Letter from the Chairman, March 2021
The nation reached a grim milestone in late February, when total COVID-19 deaths in the United States reached 500,000. While this number is only an estimate, it demonstrates that a contagious virus can cause much harm. We have known this in our health care systems for years.
Healthcare-associated infections are a leading cause of preventable harm and death in our hospitals. These are organisms that are spread to our patients by a breakdown in the contact precaution protocols. In other words, the patient did not come into the hospital with the infection; they actually contracted it while in the hospital. Lapses by health care providers of handwashing between patients, and failure of “no touch” or sterile techniques, can be culprits. Same with intravenous lines accessed without proper cleansing of the injection ports. Failure to wear a face mask when redressing a patient’s wound is another source of hospital-acquired infections. These are all simple measures, but mistakes do occur.
Our hospitals must run as “High Reliability Organizations.” This starts at the top with senior management taking the lead, and leading by example. Every episode of preventable harm must be presented at patient safety committees. Solutions must be devised to stop them from recurring. Publicizing these lapses creates awareness in the staff and keeps everyone focused on preventive measures.
The electronic patient record can become a real patient safety tool when the proper analysis of the data recorded takes place. The expansion of electronic health records (EHR) across health care, and the focus on COVID-19 in the past year, have led to software that identifies when an infection or adverse episode has occurred in a hospital. Using EHRs to identify when patient harm occurs allows for the calculation of true costs of the harm. With an identifiable etiology, specific preventive measures can be taken. This new software helps hospitals save unnecessary costs, and more importantly, protect patients from preventable harm.
In other news, David Mayer, the CEO of the Patient Safety Movement Foundation, has performed an incredible feat (and successfully raised funds for PSMF) by completing his ”Virtual Walk Across America for Healthcare Safety.” In all, he walked 2,452 miles over 350 consecutive days. He dedicated his walk to the patients, and their families, who have lost loved ones from preventable errors. Well done, David!
Mike Ramsay, M.D.
Chairman, Patient Safety Movement Foundation
Past President, Baylor Scott & White Research Institute, Dallas, TX