential for splashing of bodily fluids call for the caregiver to wear a gown. After use, the gown should be taken off immediately and stored safely for cleaning or disposal.
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