Supporting Safer Healthcare

The Salahi's in the White House - Sentinel Event or Near Miss?

After last week's news about Tareq and Michaele Salahi's White House adventures I began to consider whether, if one were applying healthcare criteria, the event would be classified as Sentinel or Near Miss.

Some unanticipated healthcare outcomes are clearly Sentinel (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, per the Joint Commission).  Many times however, there is room for educated discussion as to whether an event should be classified as Sentinel or Near Miss. 

For a hospital the difference in classification can impact the course of action and level of leadership involvement that occurs following a particular event.  Event classification is usually performed in the Risk Management or Quality Department.

Consider the Salahis. 

Since someone who was apparently not entitled to be present in the White House was touching the President, Vice-President and other officials, the matter clearly seems to meet the criteria of "the risk thereof" for death or serious injury.  Therefore, I would classify this event as Sentinel.

Some might argue that because the Salahis, along with other guests, were screened for weapons prior to entry, a Near Miss classification would be sufficient.  I would agree had the Salahis made it through some levels of screening, but been "discovered" and stopped prior to final access to the state dinner. 

For example, unplanned retention of a foreign body (we'll say a sponge) after surgery is a Sentinel Event. If however, before the site is closed and the patient leaves the OR, the count is reported as incorrect and the sponge is discovered through x-ray or re-inspection, the event becomes a Near Miss.  Initial screening methods (earlier count or surgical site inspection for example) may not have revealed the presence of a foreign body, but later screening methods did.  The patient did not enter the recovery area with a retained foreign body, therefore, the event is a Near Miss.

The White House and Secret Service appear to be treating the presence of uninvited guests at a state dinner as a Sentinel Event. There are no doubt various flow diagrams and root-cause analysis documents being reviewed by high-level leaders in order to assure this type of issue does not reoccur.  Healthcare must be as diligent.

Spectacular Sky Abingdon Virginia

 

Hospitals in the UK Under Attack for Poor Safety Record

The debate about improving US healthcare availability continues, but in the United Kingdom, where public healthcare is the standard, a firestorm over patient safety has erupted.  Headlines like these have been featured over the past several days in the British press:

The worst NHS wards ... where safety is a lottery

Chief Executive of 'appalling care' hospital has affair with safety manager

Eleven more NHS hospitals at centre of safety scandal

"An explosive report reveals a terrifying picture of many English hospitals, with people dying after being admitted with 'low-risk' conditions...  Failures lead to thousands of deaths.  Government orders new investigation."

"Research that ranks every general hospital in England against a range of safety measures has named 12 NHS hospital trusts judged to be “significantly underperforming”.

"This is despite the fact that last month the Care Quality Commission, the health service regulator, judged overall care at eight of the trusts to be good or excellent. Today’s study by Dr Foster, an NHS partner organisation that collates and analyses healthcare data, also highlights 27 trusts with unusually high death rates. Almost 5,000 more patients in their care died in the past year than was expected."

Our neighbors "across the pond" seem to have many of the same patient safety issues as hospitals in the US.  Perhaps a collaborative improvement effort is in order.

How American Healthcare Killed My Father - by David Goldhill

Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

Read the rest from The Atlantic, September, 2009

 

ABC Interview with Dr. Val - Staying Safe in the Hospital

Dr. Val Jones from GetBetterHealth.com was recently interviewed by ABC News regarding the best ways to avoid becoming a victim of hospital errors. She also relates her own patient experience with misidentification.  

(Note: If you do not have access to YouTube the video clip below will not display.)

Problem Physician Not Reported to the NPDB Now Accused of Child Molestation

Hospital and medical staff leaders often do not report problem physicians to the National Practitioner Data Bank, a federal database established as part of the Healthcare Quality Improvement Act of 1986.

HCQIA requires hospitals to report to the National Practitioners Data Bank (NPDB) any professional review action that adversely affects a physician’s clinical privileges for a period of more than 30 days. The hospital also must report the acceptance of a physician’s surrender of clinical privileges while under investigation for possible professional incompetence or improper professional conduct.

However, there is a danger in reporting, hospitals can and have been sued over Data Bank reports.  To date, there has been little danger (to the hospital) for not reporting.  The same cannot be said for patients, as there can be considerable danger to them if a hospital fails to investigate and report a physician with significant quality or behavioral issues.

Take the case of Alabama pediatrician, Dr. Michael Roy Sharpe.  The 63 year old is currently in jail on charges of rape and child pornography.

Reports now indicate that Dr. Sharpe was fired from three hospitals in Tennessee in the 1990's. Two of the three terminations, according to courtroom testimony, are rooted in allegations of inappropriate touching of female patients.  When Dr. Sharpe applied for a medical license in Alabama however, there were no red flags on his record and no NPDB reports on file.

Leadership requires courage; don't allow patient safety to be just a slogan in your hospital. 

Related Articles:

Physician with long history of misconduct finally caught by authorities - CRC Blog

Federal Appeals Court Decides When HCQIA Investigations End - Pepper Hamilton, LLP

Bloggers Weigh In on our NPDB-Hospital Report - Public Citizen

Hospitals Drop the Ball on Physician Oversight - Public Citizen

Blog Anniversary

The Supporting Safer Healthcare Blog (formerly MSSPNexus) reached a milestone this month - it's fifth anniversary.  The first post was on November 12, 2004. 

It's been more fun, more educational, and far more work than I could have ever imagined. 

Thanks for stopping by and giving me the opportunity to add one small voice to the medical blogosphere, and for adding your voices to the conversation through emails and comments. 

Every day is a new adventure!

Rita

So Many (Great) Blogs, So Little Time

What is being discussed these days in the medical blogosphere?  I took a little time this weekend to browse some of the blogs linked on the Supporting Safer Healthcare sidebar and found that as usual, the topics range from quirky to thoughtful. Here are a few that caught my fancy:

If you fly often, GruntDoc offers a bit of clever advice about finding your car in those huge airport parking lots when you get back home.

Dr. Deb Serani's timely request to mental health professionals is worth considering.

The always post-prolific Kevin M.D. shares statistical findings about a long-held belief.  Do patients hospitalized in July face greater safety risks?  

The humanity of healthcare is featured in posts by both the Anesthesioboist and Dr. Charles.  The Anesthesioboist (Anesthesiologist who also plays the Oboe if you're having a little  trouble with that one) shares a touching tale of long-time love, and Dr. Charles, one of the blogosphere's most talented story tellers, shares a bit of his family history with readers. 

For new doctors just about to sign on the dotted line for their first professional liability insurance policy, (nearly as scary a prospect as signing your first mortgage!) Presidio Insurance News shares some practical advice about what to look for in a policy, and what to avoid.

And finally, as a medical blogger who spends quite a bit of time researching and writing posts in an effort to give readers useful information, Paul Levy, CEO of Beth Israel Deaconess Hospital in Boston and author of the Running A Hospital blog, addresses an issue near and dear to my heart - how many hospitals block social media, including blogs, on their intranets. (Not so at Beth Israel Deaconess by the way.)

I've been visiting other health systems as part of my work recently and have been discouraged to realize how many medical staff, quality, risk management, and legal offices do not have access to the articles in this and other useful blogs. On a positive note, nearly everyone who has contacted their Information Technology Department and requested specific exceptions to the block has been granted access.  So make a list of your favorite blogs and put in your request. 

And now, on to another week.  Happy Monday everyone!

Medical Error Rate at Your Hospital - How Would You Know?

Ever wonder about your chances of developing a serious post-op infection, or ending up with something accidentally left inside after surgery at your local hospital?   If your hospital is in New Jersey you now have a new way to look up that data, as well as other patient safety information. 

The State of New Jersey Department of Health and Senior Services has released a new hospital patient safety report, which shows data by hospital on the following patient safety issues:

• Foreign body left during procedure
• Iatrogenic pneumo thorax
• Post-operative hip fracture
• Post-operative hemorrhage or hematoma
• Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT)
• Post-operative sepsis
• Post-operative wound dehiscence
• Accidental puncture or laceration
• Transfusion reaction
• Birth Trauma
• Obstetric trauma - vaginal delivery without instrument
• Obstetric trauma - vaginal delivery with instrument

Related information:  Patient Safety: Learn to Protect Yourself

Exit Stage Left? Most Challenging 2009 Joint Commission Standards

The Joint Commission has released its list of the standards that healthcare organizations found most difficult to meet in the first half of 2009.  These standards will no doubt be high-priority for surveyors in the months to come, so make a note if you're up for survey soon.

The full list across accreditation and certification programs can be found in the November 4th issue of Joint Commission Online.

Here's a peek at what hospitals are struggling with this year, and it's not what you might expect:

Life Safety Chapter Advice from Joint Commission Resources --> 

Complaints Trigger Nearly 15% of Sentinel Event Investigations by TJC

The Joint Commission reports that 14.8% of the Sentinel Events they investigate come to their attention through complaints, which can easily be reported through their web site. 

Minimize your risk by documenting and addressing patient complaints promptly.

Related link:  Complying With CMS Patient Grievance Regulations

Grand Rounds 6.6

This week's edition of Grand Rounds - the best of the medical blogosphere, is up at Non-Clinical Medical Jobs.  The featured categories include 

• Public Health and Patient Safety
• Medical Management
• Health Care and Politics
• Wellness and Fitness
• Health Insurance and Managed Care
• Pharma
• Wilderness Medicine
• Technology
• Research