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Do No Harm

UCLA Medicine Fall 2009-Do No HarmPRIMUM NON NOCERE

IN TODAY'S HIGHLY COMPLEX MEDICAL SETTING, OPPORTUNITIES FOR MISTAKES ABOUND. BUT BY RETOOLING INFRASTRUCTURE AND PUTTING QUALITY-CONTROL TOOLS IN PLACE, IT IS POSSIBLE FOR LARGE SYSTEMS LIKE UCLA TO CREATE THE SAFEST POSSIBLE ENVIRONMENT FOR PATIENTS.

Upon its completion in 1937, the Golden Gate Bridge represented a milestone in construction – and not just because it was, at the time and for decades afterward, the world’s longest suspension bridge. When building got underway in the early 1930s, there existed a grisly rule of thumb: One worker would be killed for every million dollars spent on a high-steel construction project.

The problem was not a callous disregard for human life but reflected the newness of the technology required for such ambitious projects. “The engineers had to first figure out how to build these structures before they could figure out how to build them safely,” says Tom Rosenthal, M.D., chief medical offi cer for UCLA Health System.

Hospitals today face a similar problem, argues Dr. Rosenthal and others. New methodologies, from organ transplants and microneurosurgery to intensive care medicine, have been developed to save lives that previously would have been lost. But in lockstep with these miraculous techniques has come an equally staggering rise in the complexity of the practice of medicine itself – one that makes mistakes almost impossible to avoid.

“Obviously,” says Dr. Rosenthal, “everyone who goes into a healthcare fi eld does so to help people. No one wants to cause harm” – primum non nocere. But in a system with so many moving parts that touch on so many lives, even a staff of highly trained and dedicated professionals sometimes might falter. To guard against that happening and create the safest-possible environment for patients, there need to be the tools and infrastructure to control and manage the intricacies of modern medicine.

To beat the grim odds at the Golden Gate Bridge, chief engineer Joseph Strauss devised an elegantly simple solution: a giant safety net, slung under the nascent bridge 60 feet below the construction workers, at a cost of just $130,000. The net would ultimately save 19 lives.

Backed by an institutional commitment to ensure the highest levels of patient care, and aided by both innovative science and the most basic health measures, UCLA Health System is at the forefront of a national effort to create a similar kind of safety net in medicine. It has embarked on an ambitious program to enhance patient safety that touches on a variety of areas, including eliminating medication errors, improving incident reporting, enhancing surgical safety and controlling infections.

“Our hospitals are very safe,” says Dr. Rosenthal. “But we can always do more.”

EACH YEAR, half-a-million injuries occur in the United States because of medication errors. To help prevent such mistakes, UCLA Health System and its four hospitals – Ronald Reagan UCLA Medical Center, Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA, Mattel Children’s Hospital UCLA and Santa Monica-UCLA Medical Center and Orthopaedic Hospital – recently rolled out its long-awaited bar-coded medication-administration system, Centricity Admin. Adding bar codes to the drugs given to patients could substantially reduce the number of medication errors, experts say, by applying an extra layer of oversight to every step in the delivery process.

In a 2008 commentary about bar-coding systems in the Journal of the American Medical Association, University of Toronto physicians David W. Cescon, M.D., and Edward Etchells, M.D., compared the bar coding of medicines to the coding systems used by delivery companies. “Just as couriers are empowered with bar codes to track their packages for safe delivery,” Drs. Cescon and Etchells wrote, so, too, can nurses be empowered with bar codes to ensure the safe administration of medication to patients.”

Unlike the bar codes on cereal boxes and milk cartons at the supermarket, medication bar codes aren’t just for inventory control but play an essential role early on in the medication-delivery process. At UCLA, after a physician sends a patient’s prescription to the hospital pharmacy, the patient’s nurse receives an electronic order for the drug, verifies it against the doctor’s orders and gathers the appropriate meds. Before administering the drug, the nurse must scan the patient’s arm band – which contains a bar code unique to that patient – then scans the bar code for each individual pill, tablet, injection or other drug to be administered. If the medication order requires that two pills be administered, the nurse must scan both before the system will advance and the medication can be administered, says Virginia Moore, a computer support pharmacist with the Department of Pharmaceutical Services, who helped to develop UCLA’s system.

Similarly, if a nurse scans a drug that’s not ordered, she cannot go forward, nor can she advance in the system if she scans a patient and the drug orders are for a different patient.

“We want to be sure we are giving the right drug, at the right dosage, through the right route, at the right time, to the right patient,” Moore says.

It sounds like it should be easy enough, but implementing the system at UCLA was no simple task, says Moore, largely because of inconsistencies among the bar codes that pharmaceutical manufacturers use on their products. Although all drugs sold to hospitals must now be labeled with bar codes per the Food and Drug Administration (FDA), “the numbers are not standardized,” Moore says.

For example, she says, some bar codes have 10 digits, and some have 11, and some have longer numbers that include information like lot numbers and expiration dates. A company might use only the National Drug Code (or NDC – the 11-digit, three-segment code with unique identifiers representing the vendor, the product and the package size), or a prefix number followed by the NDC, or the NDC followed by a suffix number. To further complicate matters, the bar codes themselves can be written in a linear format or in a two-dimensional array. And some products don’t have any bar code or only one on the outer packaging of a box that contains multiple individual doses.

Because of bar-coding variation, Moore and her colleagues had to test numerous scanning systems. “We needed to find a scanner that could read all of the various codes, in different formats, and that was quick and easy to use – you can’t have the nurse scanning the same code over and over, or it gets frustrating,” she says.

Ultimately, they found a scanner that met all of their criteria: simple, durable, reliable and able to read a variety of codes. Moore and her colleagues devised a way to program the scanner to truncate bar codes after 15 characters, to remove information like lot numbers and expiration dates. Now, 90-to-95 percent of the medications used in UCLA hospitals are bar coded and able to be read by the system.

AS IN ANY COMPLICATED SYSTEM, there are bound to be problems, even at hospitals like UCLA’s with an almost religious devotion to safety. Visitors occasionally take tumbles in hallways; equipment sometimes malfunctions; and patients may have bad reactions to their medication.

To track such mishaps, hospitals in California are now required to report any adverse events to the state’s Department of Health Services. As part of this eff ort, and to improve its own monitoring of the quality of care at its hospitals and clinics, UCLA has implemented a cutting-edge computerized event-reporting system. Before its development, individuals reporting adverse events had to fill out a lot of timeconsuming paperwork, then deliver it to a central office, a process that was not exactly conducive to producing timely updates about issues at the hospitals.

The new computerized reporting system, in contrast, can be accessed from any computer terminal within the hospitals and affiliated clinics and by virtually anyone who has involvement in patient care, from physicians and nurses to respiratory therapists and housekeeping personnel.

“One goal of the program is to see more events coming in – not because we’re producing more errors but because the system makes the process easier,” says Tod Barry, quality director for Ronald Reagan UCLA Medical Center. “If people are comfortable in reporting, they’re more likely to report, and we are seeing increased compliance from year to year.” Currently, 500 to 600 events are reported each month, which means, Barry says, that the system is doing its job.

After logging in, reporters are guided through a series of screens that ask for information such as the reporter’s name; the names of the individuals involved; the date, time and location of the incident; and if harm occurred. Using drop-down menus, users can select one of 14 possible categories of adverse events, such as “medical treatment problem or complication,” “diagnostic/testing problem,” “falls” and “medication error,” and then, based on their characterization of the event, are provided with subcategories that further define what happened. Finally, space is provided for the reporter to write a narrative describing the incident.

Once the report is submitted, the system automatically generates e-mail reports that are delivered to the reporter’s supervisor and the hospital-wide supervisor of the particular unit where the event occurred. Notification is also sent to Barry’s quality-control office, which reviews every adverse-event report submitted from within the hospital system, typically within 24 hours, and makes sure that any necessary follow-up takes place.

That follow-up, says Barry, may be as basic as a comment added to the system by a supervisor or may require a “root-cause analysis” meeting to determine the cause of “sentinel” events – unexpected occurrences involving death or serious physical or psychological injury – and how they can be prevented in the future.

And, indeed, prevention is the goal of the event-reporting system, which exemplifi es UCLA’s effort to improve the “culture of safety” in medical care. Th is initiative, says Barry, represents a shift from the traditional tendency to affix blame when an error is made.

“Rather than a ‘blaming’ culture, we want a ‘just’ culture,” says Dr. Rosenthal, “where people aren’t afraid to report their mistakes because they fear punishment” but rather report mistakes in an effort to avoid them in the future.

EVERY PILOT learns in his or her first days of flight school that an airplane is too much machine to be operated by memory. For that reason, beginning in the mid-1930s, pilots have relied upon checklists that describe every step that must be taken before take-off , during flight, before landing, after landing, in emergencies, and so on. To a pilot, using a checklist is not an admission of fallibility but the clear-headed recognition that infallibility is impossible.

The practice of medicine – and surgery and intensive care, in particular – has reached this point. In response, standout hospitals have appropriated the wisdom of aviation experts and begun using safety tools such as surgical checklists to help reduce and prevent medical error.

A January 2009 study in the New England Journal of Medicine affirmed the benefit of these checklists. In the study, eight hospitals in eight cities from around the world adopted a 19-point surgical checklist based on the recommendations of the World Health Organization’s (WHO) Safe Surgery Saves Lives program. The result? Post-surgical complications and death were reduced by nearly 40 percent.

The checklist described in the study was divided into three stages, representing three critical points – and useful stopping points – in surgical care: the “sign-in” period, before anesthesia is delivered; the “timeout,” before an incision is made; and the “sign-out” period, after the procedure is completed but before the patient leaves the operating room.

At each stage, members of the surgical team discuss information that is vital to the patient and the procedure being done. During sign-in, the team will, for example, confirm the patient’s name, surgical site and procedure; verify that pulse oximeters are functioning; note whether or not the patient’s airway and risk of aspiration have been evaluated; and confirm the availability of any necessary emergency equipment. During the time-out, the team introduces itself by name and role; again confirms the patient’s identity, surgical site and procedure; discusses the key events of the procedure and patient-related issues (such as allergies); and confirms the use of prophylactic antibiotics and the availability of instruments and imaging results. Finally, during the sign-out, the staff reviews the procedure performed; conducts needle, sponge and instrument counts; verifies that specimens are correctly labeled; and discusses the patient’s aftercare and recovery.

UCLA has developed its own modified version of the WHO model, which expands the surgical time-out that the hospital has used for nearly a decade. “Our old time-out procedure was basically to confirm that you had the right patient for the right procedure,” says Christine Pizzulli, manager of OR services. Th e new procedure addresses many other issues related to the patient (say, allergies), surgical logistics (if operating room personnel will be switching out, for example, because the procedure is particularly long), equipment and implant availability, and more.

“It’s an interactive discussion between all members of the team – surgeons, anesthesiologists, nurses, perfusionist and support staff. Everybody stops what they’re doing to give 100 percent of their attention to be part of the discussion, to make sure everyone knows if there are questions or concerns, or that the equipment, implants and blood that will be needed during the procedure are readily available,” she says.

“Traditionally, we’d have a surgeon who was familiar with the patient, an anesthesiologist/anesthetist who meets the patient on the planned date of care and who has reviewed the patient information in an electronic format. The OR clinical staff reviews the scheduling information, which focuses on the supplies, implant, instrument and equipment requirements for the procedure. They were all looking at the needs of the patient, but each member of the team had his or her own silo of information. The new process requires a few more minutes,” Pizzulli adds, “but it gives an opportunity to bring out all of the important issues and concerns to the attention of each member of the team.”

UCLA Medicine Fall 2009-Dr. Rosenthal
Everybody who goes into a healthcare field does so to help people. No one wants to cause harm," says Tom Rosenthal, M.D., chief medical officer for UCLA Health System.
LOOKING BEYOND the high-tech computerized systems, barcoded medications and other tools for promoting hospital safety, a simple fact emerges: Beating bad bugs saves lives. To that end, UCLA has developed sophisticated new protocols for tracking and controlling hospital-related infections.

Beginning in 2009, the State of California required that all hospitals report rates of particular healthcare-associated infections, such as the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant bugs. UCLA, which has long tracked these rates, has begun to explore the use of decision-support software programs that “link lab data with existing electronic data sources to automatically detect and predict infection sources,” says David Pegues, M.D., director of the UCLA Hospital Epidemiology Program. “These programs help to identify infections and other potential problems faster. That means less time for the infection preventionists sifting through data and more time on the floor to educate and put a face to our infectionprevention efforts.”

And that time “on the floor” can be used to focus on the first line of defense against all infections: proper hygiene. “It’s important to recognize that we need to go back to the basics, and the basics start with hand hygiene,” says clinical epidemiologist Teresa Zaroda, one of three infection-control professionals on Dr. Pegues’ staff.

The leadership of UCLA Health System, for example, has made an institutional commitment to hand hygiene. Patients and their family members are told that they have the right to ask anyone, at any time, to wash his or her hands. Meanwhile, staff members are encouraged to speak up if their colleagues have forgotten to wash. To further promote the practice, hand-hygiene-product dispensers are located inside and outside of every patient room, near elevators and other access points. “They’re visible everywhere,” Zaroda says.

Infection control isn’t just about bug tracking and hand hygiene, however. The Centers for Disease Control and Prevention estimates that 14,000 to 28,000 deaths occur each year due to infections in central venous catheters (CVCs) – lines placed into the large veins of the neck, chest or groin to administer medications and draw blood samples, for example. To prevent these entirely preventable infections, UCLA has developed a checklist of steps – placed prominently on the trays containing CVC instruments – detailing everything from hand-hygiene etiquette to proper mask, hair-cap, gown and sterile-drape usage. The health system has also developed codified procedures for airborne precautions (to use with patients on respirators, for example), droplet precautions, contact precautions and more, all of which are displayed throughout the hospitals and serve as constant reminders of the diligence, and standard of care, expected of every employee.

“Technology may help, but it’s not the complete answer,” says Zaroda. “We need to enhance our individual commitment to quality improvement and safety.”

The results of these efforts at UCLA are enviable – infection rates have dropped to the point that UCLA Health System’s numbers are among the lowest in the country.

A novel program developed at UCLA is helping to bolster these goals and ensure positive outcomes. The Measuring to Achieve Patient Safety (MAPS) program, started in 2006, enlists student volunteers to observe hospital personnel as they perform clinical procedures and report on any violations.

The volunteers, including pre-nursing, nursing, pre-med and sometimes high school students, will, for example, watch to see if patients are correctly identified before they’re given medication or have blood drawn and look to see if syringes are labeled and attended by a nurse or M.D. And, of course, MAPS students look at hand washing: Are healthcare workers washing when they should, how they should?

“The reports are very personal, describing if a person hasn’t done what they are supposed to do,” says Catherine Walsh, MAPS director and an accreditation manager in the Department of Nursing. “The report goes to the person’s unit director – or if it is an M.D., to their attending – and they get counseled, and then we go back and make sure they’re complying.”

Far from resenting the intrusion, UCLA’s healthcare professionals seem to welcome the reminders of the MAPS team, Walsh says. And the program has had an impact: “We have seen an increase in handwashing compliance because of the program,” she says. While the hospital’s hand-washing rates were always high, now fully 90 percent of the UCLA staff correctly washes their hands, with the other 10 percent having one incident per month in which they deviate from protocol. That rate is a far cry from the 50-percent compliance seen in many hospitals.

The program – and UCLA’s overall commitment to hygiene, infection control and other safety measures – promises to have a lasting effect. “MAPS students are going to be the healthcare workers of the future,” says Walsh. “We’re helping to set a precedent for their later practices and creating a new generation with the same of commitment to safety.”

Ultimately, a safer hospital environment translates not just to healthier patients – no small measure of quality, to be sure – but also to satisfied patients and families. Says David T. Feinberg, M.D., M.B.A., chief executive officer of UCLA Hospital System: “UCLA’s hospitals are populated with brilliant and talented physicians and staff , but there is no one here who is more important than our patients. We are dedicated to delivering care to our patients that is safe and compassionate. That is both our commitment and our responsibility.”

Kathy A. Svitil is the lead science writer at the California Institute of Technology and a former writer and editor for Discover magazine.

To see detailed results of UCLA’s efforts to enhance hospital safety and patient satisfaction, go to:
www.uclahealth.org/quality

 





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