Newsletter, May 2024

Letter from the CEO

International Nurses Day is observed on May 12. This date was chosen because it is the birthday of Florence Nightingale, who was born in 1820. Florence Nightingale is considered the pioneer of modern-day nursing. In the 1850s, she went to Crimea where, like today, there was a war going on. She imposed strict standards of care and made sure the wards were kept clean and well stocked with medical supplies. She became known as the “Lady with the Lamp,” making regular rounds on the patients at night, as she knew patients could deteriorate at night as well as during the day. Today, she would have been a strong supporter of remote patient wireless monitoring to prevent a patient’s deterioration from being missed, resulting in some being found “dead in bed”! At the end of the Crimean War, she returned to London and set up the first school of nursing at St. Thomas’ Hospital. If you work with nurses or are taken care of by nurses, or know a nurse, please thank them for what they do.

This month, The Joint Commission published the 2023 Sentinel Event Data for 2023 in the US. It is available online at https://www.jointcommission.org. The majority of events (96%) were self-reported and 88% occurred in hospital. Patient falls was the most reported sentinel event (48%) in 2023, and the remaining leading categories were wrong site surgery (8%), retention of foreign object (8%), assault (8%), and delay in treatment (6%).

To those hospitals that have a high patient falls incidence rate, please log on to our website https://www.psmf.org and download the Actionable Evidence Based Practice on preventing patient falls and institute the measures.

Wrong site surgery should be a “never event.” It is like a plane landing with the landing gear still up! Operating room checklists have been mandated, yet despite this, these errors still occur. What do you tell a patient that had the wrong kidney removed, and now the other kidney needs to go, resulting in dialysis for life or worse?

Maybe there is a role for artificial intelligence to ensure the correct actions are undertaken!

Stay safe and stay well,

Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, PSMF

Stroke Awareness

May 2024

Each year, nearly 800,000 people in the US have a stroke; over 600,000 are first-time strokes. A stroke occurs when something blocks blood supply to part of the brain or a blood vessel in the brain bursts. The most common form of stroke (87%) is an ischemic stroke, when blood flow to the brain is blocked. A stroke can cause brain damage, disability, or even death.

During National Stroke Awareness Month, it’s important that everyone, not just healthcare providers, learn the F.A.S.T. system for understanding the warning signs of a stroke and knowing when to call 911.

• F = Face drooping: Does one side of the face droop or does it feel numb? Observe how the person smiles and if it’s uneven.
• A = Arm weakness: Does one arm feel weak or numb? When the person raises both arms, does one arm appear to drift downward?
• S = Speech: Is speech slurred? Does the person have difficulty speaking clearly? Ask the person to repeat a simple sentence.
• T = Time to call 911: Immediately! if you or someone with you has any of these symptoms.

About one in four stroke survivors is at risk for a second, yet up to 80% of second clot-related strokes are preventable. If you’ve had a stroke, work with your doctor to identify the cause and make a plan to prevent another. This may involve managing high blood pressure, reducing stress, improving diet and exercise habits, and taking certain medications.

National Nurses Week

May 6–12

National Nurses Week is an important reminder to thank nurses for their dedicated service in caring for others and improving the health outcomes for all patients. This year’s theme, from the American Nurses Association, is “Nurses Make the Difference” to honor the incredible nurses who embody the spirit of compassion and care in every healthcare setting.

Nurses Week, beginning May 6 in the US, is timed to culminate with International Nurses Day on May 12, the birthday of Florence Nightingale (born May 12, 1820). Credited as the founder of modern nursing, Nightingale was a pioneer in patient safety and professionalized the training of nurses in the UK.

National Nurses Week, while celebrating the more than 5 million registered nurses in the US, also recognizes the invaluable contributions of nurses worldwide. Please join us in expressing your gratitude and supporting nurses’ tireless efforts globally to make the patient experience better and safer.

World Hand Hygiene Month

May 2024

A statement by Dr. Frank Gitgonga

World Hand Hygiene Day is a World Health Organization campaign that is celebrated every 5th of May to raise awareness about the importance of hand hygiene and its role in reducing healthcare-associated infections (HAIs) and improving patient safety.

For a long time, the link between hand hygiene and infection prevention and control (IPC) has been appreciated by the medical community. Despite the appreciation of its importance, compliance with recommended hand hygiene practices is generally low (on average 40%–60%).

According to WHO’s 2022 report, out of every 100 patients in acute care hospitals, 15 patients in low- and middle-income countries will acquire at least one HAI during their hospital stay. This shows that HAIs are quite prevalent. They are also a serious source of complications and compromise patient safety. In the ICU, the emergence of multi-drug-resistant organisms (MDROs) is a serious threat to patient safety. These MDROs are transmissible between patients by healthcare providers. Hand washing is a simple, cheap, tested, and easy-to-implement strategy to reduce infections by MDROs in the ICU.

In line with this year’s theme, care teams should think of leveraging emerging technologies, such as artificial intelligence, as a tool to monitor hand hygiene compliance with an aim toward improvement. In addition, innovative new educational tools, such as serious games and simulations, can be employed by IPC teams to teach this crucial yet lifesaving practice.

Maternal Sepsis Week

May 12–18

A recent study found that 23% of in-hospital deaths involving delivery hospitalizations and postpartum readmissions in the US were related to sepsis. With the third highest rate of maternal mortality of all high-income countries, the US sees an estimated 10 cases per 10,000 live births complicated by maternal sepsis. Worldwide, maternal sepsis causes more than 260,000 deaths out of an estimated 5.7 million cases each year.

Maternal Sepsis Week, observed the week following Mother’s Day (May 12–18, 2024), raises awareness of the unique signs and symptoms of maternal and neonatal sepsis. Organized by Sepsis Alliance, the week is dedicated to sharing survivors’ stories and remembering those lost to maternal sepsis, including the young lives lost to neonatal sepsis (within the first 28 days of birth).

The primary means to reduce sepsis risk is by preventing or quickly identifying and managing infections. Practicing good hygiene, staying current with vaccinations, and seeking treatment as soon as infections are suspected are key. Any signs of sepsis should be treated as a medical emergency, as time is of the essence to prevent long-term debilitating outcomes and potentially death.

For more information about Maternal Sepsis Week, visit the Sepsis Alliance website.

Chair’s Column

Dear Friends and Colleagues,

It was announced this week that the UK will hold a General Election in six weeks’ time on July 4. This will undoubtedly lead to a frenzied period of electioneering and canvassing for our votes.

In the UK, we have a first-past-the-post system for all 650 Members of Parliament, which equates to one MP for just below 70,000 parliamentary electors; those who are on the Electoral Roll. There are a small number of main parties, but there will also be many independent aspirants representing themselves or particular interests, which means that there are often many hopeful candidates trying to be elected, and inevitably, this number increases in constituencies where there is a famous standing Minister.

The next phase is now in play as the leading parties share their election manifestos with us all, and always of particular interest will be those promises and plans that relate to the National Health Service, but this time we will also have themes relevant to immigration, housing, education, and of course, the economy.

The current context for health is particularly unhealthy, as we are still grappling with the lingering aftereffects of the pandemic, with long waiting times for access to care, a tired and strained workforce, and a tired and in some cases old estate that requires new investment.

But Covid also taught us of the need for greater transparency and data sharing, that we should see huge benefits by recognizing the importance of behavior and human factors in all our work, and that we are the start of a transformational revolution in how we adapt to a digital health world, with access to all the benefits and challenges in using all the modalities of artificial intelligence.

If we have learned anything, it’s that we have to invest in personalizing our offer to all patients in whatever is the most appropriate setting, whether that is the acute hospital, the community or care home, the workplace, and most importantly, their own home. This means a huge reinvestment in all aspects of wearable sensor technologies such that we really do give the power of personalized health data to the very individual to whom it matters most—our patients and their families.

Not just empower our patients but give them the power within the hierarchy paradigm that we have in all our health systems.

Which new system will emerge after our General Election in the UK is anyone’s guess, but whichever party emerges as the leader will need to not just listen to the electorate but also hear and act on their concerns and ensure that their policies are truly adapted and implemented on the frontline where all our healthcare staff really need constant and consistent leadership, empathy, and support to rebuild the trust that must exist between ourselves and our representatives.

Yours,

Mike Durkin, OBE, MBBS, FRCA, FRCP, DSC

Innovation Corner*

Smart Pump Innovation

A small startup company in the Boston area assessed the frustrations and challenges associated with smart infusion pumps on the market today. They sought to design something different—an infusion system that could help mitigate the risk of setup mistakes when nurses hang IV bags or press buttons to program infusion rates or other dosing information. The objective was to face head-on the inaccuracy and unnecessary complexity that may occur with infusion technology. Inaccurate delivery can mean the patient doesn’t receive the medication on time, as prescribed, or sometimes at all.¹

The outcome of this desire to design a system that pumps differently is the Ivenix Infusion System. This recent entrant to the market utilizes a different pumping mechanism, able to deliver infusions accurately (+/-5% in normal clinical conditions) regardless of where the fluids or medications are hung, where the pump is placed on the IV pole, or even the patient’s heart level.² With a touchscreen, nurses no longer need to press potentially problematic buttons; rather, they enter data using a familiar smartphone-like interface.² This same touchscreen provides guided workflows with dose error reduction dosing limits visually displayed to the nurse during programming.²

Fresenius Kabi acquired Ivenix and delivered this 510(k) cleared pump to facilities nationwide. It received positive rankings from KLAS Research and strong evaluation metrics from ECRI.^3,4With the shared goal of helping to make infusion delivery safer, this game-changer is long overdue.

References: 1. Taylor M, Jones R. Risk of medication errors with infusion pumps. Patient Safety. 2019; 61-69. 2. Ivenix Infusion System Large Volume Pump (LVP) Instructions for Use. Bad Homburg, Germany: Fresenius Kabi; 2023. 3. KLAS Research. Best in KLAS 2023. Accessed March 26, 2024. https://klasresearch.com/report/fresenius-kabi-ivenix-infusion-system-lvp-2023-a-new-lvp-aimed-at-bringing-infusion-delivery-into-the-modern-age/2965 4. ECRI. Evaluation: Fresenius Kabi Ivenix Infusion System Large-Volume Infusion Pump.

In the News

• WHO posted an article detailing the importance of engaging patients, citing studies that show “meaningful patient engagement could result in a reduction in the burden of harm by up to 15%, saving countless lives and billions of dollars each year.”
• Cybersecurity experts from the US Department of Health and Human Services highlighted their two basic tenets: “Cybersafety is patient safety,” and “Cybersecurity is everyone’s responsibility,” at a recent healthcare conference in Florida, according to the AMA.
• As the use of AI in patient care gains acceptance among doctors, an emerging area of concern among healthcare professionals is who is legally liable when something goes wrong, according to an article in Forbes.
• The Leapfrog Group released its spring 2024 Hospital Safety Grades for US hospitals on May 1. Overall, they found significant signs of improvement in patient experience since fall 2023, and preventable healthcare-associated infections continued to drop following unprecedented rates during the height of the pandemic.
• According to Medpage Today, Kentucky became the first state to decriminalize medical errors committed by healthcare providers in the performance of their duties. However, the law does not apply to “gross negligence or wanton, willful, malicious, or intentional misconduct.”

We Want to Hear Your Story

If you or your loved ones have experienced a medical error, please share your story with us. We have over 100 patient stories on our website: https://psmf.org/patient-stories/

Donor Testimonial 

I contribute to PSMF because I am firmly committed to “first, do not harm.” Patients often feel very vulnerable and anxious, and they place their complete trust in the health team. Our primary duty is to care for them, providing the best we can offer. PSMF is a coherent organization with sound objectives. It accomplishes its goals with generosity and openness, which strongly resonates with me.

Dulia Ortega
Institucional Relationships
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