Top 10 Hospital Patient Safety Issues: Part 2

In my post from June 21, 2018, I briefly discussed how the first five of ECRI’s Top 10 Patient Safety Issues arise from some form of missing or incorrect information. Today’s column is a continuation of that discussion, focusing on the remaining five issues sited in ECRI’s top 10.

6. Management of  Behavioral Health Needs in Acute Care Settings

Behavioral health (BH) patients pose unique and complex safety challenges to clinicians. Mental conditions are often overlooked in the acute and ED setting. It’s easy to understand why safely treating behavioral health patients is a challenge to providers. Staff in non-psychiatric settings often have minimal training in and awareness of BH conditions. However, unmet behavioral needs significantly increase the chance of safety issues, such as self-harm and violence towards others.

To help support caregivers, hospital leadership can pursue several strategies. Here are two I feel are worth considering:

1. If your hospital has the means, invest in one or more BH resources. Instead of throwing money into training your ED staff on something they will most likely never develop an expertise in, bring in the people to manage BH patients properly. This can include BH technicians, licensed psychiatric social workers, advance practice nurses, and tele-psychiatry.
2. Another strategy, and one I feel is an easier and more cost-effective alternative, is to take psychiatric conditions into account when setting up safe rooms in your ED. Safe rooms have become common in EDs over the past few decades and can help reduce the risk of harm to patients with BH issues. However, boarding (keeping patients in isolation for long periods of time) can be an issue in these rooms and can lead to worsening conditions, increased agitation, aggression, and psychosis. Furthermore, the deterioration of the patient’s condition while boarded in a safe room can lead to unnecessary hospital readmissions. I suggest taking a look at these six design factors to take into consideration when designing your ED saferooms.

7. All-Hazards Emergency Preparedness

The unfortunate reality is that a disaster can strike at any time. In the past year alone, we have seen hurricanes, blizzards, wildfires, mass shootings, volcano eruptions, and cyberattacks cause significant harm to people and businesses while bringing a slew of major challenges to healthcare facilities. It is important for hospital leadership to remember the following idiom:  “Hope for the best and prepare for the worst.”

Effective disaster preparation is primarily about communication. Protocols should be in place for all types of hazards. Staff should receive education about their hospital's preparedness plans and undergo regular practice and training. Emergency preparedness staff should routinely discuss their current protocols and revise them as new information becomes available. During these reviews, staff should also try to find vulnerabilities in their plans and address them before another emergency occurs. Most importantly, hospital leadership needs to assign “command” teams in the event of a disaster and make it well known who is in charge when an emergency occurs.

To get a baseline of your organization's emergency preparedness, I recommend performing the Centers for Disease Control and Prevention's Hospital All-Hazards Self-Assessment.

8. Device Cleaning, Disinfection, and Sterilization

Following use on patients, reusable devices become soiled and contaminated with microorganisms. Even a small lapse in performing proper device cleaning, disinfection, and sterilization processes can lead to patient harm. As the U.S. Food & Drug Administration notes, "Inadequate cleaning between patient uses can result in the retention of blood, tissue, and other biological debris (soil) in certain types of reusable medical devices." The potential adverse patient outcomes include infections as well as tissue irritation from residual processing materials. Every type of reusable device, including surgical forceps, endoscopes, and stethoscopes, is a potential risk.

To improve your organization's reprocessing performance, consider the following tips:

• Advise staff to always follow appropriate cleaning, disinfection, and sterilization procedures. If staff members feel pressured to deviate from these procedures, they should immediately report their concerns to a manager.
• Ensure staff have access to the most current manufacturer's instructions for use for the devices that undergo cleaning, disinfection, and sterilization. If staff have questions about these instructions, contact the manufacturer. Make sure questions are answered adequately before your organization uses and cleans the device.
• Monitor compliance. Develop the means to effectively review and audit staff compliance with your cleaning procedures and manufacturer's instructions. You will want to catch incorrect or poor practices quickly and ensure they do not become the norm. If you identify a mistake, use this as a teaching opportunity.
• Deliver complete, consistent training. Make sure staff tasked with completing any of the cleaning processes receives the same comprehensive training on your procedures. This should include individuals with little or extensive experience. Do not assume staff members will know how to follow the rules you implemented, even if they have a strong background in these processes. There's no harm in taking the time to review procedures and appropriate practices.

9. Patient Engagement and Health Literacy

The more you can involve patients in their own care, the more likely it is that the data you collect on them will be accurate and complete. While efforts to better automate operations can help streamline the delivery of care, they also have the potential to turn patients into spectators rather than active participants in their healthcare.

Look for opportunities to promote patient involvement in the planning of their care. Educate patients on the data you capture on them and the importance of its accuracy in helping ensure safety and positive outcomes. Use resources such as The Joint Commission’s “Speak Up” campaigns to encourage patients to ask questions about information in their medical records that could affect their safety, such as family history, medications, and allergies. When reviewing information in medical charts with patients, make sure conversations involve frequent eye contact and feel more like discussions than a series of one-way questions.

10. Leadership Engagement in Patient Safety

In a post from earlier this month, "The Importance of Patient Safety in Hospitals," I explained how patient safety starts at the top of any healthcare organization. We also shared a diagram demonstrating that safety culture exists on multiple levels within an organization: systemwide, hospital, department, and unit.

Unfortunately, without strong engagement from leadership, the perception of safety culture may vary drastically on each level. For example, your hospital’s upper management may believe that patient safety is a top priority throughout the organization where in reality, individual units within the organization may neglect certain safety protocols and processes like medication reconciliation and hand hygiene. One of the more effective ways for hospital leaders to promote a patient safety culture is by increasing their exposure in the organization and making sure their pro-safety attitude and behavior is seen throughout the organization.

A common mistake I have witnessed is when a hospital’s leadership is disconnected from the everyday happenings within their organization. I suggest leaders visit and interact with a different department on a daily basis and connect with physicians, nurses, other staff, and patients. Ask their opinion on patient safety initiatives and where they think the hospital can be doing better. Also, award and recognize members of your hospital who go above and beyond in the service of patient safety.