Washington Hospital Center safety program seeks to catch ‘near-misses’

August 2, 2011

The safety team at Washington Hospital Center thought it had a simple solution for identifying patients at risk of falling: have them wear yellow wristbands and yellow socks with nonskid soles to prevent slipping.

Except the socks themselves turned out to be a danger. Many were too big. Instead of averting falls, they were increasing the chance of taking a tumble, officials said.

But a nurse used a new alert system to report the problem with the socks: A supply cart was stocked only with super-large yellow socks, even though a smaller size was available. Officials said the size issue would likely have gone unnoticed until a patient had fallen.

As hospitals across the country are under growing pressure to reduce medical mistakes, the Hazard Alerting Loop system is designed to catch “near misses” before they turn into serious hazards. The shocking errors, such as operations on the wrong limb, get everyone’s attention. What’s harder to catch are the close calls that could hurt patients. The alert system encourages front-line personnel to report, anonymously if they prefer, even the smallest issues.

“I don’t want it that 99 times someone catches it and someone says, ‘Oh, thank God we caught it,’ because you know that the 100th time, we might not catch it,” said Janis Orlowski, the hospital’s chief medical officer.

The hospital is trying to focus on safety in real time instead of reviewing charts and paperwork after incidents have occurred, experts said.

Federal and state governments, and at least one major insurer, are increasingly linking payment to performance. And as part of the health-care overhaul law, Medicare for the first time is paying hospitals for how well they take care of patients rather than for how many procedures, tests and services they perform. (Since 2008, Medicare has not paid hospitals for patient falls, bed sores, and certain types of infections and other hospital-acquired conditions that are considered to be preventable.)

The checklist for good care, for example, will include providing antibiotics to surgical patients an hour before an operation; treating heart attack victims within 90 minutes of arrival; and making sure heart patients are sent home with discharge instructions, among about a dozen quality-of-care measures.

Washington Hospital Center is among 3,500 acute-care hospitals whose Medicare payments next year will be based on such performance as well as patient satisfaction. The grading period began July 1; the first payments will be made October 2012.

The money for these bonus payments will come from cuts in Medicare reimbursements. For WHC, that means the hospital stands to lose $5 million but could earn up to $10 million next year if it performs well.

But officials are quick to point out that more than money is on the line.

WHC is the region’s largest private, nonprofit hospital, with 926 beds and 41,223 inpatient admissions last year. Part of Columbia-based MedStar Health, which also owns Georgetown University Hospital, WHC has been promoting its recent top ranking by U.S. News & World Report as the Washington region’s best hospital.

When it comes to measuring the safety of hospital care, however, experts say there is no one yardstick. The hospital compares favorably with its suburban Maryland and Virginia counterparts as well as with the country’s top-performing hospitals on narrowly defined, self-reported quality measures on the federal government’s “hospital compare” Web site, hospitalcompare.­hhs.gov.

But the hospital’s own staff gave low marks to patient safety in a survey by the federal Agency for Healthcare Research and Quality. About 4,400 of WHC’s roughly 6,000 employees participated. The hospital was below the national average on all 12 safety measures. Fifty-two percent gave a positive response to overall perception of safety at the hospital, compared with the national average of 65 percent. Only 30 percent gave a positive response when asked whether they feel their mistakes are not held against them, compared with the national average of 44 percent.

Hospital officials have said that the survey was a baseline, meant to show where improvement is needed, and that it was taken when tensions were high because of a nurses’ contract dispute. That dispute was settled in the spring.

In the past two years, the hospital’s focus has been on changing staff behavior on safety. Shifts begin with a “huddle” of each unit, which includes sharing how errors were caught across the hospital. The hospital has also dramatically reduced its rate of central-line infections. And last year, the hospital hired a consulting firm to identify possible patterns in preventable errors.

Anonymous information

The early alert system the hospital is testing is a product of Frontline Insight, founded by a retired Navy pilot. A sister company, Helmet Fire, has done similar work for the Defense Department, co-owner Laura Hunt said.

The interest from health-care institutions has been slow. Some have told her that they don’t need anything because “that’s what my malpractice insurance is for,” she recalled.

The University of Rochester Medical Center tested the system three years ago to see whether it could boost reporting by doctors in the emergency department. It performed well and uncovered new issues, medical center executives said. But it was not continued because of cost — as much as its existing event-reporting system — and because anonymous reports did not allow for enough individual follow-up.

Terry Fairbanks, who is in charge of human factors engineering at WHC’s parent company’s Institute for Innovation, said hospitals traditionally prefer specific information for follow-ups. But that often blames individuals, which becomes “a negative incentive to reporting,” said Fairbanks, who pushed to test the new system.

WHC began a six-month trial in mid-May. The $60,000 cost includes the machines and analysis but not staff time. Some comments praised teamwork. Others talked about problems with supply levels and a malfunction in medication dispensing, which was immediately fixed.

Nursing supervisors knew of ongoing supply issues, but the specific comments helped get them addressed, officials said.

The note about the socks was typed in by a nurse in 4H, the intensive-care unit for burn patients, on May 20, during the first week of testing. She reported that “these darn socks are too big and clearly a fall hazard,” said Andrea Ryan, data coordinator for surgical critical-care services. The hospital had begun using the yellow socks and wristbands in March.

The nurse sent the comment as routine, not as an immediate hazard. On May 31, the sock-size issue was included in other routine information sent to Ryan.

Ryan alerted the unit’s nursing supervisor and the fall-prevention committee. The potential hazard was also written up in that week’s internal flier, which provides feedback to staff.

Hospital officials found that the supply cart had only extra-large socks and that the hospital inventory had the next smaller size but none in the smallest size, so all three sizes were ordered.

The small socks arrived at the distributor June 10 and were supplied to all hospital units six days later.

That same day, all staff were given additional training and told to use regular tan socks if the yellow socks didn’t fit.

Empowering staff

Despite more than a decade of a national focus on patient safety, medical errors and other “adverse events” occur in one-third of hospital admissions, according to a study in the April issue of Health Affairs.

Experts say individual hospitals have been able to dramatically reduce errors in particular areas, such as reducing central line infections or the risk of bedsores. “But the country is finding it very difficult to spread those innovations to systematically improve safety across the board in all hospitals and in all institutions,” said Janet Corrigan, president and chief executive of the National Quality Forum, a nonprofit group focusing on quality and safety measures.

Issues that might seem simple are often complex and have multiple root causes, said Don Goldmann, senior vice president at the Institute for Healthcare Improvement, a nonprofit that works on health-care innovation and quality.

Although there is no gold standard for how best to ensure patients are safe, experts say generally accepted principles include empowering and rewarding staff to speak out when they have safety concerns and focusing on near misses.

Nurses at WHC say they like the new system so far.

“Bringing safety down to the front line makes a lot of sense,” said Stephen Frum, a nurse on 4H.

He is hoping that another small issue that hasn’t been given much priority gets reported so it gets attention: Some of the fitted bedsheets for that unit are too small. Beyond aesthetics, sheets that don’t completely cover the mattress can pose a host of safety risks, including falls.

Lena H. Sun is a national reporter for The Washington Post, focusing on health.
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