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Hospital Consult - October 2016

Dangerous Patient Identification Errors and How to Avoid Them

PLYMOUTH MEETING, PA – How often has someone at your hospital done one of the following:

  • Used a room number or bed assignment to identify a patient who has been moved to a different room or bed.
  • Asked a patient to confirm his or her name (“Are you Mr. X?”) instead of asking the patient to state his or her name (“Tell me your name.”).
  • Mistakenly pulled the medical record of a patient with a name similar to that of the intended patient.
  • Entered orders in the wrong patient’s chart.
  • Inquired about the patient’s identity without using two acceptable identifiers or checking the patient’s identification band.
  • Administered a patient’s medications before confirming the patient’s identity with bar code scanning.
  • Relied on patients with impaired ability to confirm their identifying information.

Those errors, as well as some others — admitting a patient under another patient’s medical record, creating duplicate records at registration, retaining previously recorded patient demographic data when a new patient is connected to physiologic monitoring equipment, or matching portable telemetry equipment with the wrong patient — increase the risk that patients will be misidentified, according to a new report from ECRI Institute PSO.

ECRI’s Deep Dive review of reported events involving patient identification emphasizes that wrong-patient errors are significant and often are driven by increasing patient volume, frequent handoffs among providers, and increasing interoperability and data sharing among IT systems.

Yet, the report emphasizes, most, if not all, wrong-patient errors are preventable.

In this review of 7,600 wrong-patient events occurring over a 32-month period that were submitted by 181 healthcare organizations, most patient identification mistakes were caught before care was provided. About 9% of the events led to temporary or permanent harm, or even death.

"Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO and our partner [patient safety organizations] have collected thousands of reports that show this isn't the case," explained William M. Marella, MBA, MMI, ECRI Institute executive director of PSO Operations and Analytics. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters."

The ECRI Institutes notes that the events were voluntarily submitted and could represent only a small percentage of all wrong-patient events occurring at the healthcare institutions.

Incorrect patient identification, according to the review, occurs during a range of processes including patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care, and can happen in every healthcare setting from hospitals and nursing homes to physician offices and pharmacies.

Researchers also found that many patient identification errors affected at least two people: When a patient receives a medication intended for another patient, for example, the harm is done both to the patient receiving the wrong medication and the patient who failed to receive the correct medication.


Bundled Payment Program Lowers Medicare Costs for Joint ReplacementsMax Money MACRA Webinar Ad_Vertical

FALLS CHURCH, VA – Does the Bundled Payments for Care Improvement (BPCI) program reduce Medicare payments without a decline in quality of care for patients receiving lower extremity joint replacements at participating hospitals?

That was the question addressed in a recent article in the Journal of the American Medical Association, focusing on BPCI-participating hospitals that are accountable for total episode payments, i.e., the hospitalization and Medicare-covered services during the 90 days after discharge.

The BPCI initiative was launched in 2013 by the Centers for Medicare & Medicaid Services (CMS) to test whether linking payments for services provided during an episode of care can reduce Medicare payments while maintaining or improving quality.

CMS invited hospitals, physician group practices, post-acute care providers such as skilled nursing facilities and home health agencies, and other entities to participate in BPCI, which holds them accountable for Medicare payments for services provided during an episode of care initiated by a hospitalization.

Similar to other alternative payment models, BPCI is designed to reward clinicians and facilities that deliver care more efficiently and effectively, according to background information in the article.

For the study, led by researchers from The Lewin Group in Falls Church, VA, the change in outcomes for Medicare fee-for-service beneficiaries who primarily had hip or knee replacements at a BPCI-participating hospital was estimated.

Overall, there were 29,441 lower extremity joint replacement episodes in the baseline period, which began in October 2011 and continued through September 2012. The intervention phase from October 2013 through June 2015 involved 31,700 episodes at 176 BPCI-participating hospitals. Beneficiaries with the same surgical procedure were matched with 768 comparison hospitals in the baseline period and 841 in the intervention period.

Results indicate that, on average, Medicare payments for a lower extremity joint replacement hospitalization and the 90-day post-discharge period declined $1,166 more for Medicare beneficiaries with episodes initiated in a BPCI-participating hospital than for beneficiaries in a comparison hospital.

Researchers determined that the lower Medicare payments were primarily due to reduced use of institutional post-acute care. Claims-based quality measures, including unplanned readmissions, ED visits, and mortality, however, were not statistically different between the BPCI and comparison populations, the study authors pointed out.

“This analysis of lower extremity joint replacement episodes, which account for more than 450,000 Medicare hospitalizations per year, significantly extends the evidence on the use of payment incentives to reduce spending for episodes of care, while maintaining or improving quality,” study authors concluded. “Further studies are needed to assess longer-term follow-up as well as patterns for other types of clinical care.”

Infant Safe Sleep Protocols Not Always Followed in Hospitals

COLUMBUS, OH – Despite the intense focus on the American Academy of Pediatrics (AAP) recommendations on creating a safe sleep environment at home for infants, many hospitals don’t follow all of those protocols consistently.

The issue is not only immediate danger to the child, according to a new article in the journal Pediatrics, but that parents and caregivers tend to model sleep patterns observed in a hospital setting.

A project led by researchers from Nationwide Children’s Hospital assessed the change in infant safe sleep practices within six children's hospitals after the implementation of a statewide quality improvement program in Ohio.

As part of the effort, the AAP recruited hospitalists from each of the state’s children’s hospitals and asked them to form “safe sleep teams” within their institutions. A standardized data tool was used to collect information on the infants’ age and sleep position/environment. Data included baseline as well as weekly updates for the duration of the 12-month project.

In addition, the safe sleep teams were required to implement at least three Plan-Do-Study-Act cycles. Changes in safe sleep practices were calculated over time, with providers receiving Maintenance of Certification Part IV credit for participation.

Overall, the teams collected 5,343 audits at participating sites. At baseline, only 32.6% of the sleeping infants were observed to follow AAP recommendations. Results indicate at the project’s conclusion, however, that percentage had jumped to 58.2%.

Study authors emphasized that the greatest improvement — 77.8% from 50.0% — was the presence of cribs without extraneous items. To that end, removing loose blankets was the most common change made, they explained.

Audits also showed an increase in education of families about safe sleep practices from 48.2% to 75.4%.

“Multifactorial interventions by hospitalist teams in a multi-institutional program within one state’s children's hospitals improved observed infant safe sleep behaviors and family report of safe sleep education,” the study authors concluded. “These behavior changes may lead to more appropriate safe sleep practices at home.”

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Hospitals Up Broad Spectrum Antibiotic Use, But Hold Steady Overall

ATLANTA – Use of broad spectrum antibiotics increased in U.S. hospitals from 2006-2012, even while overall rates of antibiotic use remained relatively unchanged.

That’s according to a new report published online by JAMA Internal Medicine. The article notes that ensuring appropriate antibiotic use in the United States is a national priority because of the threat of antibiotic resistance and other consequences when the drugs are used unnecessarily.

The study, led by CDC researchers, used proprietary administrative data from the Truven Health MarketScan Hospital Drug Database, which included about 300 hospitals and more than 34 million discharges, to estimate inpatient use of antibiotics.

Results indicate that, from 2006 through 2012, 55.1% of patients received at least one dose of antibiotics during a hospital stay. That translates into overall national days of therapy (DOT) of 755 per 1,000 patient-days, an increase of about 5.6, according to the report.

That does not represent a significant change in overall use over time, according to the authors. On the other hand, they expressed alarm at the increase in use of some power antibiotic classes:

  • third- and fourth-generation cephalosporins, 10.3;
  • glycopeptides, 22.4;
  • β-lactam/β-lactamase inhibitor combinations, 18.0;
  • carbapenems, 7.4;
  • tetracyclines, 3.3%; and
  • macrolides, 4.8%.

“This trend is worrisome in light of the rising challenge of antibiotic resistance,” the study authors concluded. “Our findings can help inform national efforts to improve antibiotic use by suggesting key targets for improvement interventions.”

Although prescribing antibiotics remains common and the use of the most powerful antibiotics is on the rise, studies have unveiled a number of important opportunities for hospitals to improve antibiotic use.

“We are committed to combatting antibiotic resistance by ensuring that every hospital in America has an active antibiotic stewardship program so that every patient gets the best possible treatment for their condition,” said Arjun Srinivasan, MD, of the U.S. Public Health Service, Associate Director for CDC’s Healthcare-Associated Infection Prevention Programs.

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