How Best to Prevent Patient Falls?

By ThinkReliability Staff

Though there is consensus that improvement must be made in the area of injury due to patient falls, how to reduce patient injury due to falls has raised questions about effective solutions to this problem.

According to the Agency for Healthcare Research and Quality, accidental falls contribute to patient complications in 2% of hospital stays.  Specifically in the state of Washington, where potential legislation aims to reduce the risk of patient falls, falls are found to kill or injure a few dozen patients per year.  The American Nurses Association said in a statement: “Falls are a leading driver of healthcare costs, especially for the elderly.  What’s more, Medicare and Medicaid do not reimburse hospitals for costs associated with injuries from inpatient falls, essentially increasing unreimbursed hospital healthcare costs.”  Obviously, patient falls cause an impact to both patient safety and quality of care, and may affect hospital reimbursement.

A recent fall case in Washington raised some of the concerns at the forefront of the falls prevention debate.  A patient was badly injured after he fell while being medicated with a sleeping pill (zolpidem).  A study has found that hospital patients taking zolpidem are four times more likely to fall. Some hospitals have begun phasing out zolpidem as a sleeping pill because it makes patients more likely to fall.

Most hospitals rely on a fall risk assessment for their patients to determine the level of fall prevention care required.  However, changes in patient status – such as the use of medication that increases fatigue or confusion – must cause a re-evaluation of a patient’s risk.  For hospitals that continue to offer zolpidem, its use may lead to a patient that was previously classified as a low fall risk becoming a high fall risk, leading to additional protocols or care depending on the hospital’s fall prevention plan.

Studies show that more nurses result in fewer patients falling.  Nurses in Washington have supported legislation requiring higher staffing levels.  But hospital management is concerned about the cost of this requirement, although the hospital did add 29 more nurses at the hospital where this fall occurred.   Additionally, that hospital’s Chief Nursing Officer says “What we have found is it has much less to do with staffing ratios than with having good solid reliable processes in place and following those every single time.”

Many of these processes involve bed alarms – which some studies have shown to be ineffective at preventing falls.  Additionally, as a nurse states, “You still need a person to be close enough nearby to be able to respond to the alarm.”

When looking at the causes that result in an issue impacting the organization’s goals, the analysis step may seem like the most difficult part to get through.  However, in many cases, especially where patient safety, staffing, funding and reimbursement come into play, it can be even more difficult to determine which solutions should be implemented to reduce the risk of the issue recurring, especially when studies may offer conflicting or confusing evidence about the effectiveness of various interventions.  In this case, it is particularly important that organizations determine the required reduction in risk (in this case, most hospitals are attempting to end patient injury due to falls) and the solutions (interventions) that will result in that reduction based on the needs and available resources of the organization.

Most importantly, after a specified time period, the solutions need to be evaluated for effectiveness, based on carefully determined criteria.  In this case, whatever intervention is selected to reduce injury from patient falls should be evaluated against the number of injuries due to falls at that facility.  If the risk has not been reduced as desired, additional interventions are in order.

To view the fall issue discussed here in a Cause Map, with notes about solutions under consideration for reducing fall risk, please click “Download PDF” above.  Or click here to read more.

Increase in Resistant Bacteria and Fungus Threatens Public Health

By ThinkReliability Staff

On September 16, 2013, the Centers for Disease Control and Prevention (CDC) issued a report “Antibiotic Resistance Threats in the United States, 2013”This report detailed the impacts, causes and recommended solutions related to antibiotic resistance within the US (although the concerns are similar worldwide).

The report takes the form of an incident investigation.  Specifically, the report addresses the impacts to the goals of the CDC, the cause-and-effect relationships resulting in these impacts, and what is recommended to reduce the risk of these impacts continuing. The information presented in their report can be captured in a Cause Map, or visual root cause analysis, which allows a demonstration of the interaction of the various causes presented in the report.

The report begins with the goals being impacted by the problem of antibiotic resistance.  Specifically, the CDC conservatively estimates that more than 2 million people are sickened in the US every year by antibiotic-resistant infections.  More than 23,000 are estimated to die as a result.  The risk is not just for the general public, but healthcare providers as well, who are implicated in the report as having resistant strains on their hands, which causes a health risk for them as well as patients.  The report identifies not only person-to-person spreading of infection, but also spreading from environmental causes, such as food.  The presence of these strains impacts the environmental goal as well.

The cost of these infections is staggering.  It is estimated that up to $20 billion per year is spent on direct excess healthcare costs as a result of these infections in the US alone.  The productivity cost (loss of productivity across industries due to employees being out sick) is estimated to be as high as $35 billion per year.  (While the causes discussed in the report are of concern globally, the impacts to the population are specific to the US.)

Increased illness from resistant infections results from exposure to resistant infections, decreased protection from infection, and a shortage of drugs available to treat these infections.  Exposure to antibiotic-resistant infections results from either person-to-person or environmental spread.  Spread can pass from anybody who has antibiotic resistant bacteria or fungus, but a primary source is healthcare providers, who can easily pass the infection with improper hand washing (or none at all).  Environmental causes include surfaces (again, healthcare providers are a frequent source here) but also food.  Food animals are given antibiotics to control disease, but also sometimes are given antibiotics without a diagnosis to prevent infection or promote growth.  These antibiotics kill off non-resistant bacteria but not resistant bacteria, which remains in the meat and feces.  If meat is improperly cooked, the bacteria can be passed on to humans.  But the issue is not just with improperly cooked meat.  Other foods can be contaminated with animal feces, which can also contain the resistant bacteria.

When a person is taking antibiotics, they have a decreased protection from infection.  This is because antibiotics kill all bacteria – including “good” bacteria that helps prevent infection.  While antibiotics are used to treat disease,  the CDC estimates that 50% of prescriptions are unnecessary or not optimally effective.  The use of antibiotics has been identified as the single most important factor leading to antibiotic resistance.

The increase of antibiotic-resistant bacteria (and fungi) means that more and more drugs are becoming ineffective in treating these infections, increasing the risk of death when infections occur.  Additionally, research and development into antibiotics is slowing, compounding the problem of effective drug availability.

As part of the report, the CDC provides wide-ranging recommendations to limit antibiotic-resistant infections.  The recommendations are for healthcare providers, communities and individuals.  They aim to first prevent the spread of infection by ensuring that antibiotics are prescribed and used properly, as well as by better tracking the spread of antibiotic resistant pathogens.  This includes stopping the use of antibiotics in feed animals for growth promotion.  Additionally, better cleanliness control for healthcare providers, food preparers and the general population will reduce the spread of disease.  Secondly, the CDC aims to provide better treatment for these infections by investing in research and development to provide new antibiotic treatment options.  It is also hoped that surveillance data can provide more effective diagnostic tools and use of the treatments currently available.

To view the Outline and Cause Map, please click “Download PDF” above.

Want to learn more?
Read the CDC report.
Read our previous blog on Carbapenem-Resistant Enterobacteriacae (one of the “Urgent” threats identified in the CDC report).

RISK: Vaccines vs. Disease

By ThinkReliability Staff

Although endemic transmission of measles has been considered “interrupted by vaccination” in the United States, a recent measles outbreak has brought to the forefront the risks of not getting vaccinated.  A member of a church in Texas, who had not received the full measles vaccination, traveled to Indonesia, an area where measles is still endemic.  The disease, which is easily spread in close contact, then infected at least 20 other members of his church, which has concerns about the risks of vaccination, especially bundled vaccinations like the MMR (measles/ mumps/ rubella) vaccine.

In recent years, people have been increasingly concerned about the risks of vaccination.  One of the main concerns with the MMR vaccine is its purported link to autism (which was first mentioned in a 1998 study that has been mostly discredited).  There are, of course, risks to vaccination for any disease.  According to the CDC, risks from the MMR vaccine include mild problems, such as fever (up to 1 person out of 6), mild rash (up to 1 person out of 20) and very rare severe problems, such as allergic reactions (which occur in less than 1 out of a million doses).

However, as the CDC notes “The risk of the MMR vaccine causing serious harm, or death, is extremely small.  Getting the MMR vaccine is much safer than getting measles, mumps or rubella.”  This brings us to the other side of the equation.  People who do not get vaccinated for these diseases face the risks of getting the disease.  According to Dr. Paul Offit, Chief of the Division of Infectious Diseases and Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, “There are only two ways you can develop specific immunity, either be infected by the natural virus or be immunized.  A choice not to get a vaccine is not a risk-free choice, It’s a choice to take a different and more serious risk.”

Because transmission of measles had been considered effectively stopped in the US, not vaccinating may have seemed like a minor risk.  After all, there are some people who cannot receive the vaccine.  This includes young children, pregnant women, and those who may be suffering from other health concerns.  These people have generally been protected by “herd immunity”.   This refers to the unlikelihood of getting measles when a very high percentage of the population is vaccinated against it.

However, in recent years, the number of people choosing not to get vaccinated has been increasing.  Sometimes these people are clustered geographically, such as within a church that has expressed its concerns about vaccinations (as in the recent outbreak in Texas).  When unvaccinated persons travel to an area that has not made as much progress towards eradicating disease, the likelihood of disease spreading is much higher.

This is true for other diseases as well.  The Texas Department of State Health Services has recently released a health alert regarding vaccination against pertussis (whooping cough) after more than 2,000 cases this year, including two deaths of infants too young to be vaccinated..  Says Dr. Lisa Cornelius, the Department’s infectious diseases medical officer, “This is extremely concerning.  If cases continue to be diagnosed at the current rate, we will see the most Texas cases since the 1950s.”

Although the potential risk of a vaccine may seem frightening, it is important to ensure that everyone in your family is fully vaccinated.  Not only will this provide the best protection for each of you, it will also provide protection to those members of your community who cannot be vaccinated, and limit the spread of these diseases.  Some communities are experiencing this the hard way. The Texas church involved in the outbreak has begun offering vaccination clinics for its members to attempt and stop the outbreak and protect against another one.

You can view the Outline and Cause Map discussing this issue by clicking “Download PDF” above.

Teen Dies From Peanut Reaction Despite Epinephrine Injections

By ThinkReliability Staff

Even with the best medical treatment known provided quickly after an anaphylactic reaction, a teen died after taking a bite of a snack containing peanuts, to which she was severely allergic. It is important to note that the snack was not clearly marked to contain peanuts and it was a style of treat (Rice Krispies) that would not ordinarily contain peanuts.

In a situation requiring emergency response, it is important to ensure that all the prescribed steps were taken.  The required steps can be diagrammed visually within a Process Map.  In this case, all available actions were taken to attempt to reverse the allergic reaction. (View the Process Map of the appropriate food allergy response by clicking “Download PDF” above.)

For reasons as yet unknown, food allergies have been increasing over recent years.  This has resulted in a greater risk for anaphylactic reactions, which can result in serious injury and even death, usually from throat closure from swelling (known as severe laryngeal edema).

According to John Lehr, the Chief Executive Officer of  Food Allergy Research & Education:  “Avoidance is the only way to avoid a reaction, but we know accidents happen.  That’s the insidious nature of food allergies.”

Because avoidance is the only way to avoid an anaphylactic reaction, many schools and other public facilities have stopped offering any food containing peanuts.  Others have designated peanut-free zones to help those with allergies avoid contact with peanuts.  (Although peanut allergies are not the most prevalent, they are the most dangerous, both from reaction severity and likelihood of contact.)  Certainly, snacks containing peanuts must be clearly marked as such.

Because of the high risk of serious injury or even death from food allergies,  please pass the word about food allergies.  If you are an allergy sufferer, ensure that you have multiple epinephrine auto-injectors that have not expired.  It may save your life.  (Although up to 40% of anaphylaxis victims require two or three epinephrine injections, death after receiving injections is extremely rare.)   Also note, from John Lehr:  “We tell people that their last reaction is not an indication of their next reaction.  Don’t think because you have not had a severe reaction that you can’t have one.”  If you provide food to the public or children, consider removing peanuts from your  kitchen and at the very least, clearly mark anything that does contain peanuts.   Remember, the risk from food allergies is very real, and can be very severe.

You can see the cause-and-effect relationships that led to this tragedy, as well as the Process Map discussing anaphylactic response, in visual form, by clicking “Download PDF” above.  Or click here to read more.