Work Associated w/ HC Archives • Patient Safety Movement

Awareness, Involvement and Action: How Patients and Their Loved Ones Can Fight the Opioid Epidemic

The opioid epidemic is a major public health concern in the U.S. According to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. Even more alarming is the fact that there are an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks – both in and out of the hospital setting.

The fight against the opioid epidemic is a hard and tricky one but there are ways to get involved and play a fundamental part in solving the problem. Awareness, involvement and action are three critical components to fight the endemic, here are some examples of how you can play a role:

Awareness: Act responsibly and be aware of available resources.
- Take prescription drugs exactly as directed by your physician and dispose of any remaining medication properly.
- Never allow anyone else to take the pills prescribed to you, don’t take them for unrelated conditions and always ensure they are out of children’s reach.
- If a loved one is taking opioids, be aware of how the person feels and the amount of medication he or she is taking. Download the PatientAider® app on your cell phone. This free tool provides additional information about what you should do when you or a relative of yours is taking prescribed opioids.
- New technologies are also available to help with opioid addiction. A person who is addicted to narcotics will face a difficult journey in trying to stop consumption so tools like Bridge, a neurostimulation device that targets areas in the brain to reduce opioid withdrawal symptoms, can help them through the process. This small device is placed behind the ear and sends electrical signals to the amygdala, the part of the brain that controls fears, pain and the emotional response to pain, reducing the symptoms of opioid withdrawal like anxiety, nausea and abdominal pain, among others.
- If you know someone who is abusing opioids or taking them illegally, help and encourage them to seek professional support.

Involvement: Be active in your care plan and ask for monitoring.
- Always be aware and educated on the type of medication being prescribed. Look around to see if a hospital displays their commitment to preventing adverse opioid events, and if it is not clearly visible ask to learn about the plans in place.
- If a person is under patient-controlled analgesia (PCA), meaning that he or she has a pump releasing opioids to push when they feel pain, it is important that they are monitored. The Joint Commission, the organization that accredits hospitals, recommends continuous monitoring of oxygenation and ventilation of patients after surgery. Therefore, don’t be afraid to ask the hospital staff what monitoring protocols are in place.
- Be prepared when taking a patient home. Unfortunately, when signs of an overdose occur it is often too late. At home care must include respiratory monitoring to help family members ensure that the patient has good ventilation. Additionally, to prevent respiratory depression, another important parameter to track is oxygen saturation. To control it, the patient needs to have continuous pulse oximetry with centralized alarms. Before discharge, ask the hospital what devices are available to help you monitor at home.

Action: Reach out to your legislation to address concerns. Today, the way opioids are prescribed and monitored vary by hospital. But new legislation is aiming to improve patient safety and reduce preventable opioid-induced injuries and deaths in inpatient settings.
- Reach out to show your support for the Inpatient Opioid Safety Act of 2021 to help ensure that this issue is addressed proactively.
- Connect with your legislators to ensure the Patients Right to Know Act of 2021 is implemented in your state. This act awards grants to states in order to educate their healthcare providers about opioid prescribing practices. To earn this grant, states must also have a law or regulation in place that requires providers to inform patients about the risks involved before prescribing an opioid for acute pain and also share alternative options.

Patients and their loved ones are a valuable element of ending the opioid epidemic. Never hesitate to ask questions and get involved in your own or your loved one’s treatment.

About the Author: Diane Perez, MD, is a member of the advisory board of the Patient Safety Movement Foundation. She has received numerous awards for her work as an advocate of healthy living and is passionate about patient safety. Perez is a resident of San Diego, living in the Bay Ho neighborhood.

CBS News – 60 Minutes

NBC Bay Area

PSMF CEO Michael Ramsay Weighs in on the OIG Report for Adverse Events in Hospitals

In the month of October 2018, 25% of Medicare patients experienced harm during their hospital stay – for 43% of these patients, the harm events were preventable. The common types of harm events were related to medications, pressure ulcers, and surgical complications such as hypotension and hospital-acquired infections.

The cost of the harmful events was calculated to be in the hundreds of millions of dollars for the month of October. 64% of adverse events that resulted in patient death were preventable. Preventable events were commonly linked to substandard or inadequate care. The previous report in 2010 reviewing the month of October 2008 shows very similar numbers of patient harm events as this report.

Recommendations:

Given the scale and persistence of patient harm in hospitals over the last decade, since the last report: HHS leadership and agencies must work with urgency to reduce patient harm in hospitals
CMS to update its list of Hospital Acquired Conditions HACs
CMS to expand the use of patient safety metrics for healthcare payment
CMS to enforce hospitals tracking and monitoring of patient harm
AHRQ to update Quality Strategic Plans
AHRQ to optimize the use of Quality and Safety Review System
AHRQ to develop national clinical best practices to improve patient safety
AHRQ to identify and develop new strategies to prevent patient harm events in hospitals

To read the full Adverse Events in Hospitals OIG report from the U.S. Department of Health and Human Services, click here.

Healthcare Weekly

The Summit Session One Experience

Annually, the first quarter of the year marks the Patient Safety Movement Foundation’s highly anticipated World Patient Safety, Science & Technology Summit. Per usual, this year’s sessions were filled with empowering, crucial conversations with healthcare professionals and patient safety advocates committed to making a positive change in the medical field.

This year’s summit united world leaders and experts in bringing together result-driven ideas and solutions to achieve the audacious goal of eliminating preventable patient harm. In addition, the summit also marked the Patient Safety Movement Foundation’s first 10 years of achievements and success.

As a student intern of the Patient Safety Movement Foundation, I had the honor of attending Session 1, a talk centered on “Overcoming Obstacles for Applying High Reliability Principles in Healthcare.” Moderated by Dr. Dave Mayer and led by Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi, Session 1 explored various topics, such as patient safety’s application to different industries and thoughts on public health systems.

The panel began with introductions, beginning with Dr. Mayer, the former Chief Executive Officer of PSMF and executive director of the MedStar Institute for Quality & Safety. Also introduced were: Dr. Abdulelah Alhawsawi, a transplant and hepatobiliary surgeon and former Founding Director General of the Saudi Patient Safety Center; Dr. Michael Privitera, a consultation liaison psychiatrist; and Mr. Keith Conradi, the chief investigator of the English Healthcare Safety Investigation Branch.

To kick start the session, Dr. Mayer shared a quote by Dr. James Reason: “to err is human”, also the title of the Institute of Medicine report. “James Reason says we can’t change the human condition, but we can change the condition under which humans work,” says Dr. Mayer, “HRO and resilient science has been studying this for over 30 years and have shown great success in other industries.”

Branching out from the topic of other industries, a question was raised: over 30 years of research, what was it that could be learned from other industries that had successfully taken action and changed cultures to one dedicating safety as their top priority?

Mr. Keith Conradi, with his extensive aviation background, provided an interesting thought: “It’s not necessarily you, but it is the environment around you that actually contributes to where something may go wrong,” he said.

Simply said, little errors aren’t a rarity; however, the system in place is what prevents them from becoming critical and causing harm. “Something that we often describe as a safety management system is pretty much mandatory in airlines across the world,” commented Mr. Conradi, “That means that it’s not only systematic, but it’s proactive.”

Mr. Conradi emphasized that healthcare would benefit from not simply reacting to circumstances, but rather taking a systematic approach. “One of the big things that we often are starting to recommend when we do investigations is that people implement a proper safety management system,” he said, in regards to his line of work.

As a clinician, Dr. Michael Privitera found great interest in analyzing where most errors came from and discovered that “the most common causes of errors are system based, and that the most common reasons for clinician burnout are system based.” To Dr. Privitera, this posed the great question: what can we do about the system?

When it comes to medical error, unfortunately, some are human induced. Human casualties may happen because no person is completely perfect, but it is crucial that we take steps to prevent errors from happening at all. “How can we keep track of how long a person is working after the last patient is seen? So they’re better rested the next day?” questions Dr. Privitera.

To Dr. Abdulelah Alhawsawi, focusing more on systems than individuals in the system may be a viable solution. In healthcare, there’s a larger focus on individuals in the system. “That’s another area that we could learn from [other] industries,” he says.

Human errors could lead to “pointing fingers”- but in general, patient safety is not a simple black-and-white situation. On this topic, Dr. Privitera raised the point of “just the whole idea of not placing blame, but just to that effect, that it can happen.”

Continuing on with the discussion of the individual, Dr. Privitera agreed on how there was much emphasis on the individual and the widely circulated idea that it’s simply on the individual’s error and ultimately their fault to bear. “But what about all the how upstream decisions may have affected resources?” asks Dr. Privitera, raising a thought-provoking question.

Ultimately, patient safety also comes in hand with “diffusing the issue of blame,” and as Dr. Privitera best put it, “realize this is human nature.” “We’re all in the human club. So this can happen,” he remarked.

When it comes to the aviation industry, the system is better structured than healthcare; from training interviewers going to areas of mishap or danger immediately, whereas healthcare has a three to four week delay of schedule, the aviation industry has further acted upon their patient safety concerns.

When asked about his experience in the aviation industry in regards to the system, Mr. Conradi shared that the aviation industry was able to harness much emphasis on simulation and simulated training. “We were able to embed that sort of culture every six months as pilots went through that particular emergency training and all the different scenarios,” he says.

Another point noticed was the fact that in aviation, most states only have one regulator. Compared to the Federal Aviation Administration (FAA) of the United States, Britain has a Civil Aviation Authority.

When coming into the field of healthcare, Mr. Conradi shared that he was surprised to see such a vast number of regulators. While the autonomy of various groups working as extended networks was an interesting concept, Mr. Conradi shared that it may potentially lay open space of mistakes to lead to harm.

Not only should systems be continually sought to be improved upon, accountability should be more seriously taken. “If we blame the system and process every time when there was preventable harm, that would almost be anarchy,” commented Dr. Mayer. With accountability, patient safety could be reduced in the future through actionable ideas. “We also as leaders have to be responsible and accountable to act on that and to ensure the safety of our patient population,” said Dr. Mayer.

Throughout this session, I was able to listen to different perspectives all over the world on their specific line of work and culture’s effect when it came to the healthcare system. It was truly enlightening to hear genuine questions raised in regards to the issue of patient safety and to hear potential ideas for the future as well.

With our continued advocacy and passion for patient safety, we have the power to influence the healthcare system for the better. As affirmed by this session, to move forward, we must take responsibility to support positive outcomes for patients and individuals.

A huge thank you to the panelists, Dr. Dave Mayer, Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi! On behalf of the Patient Safety Movement Foundation, I sincerely appreciate your words and support.

The Patient Safety Movement Foundation Admonishes the Criminalization of Medical Errors

First and foremost, the Patient Safety Movement Foundation would like to express its deepest condolences to the family and friends of Charlene Murphey, a patient at Vanderbilt University Medical Center who died after a medication error in December 2017. As a global non-profit committed to eliminating preventable patient harm and death across the globe by 2030, we believe even one loss is one too many.

Reaching zero harm will require healthcare systems and their staff to acknowledge faulty processes and embrace the reporting of near misses in order to create long-lasting change. However, on Friday, March 25, 2022, RaDonda Vaught, the nurse at Vanderbilt University Medical Center in Nashville, Tenn., was convicted of criminally negligent homicide and abuse of an impaired adult for the fatal medication error she made. From the outset of the incident, Vaught had told the truth and admitted the mistake. As an organization, we are saddened to see this case move to the criminal court system and believe criminalization of medical errors will rewind major gains the healthcare industry has made over the years in patient safety improvement.

Many medical errors are preventable, and this incident underscores a systemic problem rather than an employee issue. The underlying question should be how do we prevent this from happening again?

Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur.

The Department of Health and Human Services and Centers for Medicare and Medicaid Services has released their summary of the event. While the nurse has obligations to monitor a patient after administering a medication, it was clear in this instance that the root cause of this tragic incident was a “process error.” The medication dispensing machine should never have delivered medication for the patient that was not ordered by the clinician.

To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses. Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur. Some healthcare systems have taken this one step further to celebrate near misses and to recognize the healthcare workers who have stepped forward to admit mistakes and be part of finding solutions to correct processes.

The Patient Safety Movement Foundation is committed to helping healthcare organizations make the change needed to eliminate preventable medical errors, this includes:

Creating high reliability organizations: To truly minimize preventable harm, the healthcare industry would benefit from becoming a highly reliable industry, such as aviation or nuclear power, which anticipates problems before they occur and are transparent about errors and root causes when they do happen. This requires a significant commitment by the executive team and governing body. A journey to high reliability will not succeed without their buy-in, continuous reinforcement and modeling of behavior. High reliability organizations need to create awareness about patient safety at every touch point across the organization, train leaders and staff in improvement processes, as well as commit to and model transparent, open and honest communication.

Supporting the CANDOR method: The Communication and Optimal Resolution (CANDOR) toolkit is a well-studied Communication and Resolution Program (CRP) used by many healthcare organizations and practitioners to improve patient safety through an empathetic, fair and just approach to medical errors. This approach focuses on putting patients, families and caregivers first and providing timely, thorough and just resolutions after adverse events occur. Through this process, healthcare organizations and their patients can feel confident that processes will be examined in real-time and clear communication will occur throughout an unexpected event. Successful execution of the CANDOR process can lead to improved patient outcomes and satisfaction and the support of staff involved in the incident.

The Patient Safety Movement Foundation stands with many other organizations condemning the approach of criminalizing medical error including, the Institute for Healthcare Improvement, American Nursing Association, Academy of Medical-Surgical Nurses, American Association for Respiratory Care and American Hospital Association.

Those interested in learning more about available resources can connect with the Patient Safety Movement Foundation, which exists to support healthcare organizations as they work towards zero preventable medical errors, as well as patients, families and caregivers impacted by medical error. Together, we can save lives.

Respectfully,

Michael Ramsay, MD, CEO of the Patient Safety Movement Foundation

Event Brings Together Key Industry Leaders and Healthcare Organizations to Confront Leading Patient Safety Issues

IRVINE, CALIF. (April 4, 2022) – The Patient Safety Movement Foundation (PSMF) will host the 8th annual World Patient Safety Science and Technology Summit (WPSSTS) virtually April 29 and April 30, 2022. The event is co-convened by the American Society of Anesthesiologists, the European Society of Anesthesiology and Intensive Care, the International Society for Quality in Health Care and the World Federation of Societies of Anaesthesiologists. Creating a powerful forum for industry leaders and healthcare organizations to confront leading patient safety issues with actionable ideas and innovations to transform the continuum of care, the event supports PSMF’s mission to reach zero preventable patient harm and death across the world by 2030.

“The last two years have been taxing on the healthcare sector to say the least. The global pandemic placed relentless stress on health systems and medical personnel, which resulted in an increase in preventable medical errors,” said Dr. Michael Ramsay, CEO of PSMF. “Our organization is eager to bring key stakeholders together to help develop solutions to dramatically improve patient safety and eliminate preventable patient harm and death.”

The summit will include a fireside chat with patient safety luminaries, seven keynote addresses, as well as five panel sessions covering various topics in patient safety led by esteemed healthcare leaders. This year’s WPSSTS sessions focus on key issues impacting the healthcare industry, including:

Overcoming Obstacles for Applying High Reliability Principles in Healthcare
Embracing the Science of Human Factors to Unleash Safety Innovation in Healthcare
Patient Advocacy: The Compass for Innovation
How Regulation Can Support Quality and Value in Healthcare
Healthcare Safety During the Pandemic

Attendees will have the opportunity to network with top hospital executives, patients and family members who have been impacted by medical error, public policymakers and government officials, as well as leaders across the healthcare continuum. Keynote speakers include:

Randall Clark, MD, FASA, president of the American Society of Anesthesiologists
Edoardo de Robertis, MD, PhD and president of the European Society of Anaesthesiology and Intensive Care – ESAIC
Neelam Dhingra-Kumar, MD, unit head of the WHO Patient Safety Flagship
Carsten Engel, MD, CEO of the International Society for Quality in Health Care
Joe Kiani, founder & immediate past chairman of the Patient Safety Movement Foundation, as well as founder, chairman & CEO of Masimo
Peter Pronovost, MD, PhD, chief clinical transformation officer at University Hospitals
Thomas Zeltner MD, chairman of the WHO Foundation, Geneva (Switzerland) and deputy chair of the University Council of the Medical University of Vienna (Austria)

The summit is open to anyone interested in actively planning solutions around the leading patient safety challenges that cause preventable patient deaths in hospitals and healthcare organizations worldwide. Discounted registration is offered for students, patients and family members. To register for the 2022 WPSSTS or to learn more about the event, visit: https://patient.sm/WPSSTS

The War in Ukraine and its Impact on their Health Systems

Dear Friends and Colleagues

These last weeks have reminded us of the fragility of peace and safety. It is not that we are unaware of the turbulent lives that many across our world experience in places like Yemen, Somalia, Afghanistan, Myanmar and Syria; it is that we are now seeing on our daily news and social media the impact of war in Europe against a nation which is being decimated by relentless bombing of its people and infrastructure. A recent communique from the World Health Organisation outlined that:

“One month of war has had a devastating impact on Ukraine’s health system, severely restricted access to services, and triggered an urgent need to treat trauma injuries and chronic conditions. Destroyed health infrastructure and disrupted chains of medical supplies now pose a grave threat to millions of people.

Close to 7 million people are internally displaced, and the number of people that have fled to neighbouring countries is fast approaching 4 million. That means that 1 in 4 Ukrainians are now forcibly displaced, aggravating the condition of those suffering from noncommunicable diseases. According to the International Organization for Migration (IOM), 1 in 3 of the internally displaced suffers from a chronic condition.

A number of hospitals have been repurposed to care for the wounded: a shift due to necessity – which comes at the cost of essential services and primary health care. Approximately half of Ukraine’s pharmacies are thought to be closed. Many health workers are displaced themselves or unable to work.

Close to 1000 health facilities are close to conflict lines or are in changed areas of control. The consequence of that – limited or no access to medicines, facilities, and health professionals – mean that treatments of chronic conditions have almost stopped. “

Our hearts go out to the people of Ukraine as they deal with the impact of the war and our thoughts and prayers go to support all healthcare workers and volunteers as they support their patients, not only in Ukraine but in all its neighbouring countries who are giving without question, ongoing support to those who have lost their homes and families as they seek asylum.

We have seen however that even in our so-called high-income and “peaceful” nations we all have fragile and vulnerable services and settings. Today and for the next few years we are realising the impact of the Pandemic on our workforce, our cancer programmes and other non-communicable disease groups.

So building in effective and evidenced based solutions is and will be a key set of interventions that all health systems must employ and I know that with your help we can continue to utilise the Actionable Patient Safety Solutions (APSS) in identifying best practice and current evidence on solutions to put into action.

Our mission is to reduce to zero preventable deaths and harm in healthcare and we have risen in all countries to the task of trying to support our patients against the advancing tide of COVID- 19 with advances and availability in PPE materials, vaccination, and booster programmes, targeted antiviral therapies, and increasing aid to low- and middle-income countries.

Our task though is to call to action on all fronts to combat the causes of harm as well as the implementation of solutions to many known harms. These causes we have known for decades as they relate to a lack of transparency, to be able to report incidents without fear, to be able to act with honesty and respect to all our patients as well as their families and carers when things have gone wrong, and equally to act with absolute candour when explaining to patients and families not only what went wrong but, if we know, then why things have gone wrong.

Our Summit next month will provide a great opportunity to listen to committed and knowledgeable experts in healthcare from a large number of countries, specialties, and industries. It will also offer a chance to challenge policy and political leaders as they discuss not only the impact on our current position but also what are the likely solutions and initiatives that need to be put in place over this next decade of action for patient safety.

I hope you will join us at the World Patient Safety, Science & Technology Summit on April 29-30, 2022, not just to be recipients of information but also as activists and energisers of our current movement. So please challenge us and the Patient Safety Movement Foundation such that we can be of help to you as an individual or as a group to continue to work towards eliminating preventable death and harm.