Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Patient Safety Strategies:
Past Evidence Informs the Future

Among my partners and I, we've had conversations about one of the locations in which we do surgery. We cover several locations in the area east of Los Angeles, and at one particular location, it seems our infection rates are higher than at other locations. This has been a somewhat ongoing issue for us, to the point that several of us will add antibiotics to the preoperative regimen in patients where we might not have previously. One of the possible contaminants in the chain leading to postoperative infection, I thought, may be instrument processing and sterilization.

Patient Safety Strategies Surprised was I, then, when I was scrolling the Internet the other day, to find a news article about New York governor Andrew Cuomo signing into law a new infection control bill on August 1, 2013. This law requires Central Service professionals (those who maintain, sterilize, and process our instruments) to become certified and maintain continuing medical education credits.¹ Apparently, until this bill was signed into law, New Jersey was the only state that required these workers to maintain their education in this way, and now other states are beginning to move in similar directions.

I applaud this bill and its soon-to-be-born progeny, and I'm frankly surprised these folks didn't previously have to maintain continuing education. Perhaps we've placed so much emphasis on direct providers like doctors and nurses maintaining their education, that we've forgotten about other areas of patient care.

Continuing education not only provides information on the newest important techniques and technologies. It's also a reminder of the importance of patient safety. In that vein, I came upon an important article from Annals of Internal Medicine reporting recommendations of patient safety strategies that may be implemented now. These recommendations come from an international group from multiple research-oriented medical universities such as Johns Hopkins, the University of California San Francisco, Stanford, and other concerns such as the RAND Corporation. The recommendations derive from the best available evidence stemming from years of research that began after the 1999 Institute of Medicine's To Err Is Human, the landmark publication that opened our eyes to patient safety.

Tonight's Premier Lecture is
Staged Correction of the
Flatfoot Deformity
by Ryan Fitzgerald, DPM

The following patient safety strategies are highly recommended:²

Preoperative checklists and anesthesia checklists to prevent operative and postoperative events
Bundles that include checklists to prevent central line–associated bloodstream infections
Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia
Hand hygiene
The do-not-use list for hazardous abbreviations
Multicomponent interventions to reduce pressure ulcers
Barrier precautions to prevent health care–associated infections
Use of real-time ultrasonography for central line placement
Interventions to improve prophylaxis for venous thromboembolisms

For a list of the "encouraged" measures, read the article further. It is clear that many of these "encouraged" measures will become mandatory in the near future. For example, one of these, computerized provider order entry, is a major component of meaningful use for electronic medical records. And we all know where THAT is going.

What is so significant about these recommendations is that it is now possible to even make them based on a large amount of current research evidence, something that was not possible in the late 1990's. We've come a long way, baby. It's no longer just about the simple time out – it's a whole new world.

If you consider these 10 patient safety strategies, you'll notice several of which have been in effect in many of your hospitals for some time. Unfortunately, despite their supposed universal use, we still have sentinel events and other unfortunate situations. Additionally, many of these already are or will soon be part of hospital core measures, which, as we all know, are now major players in health care and hospital income.

It behooves each of us to understand where patient safety strategies are going, so that we may be ready for them if and when they become "the law." I would argue this is the natural evolution of evidence-based medicine, at least as it pertains to patient care and safety. In a matter of time, these "recommendations" will become "requirements." In the past 14 years, patient safety research has reached its adolescence. Considering how rough adolescence can be, let us hope adulthood comes quickly.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

###

References:

https://www.infectioncontroltoday.com/news/2013/08/new-york-governor-signs-patient-safety-bill-into-law.aspx August 2, 2013
Shekelle P, et al. The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now. Annals of Internal Medicine, March 2013; 158(5, part 2): 365-369.