Patient Safety

A Mediaplanet Guide to Combating Human Error in Healthcare

Patient Safety

Dr. David W. Bates, M.D., M.Sc. How technology is improving healthcare safety

Discover an innovative solution to one common but dangerous human error in the operating room Learn why advocates are fighting for major legislative change to insurers’ copay assistance policies

MARCH 2021 | FUTUREOFPERSONALHEALTH.COM

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Health Plans Should Count the Value of Copay Assistance Towards Patient Out-of-Pocket Costs

Patient Safety Is in the Spotlight During the COVID-19 Pandemic

One small policy change could make a world of difference to people living with medical conditions who struggle to afford high copays on medication.

Patients with hemophilia, cancer, autoimmune diseases, and other medical conditions often rely on copay assistance programs in the form of coupons and vouchers to afford their prescription medications.

But more frequently, health insurance companies are instituting policies that don’t count the value of copay assistance toward a patient’s out-of-pocket cost responsibility. Sometimes referred to as a “copay accumulator adjustment program,” these policies leave many unable to afford their medications and allow health insurers to double their profits at the expense of patients.

According to a National Hemophilia Foundation (NHF) survey, 86 percent of registered voters across political parties believe the government should require copay assistance to be applied to a patient’s out-of-pocket costs. Several states — including Georgia, Illinois, and Virginia — have taken action to ensure health plans count the value of copay assistance, but federal policymakers must take action to prohibit these policies and protect patients from rising out-of-pocket prescription drug costs.

Kollet Koulianos MBA, Senior Director Payer Relations, National Hemophilia Foundation

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Eye-opening data shows that most Americans are unaware of patient safety concerns, but greater awareness is vital to improve patient outcomes. he Patient Safety Movement Foundation is striving to reduce the number of preventable deaths to zero by 2030. Donna Prosser, chief clinical officer of the nonprofit, said there’s only one way they can get there, if organizations like theirs work in tandem with healthcare workers and patients themselves.

“We recognize that we have to be aligned, and we have to collaborate because none of us can fix this problem alone — but we can fix this problem together,” Prosser said.

Prosser thinks about patient safety as the “absence of preventable harm and death.”

“There are always accidents that happen that can’t be foreseen,” she acknowledged. “That’s not really what our focus is. What we want to do is look at healthcare the same way that we look at

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those highly reliable industries like nuclear power or aviation, the way they look at safety, and be anticipating problems before they occur so that they can be prevented in the first place.”

The top patient safety concerns are healthcare-acquired infections, medication errors, and surgical safety, she explained. During the COVID-19 pandemic, health worker safety has emerged as another key area.

“We can’t have patient safety without health workers’ safety,” Prosser emphasized.

To enable health workers’ safety, they must have adequate PPE, resources for managing burnout and stress, and environmental safety.

“Patients are not going to get great care if our clinicians are not in tiptop shape and able to provide that for them in the first place,” she added.

Furthermore, communication among healthcare teams, especially

when many patients have multiple providers, is critical for patient safety, Prosser said. “Without one person there to oversee the coordination of all of that care, it’s easy to see how things can fall through the cracks and patient safety issues can occur,” she explained. “So, I would say those are the two leading causes to preventable death, the lack of communication and lack of coordination of care.”

A silver lining of the pandemic is it has put patient safety in the spotlight, Prosser said. Patient Safety Movement conducted a poll of U.S. residents in April 2020, shortly after the pandemic began in the United States, and found that 91 percent of respondents reported hearing nothing about patient safety issues in their area, which Prosser said was “eye-opening” for the organization. n Melinda Carter

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The Solution for Ending Retained Surgical Sponges

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very year 4,500 to 6,000 patients have retained surgical foreign objects unintentionally left in their bodies following surgical procedures. The majority of those objects are retained surgical sponges (RSS), typically the result of human error in the operating room.

Leaving a sponge behind in a patient is considered a “never event” — a medical error that should never happen. That’s according to The Joint Commission, a nonprofit committed to quality improvement and patient safety in healthcare.

“It’s a big deal,” says Valerie Y. Marsh, DNP, RN, CNOR, who’s been an operating room nurse for over 35 years. “More so now than ever, just because we’re looking at good quality for our patients and keeping them safe.”

Keeping count According to a medical study of 319 occurrences of retained

surgical sponges from 2012 to 2017, over 50 percent of sponges were retained in the abdomen or pelvis and nearly 24 percent were in the vagina.

Almost 70 percent of the cases had unexpected additional care or extended stay, while nearly 15 percent had severe temporary harm. One patient died as a result of a retained sponge.

“If there’s a miscount in sponges, sometimes they’ll take the patient right back to the operating room from the post-procedure area,” says Marsh, noting a patient may need to be x-rayed to see if the sponge was left inside. “Other times, the patient might start to exhibit symptoms after a few days, like infection or abdominal pain.”

In the OR, nurses and doctors count and track the sponges used during a procedure. Radio frequency devices can detect how many sponges have been used but that technology is not always accurate.

Newer technology, the SurgiCount Safety-Sponge System, is designed to reduce the risk of leaving a surgical sponge inside a patient. Each sponge has a unique barcode for 100 percent identification accuracy. The system operates on a scan-in/scan-out process, accounting for every sponge used during surgery.

Marsh, a consultant for Stryker, the medical technology company that makes SurgiCount, compares it to scanning food at the grocery store.

“The SurgiCount will say, ‘this is sponge number 12.

This is sponge number 13,’” she says. “It scans them in and it gives you the numbers, and when you scan them out, it gives you the numbers. It matches sponge to sponge before and after surgery.”

Stryker says this product has been used for over 11 million procedures across the country without any retained items.

The Association of Operating Room Nurses advises

counting the sponges five times — manually and with technology — before, during, and after surgery. Marsh agrees and says doing both is “double protection.”

SurgiCount’s user-friendly tablet interface has expanded capabilities, including WiFi capability with real-tile data transfer, secure cloud-based server/storage, and an admin portal for password protected, VPN access from any computer, onsite or remote.

Risk-sharing By investing in this technology, providers and facilities can avoid the “never event” of RSS, which protects patients, providers, and facilities. The American Society of Anesthesiologists reports RSS malpractice suits cost over $150,000 per case.

“The cost analysis of bringing in this product versus litigation and the emotional stress of the litigation is going to be a huge benefit to the institution,” says Marsh.

Stryker has a risk-sharing program, where the company agrees to provide up to $5 million to cover legal costs if a sponge is inadvertently left in a patient. They also agree to refund incremental costs necessary for up to three years for hospitals to implement the SurgiCount system over a prior sponge system.

Marsh says this technology helps providers ensure they’re consistently tracking surgical sponges.

“It’s important to have a standard process and standard policy, and following the work and not varying from your practice,” says Marsh. “Do it the same way every single time and you won’t make a mistake.” n Kristen Castillo

To learn more, visit stryker.com/us/ en/index.html

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Patient Safety Is Sometimes as Simple as Washing Your Hands Sometimes the most effective ways to protect patients are the simplest, such as preventing Healthcare-Associated Infections (HAIs) through handwashing.

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eople receiving healthcare are at risk of getting infections while being treated for something else. These infections are called healthcare-associated infections (HAIs). CDC estimates that on any given day, 1 in 31 hospitalized patients has at least one HAI, and every year 1 to 3 million HAIs affect residents of nursing homes, skilled nursing facilities, and assisted living facilities. For more than 150 years, hand hygiene has been recognized as a foundational measure all healthcare personnel should use to prevent infections. Hand hygiene

includes cleaning hands with alcohol-based hand sanitizer (ABHS) or handwashing with soap and water.

The easiest way to kill germs Sanitizing hands with ABHS containing 60 to 95 percent alcohol is the preferred way for healthcare personnel to clean their hands in most situations. ABHS is convenient and easy to use as healthcare personnel move between patients and tasks.

Healthcare personnel should clean their hands immediately before and after touching a patient or things near a patient, as well as before and after tasks like starting an IV, even if they

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are wearing gloves. ABHS does not kill certain germs, like C. difficile, but sanitizing hands is still the overall recommended method for hand hygiene in healthcare.

PPE that covers more than the face Gloves — and sometimes other personal protective equipment, such as gowns — should be worn by healthcare personnel whenever they may have to touch blood or body fluids, or care for patients that might have infections that may be spread by contact, like methicillin-resistant Staphylococcus aureus (MRSA). Gloves protect the hands from contamination,

but do not replace the need to clean the hands before putting gloves on and after removing them. In addition, healthcare personnel should remove their gloves and immediately clean their hands whenever they move from one patient to the next and any time their gloves become visibly dirty during care.

Hand hygiene is a critical part of keeping patients and healthcare personnel safe. Patients and their loved ones should feel empowered to remind healthcare providers to clean their hands. Protect yourself and others by cleaning your hands often. n Kristen Castillo

Improving Healthcare Safety With Technology Some estimates suggest that errors and adverse events represent the third-leading cause of death in the United States.

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ealthcare can be dangerous. Things can go wrong.

This has probably never been truer than now as we deal with the COVID-19 pandemic and our institutions are stretched to their limits. Still, if you are sick, it is important to interact with the healthcare system. It is unsafe to have a serious condition, so let your healthcare providers know you are having problems.

But technology is helping make care safer, even during this pandemic, and this has happened in many ways. We have better data about what is happening, and numbers can guide policy. Technology has accelerated research, and telemedicine use has taken off.

Going virtual From the patient perspective, the switch to telemedicine may be one of the most noticeable. In the outpatient setting, telemedicine has decreased risk of transmission of the virus to both patients and healthcare workers. Although some things can’t be done well virtually, this has been a major win. Inside the hospital, telemedicine has helped a lot too. Many hospitals are giving COVID patients tablets like iPads so they can interact with their providers virtually, again decreasing risk to all parties. This can also make it easier for patients to access their information.

Personal health records can also help with safety. These are an extract of your electronic medical record that lets you look at your information, like your laboratory tests, what

screenings and vaccinations are due, and your medication list. In many states, COVID vaccinations have been scheduled through personal health records, and that alone is a good reason to sign up for one.

Staying on top of vitals A host of monitoring technologies are becoming available that are also making care safer. These have been used for some time in intensive care units, but they are now increasingly

available throughout the hospital and are also being used more in homes for people who need them.

They can monitor the vital signs, like pulse and respirations, but also assess things like how much someone is moving. Hill-Rom, the nation’s largest hospital bed manufacturer, makes the Centrella Smart Bed which can help with things like pressure ulcer and fall prevention, detect incontinence, and even measure the patient’s pulse and respirations. In one study, an evaluation including some of the technology in this bed in patients on

medical and surgical units showed that patients spent about half as many days in intensive care later, and they were over 80 percent less likely to have a cardiac arrest.

The rise of smart medicine One of the most exciting technologies which has the potential to make nearly all safety issues less frequent is artificial intelligence. This can be directed in many ways, but perhaps most powerfully they can bring together all the information about a patient to make better choices about what treatment may be best for them specifically, or to detect earlier when they are developing an infection. The use of this approach is already widespread in a few big systems, like HCA Healthcare, which uses real-time monitoring and predictive analytics to help clinicians “spot” sepsis infections. In one year, HCA estimates this reduced their sepsis mortality by 22.9 percent.

It can be hard for patients to know what technologies their healthcare systems are using, but increasingly this is featured on their websites. Nearly everyone in the United States now has access to telemedicine and a personal health record — and you should sign up if you have not. You should look to see which of these technologies your local institutions are adopting.

Together, they promise to make a big difference in safety. n David W. Bates, M.D., Chief of General Internal Medicine, Brigham and Women’s Hospital; Past-President of ISQua, Chair, International Academy of Quality & Safety (IAQS)

After His Daughter’s Death, One Man Started a Foundation to Raise Awareness of Medical Errors An estimated 231,000 people die each year in the United States due to medical errors, making it the third leading cause of death in the country.

The No. 1 barrier to reducing this number, which may be higher as a result of underreporting, is lack of awareness among physicians and patients alike, said patient safety advocate Christopher Jerry.

In 2006, his then-2-year-old daughter, Emily, having an amazing prognosis for a complete recovery, died due to a medical error on what was supposed to be her very last day of chemotherapy.

Specifically, an overdose of sodium chloride in chemotherapy killed Emily, just days after celebrating her second birthday at the hospital where she was receiving treatment.

“What I discovered was most all preventable medical errors in the United States occur as a result of the inherent human error component of medicine,” said Jerry, who is based in Cleveland, Ohio. “So, the focus of my work through the Emily Jerry Foundation over the past decade now has been to focus on the modification of core systems, processes, and protocols in healthcare, and to finding ways to reduce the probability from creeping into the equation during the course of treatment.”

Jerry noted that the next patient safety issue at hand is acknowledging that human error itself is unfortunately inevitable in healthcare. Therefore, the core systems, processes, and protocols must be designed to account for this fact, Jerry argued.

“I thought this was just a freak accident that happened to Emily, and then I discovered preventable medical error has been identified as the third leading cause of death,” Jerry said. “That makes it an issue that affects each and every one of us because we all receive healthcare during the course of their lifetime, and all of our loved ones receive healthcare during the course of our lifetimes. This is why we all should be concerned about it and paying attention.”

Christopher S. Jerry, President and CEO, Emily Jerry Foundation

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It’s High Time for the American Medical System to Catch Up When It Comes to Safety

Mothers on a Mission Against Medical Error Longtime advocate Helen Haskell is committed to raising awareness regarding patient safety.

For two decades, Helen Haskell has fought to help prevent medical mistakes. For her, the crusade is personal.

Haskell said after four days in the hospital for a supposedly safe surgical procedure, her healthy 15-year-old son, Lewis, was gone, the result of a medication error that led to a perforated ulcer, a very dangerous condition that must be treated immediately.

Weekend residents didn’t understand the gravity of the situation, and, according to Haskell, nothing was done.

“I became a patient safety advocate, as a way of giving meaning to his life and death,” Haskell said. “I formed the nonprofit Mothers Against Medical Error with several other parents about two years after Lewis’ death. We worked initially on legislation, and quickly passed two patient safety bills in our state of South Carolina.”

Haskell, co-chair of the World Health Organization’s Patients for Patient Safety group, believes that as patient care becomes more high-volume and business-driven, the solution lies with patient-oriented, transparent use of technology and data analysis.

“We have a number of software programs that can monitor patients and allow timely rescue of patients who are declining precipitously. This never needs to happen, but it does. It’s a question of raising our national standards, so that providers have to make the needed investments in safety. This is where the patient voice comes in. If patients know what the risks are, they demand safety.”

Cindy Riley

Dr. Karen Wolk Feinstein, president and CEO of the Jewish Healthcare Foundation, is one of the nation’s leading voices in patient safety and healthcare quality, and she’s ready for a fundamental change in how we identify, analyze, and address incidents of medical error.

“I am not one who believes that if you do a larger dose of something that doesn’t work, you’ll get cured,” Feinstein said. “So I knew that we were likely to have a new administration who would be looking at the other aspects of the Affordable Care Act, which have to do with quality, safety, and workforce, that we might have an opportunity to do something big, not what we’ve been doing in the past, because it hasn’t worked.”

Feinstein has called for a National Patient Safety Authority (NPSA) to address what she sees as inefficient and impractical standards when it comes to medical safety in the United States.

At the moment, best practice standards call for practitioners to “go into a mode of root cause anal-

ysis” immediately in response to every incident, whether major or minor, which, Feinstein pointed out, is impractical for the frontline of healthcare “where there’s a certain amount of frenzy that makes it very difficult to be able to stop what they’re doing.”

By some estimations, medical error is the third leading cause of death in the United States, with very little progress in the past few decades. So, Feinstein is advocating for a big change in approach, starting by looking at how other industries stay safe.

“They almost all have a national authority committed to their safety,” Feinstein found.

Her vision for a national medical safety authority would follow the model set by the National Transit Safety Board (NTSB). “It does a lot of research and comes up with solutions, but it doesn’t regulate sanction or penalize. And we found that that would probably make it much more popular and bring about less resistance.”

The organization would use a centralized repository of credible data to analyze incidents of

medical error, and set criteria for prioritizing the incidents to investigate first. “That would be a central data repository evaluating the others who were already collecting data, only relying on the best, forming partnerships, and most importantly, promoting the ongoing surveillance, detection, and monitoring of adverse events and bringing about autonomous correcting action,” Feinstein said.

But she acknowledges that bringing about such a change won’t be easy, especially in times of turmoil such as these, even as the pandemic has brought to light large gaps in our system.

“In so many ways, the pandemic is consuming resources of every kind, intellectual, clinical, financial,” Feinstein said. “But it has also exposed so many flaws in our system. Our logistics, our distribution systems are terrible.

Our public health infrastructure is sorely lacking. So we see a lot of things that we think people will say, look, when we get this settled down, we need to rebuild.” n Lynne Daggett

We have an opportunity to improve healthcare safety for decades to come.

Join our national advocacy coalition today. jhf.org/npsa 6

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Copay assistance includes coupons, discount cards, and vouchers provided by manufacturers and nonprofit organizations.

Health plans are instituting policies that don’t count the value of copay assistance towards a patient’s outof-pocket cost responsibility.

86 percent of registered voters across political parties believe the government should require copay assistance to be applied to patients’ cost-sharing requirements. i

When patients can’t afford their medication, they often skip doses or stop treatment altogether.

When plans don’t count the value of copay assistance to the out-of-pocket limit, people who need specialty medicines can be forced to pay as much as $8,550 for an individual or $17,100 for a family before they can get lifesaving medicine.

6 in 10 patients and caregivers say they would have extreme difficulty affording their medications without copay assistance programs being applied to their out-of-pocket costs. ii

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@NationalHemophiliaFoundation

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Where do you Zero harm* is attainable. Join us on the journey.

At Stryker, we have had the privilege to partner with you for decades. Through this, we observed the risks, challenges and unintended outcomes you encounter in the operating room. This is why we champion technologies that are designed to be a safeguard. As your trusted partner, we support your culture of safety measures and quality management by prioritizing zero harm. You deserve to have zero doubt and total peace of mind knowing your operating room is safe for everyone who steps inside.

Learn more and start your journey at safeor.com.

Stryker or its affiliated entities own, use, or have applied for the following trademarks or service marks: Stryker. All other trademarks are trademarks of their respective owners or holders. The absence of a product, feature, or service name, or logo from this list does not constitute a waiver of Stryker’s trademark or other intellectual property rights concerning that name or logo. *Zero splash and spills, zero airborne contaminants, zero smoke, zero retained surgical sponges, zero blind spots, zero trips & falls, zero drug diversion, and zero doubt messages are not guarantees and are aspirational in nature.

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