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

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.

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The saga of the yellow socks

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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.