10 patient safety tips for hospitals

Medical errors can occur at many points in the health care system, particularly in hospitals. The Agency forHealthcare Research and Quality (AHRQ) has funded more than 100 patient safety projects since 2001. Many ofthe findings can immediately be put into practice in hospitals by following 10 simple tips: 1. Survey staff in individual units and throughout
6. Use senior nurses and maintain appropriate
the hospital to assess and improve the culture of
round-the-clock staffing levels in ICUs to
patient safety, as noted in the 1999 Institute of
prevent airway tube complications. A study of
Medicine report, To Err is Human. The AHRQ adverse events occurring in adult and pediatric survey and its accompanying toolkit materials are ICUs found that more than half were considered designed to provide hospital officials with the basic knowledge and tools needed to conduct a safety frequently during daytime hours (7:00 a.m. to 3:00 culture assessment, along with ideas for using the p.m.), and their negative impact was limited by skilled assistants, backup, and cross-coverage. ICUmanagers should take steps to ensure that 2. Limit shifts of more than 24 hours for medical
appropriate staffing and training levels are residents and make sure they do not drive home
maintained to limit the impact of adverse events.
after working extended shifts. Medical residents
who work longer than 24 hours are more than twice
7. Ensure that personal digital assistant-based
as likely to have a car crash leaving the hospital and drug information is readily available at the point
5 times as likely to have a near-miss incident on the of care. Epocrates RxPro, Lexi-Drugs, and
road than medical interns who work shorter shifts.
mobileMicromedex met AHRQ’s quality and safetycriteria by reducing potential errors associated with 3. Eliminate the tradition of shifts of more than 30
insufficient or incomplete drug information.
consecutive hours by interns working in hospital
ICUs. The rate of serious medical errors at two
8. Download a free software tool
Boston hospital ICUs committed by first-year (http://chrp.creighton.edu/documents/bestpractices.
interns dropped by 36 percent when 30-hour-in-a- pdf) to identify ways to improve medication
safety in the ambulatory care setting. The tool,
called the Medication Safety Best Practices Guide,
4. Adopt interventions to reduce the incidence of
helps hospitals identify ways to create safe ventilator-associated pneumonia in critically ill
practices for medication use, manage medical patients. Putting patients in a semi-recumbent
errors, and contribute to patient safety education in position and using sucralfate rather than H2- antagonists to prevent stress ulcers can preventventilator-associated pneumonia in critically ill 9. Use computer-based order entry to reduce
catheter-related urinary tract infections. A
computer-based order entry system prompting
5. Count surgical instruments and sponges before
catheter removal after 72 hours decreases the and after procedures, and X-ray patients after
duration of urinary catheterization by about one- surgery to reduce the likelihood of objects being
left inside patients. These simple techniques can
reduce the incidence of these types of medical
10. Minimize interruptions and other distractions
errors, which occur in more than 1,500 patients faced by the nursing staff in their day-to-day
routines. Researchers have visually re-created the
fast-changing nature of nurses’ work, highlighting
areas where interruptions can affect patient safety.
(See reverse for references)
Project Title: Training Physicians to Use a Handheld Device
for Electronic Prescribing
Project Title: Hospital Survey on Patient Safety Culture.
Principal Investigator: Kimberly Galt, Pharm.D
Developed under contract for the Agency for Healthcare Reference: Galt, KA, et. al. Personal digital assistant-based
drug information sources: potential to improve medication Reference: http://www.ahrq.gov/qual/hospculture/
safety. J Med Libr Assoc. 200 Apr;93(2):229-36.
Project Title: Effects of Extended Work Hours on ICU Patient
Project Title: Impact of Personal Digital Assistant Devices on
Principal Investigator: Charles Czeisler, M.D.
Principal Investigator: Kimberly Galt, Pharm.D.
Reference: Barger LK, et. al. Extended work shifts and the
Reference: http://chrp.creighton.edu/
risks of motor vehicle crashes among interns. N Engl J Med Project Title: Targeting Interventions to Reduce Errors
Project Title: Effects of Extended Work Hours on ICU Patient
Principal Investigator: Timothy Hofer, M.D.
Reference: Cornia, PB, et. al. Computer-based order entry
Principal Investigator: Charles Czeisler, M.D.
decreases duration of indwelling urinary catheterization in Reference: Landrigan, CP, et. al. Effect of reducing interns’
hospitalized patients. Am J Med. 2003 Apr 1;114(5):404-7.
work hours on serious medical errors in intensive care units. 10. Project Title: Work Environment Effects on Quality of
N Engl J Med. 2004 Oct 28;351(18): 1838-48.
Project Title: Targeting Interventions to Reduce Errors
Principal Investigator: Bradley Evanoff, M.D.
Principal Investigator: Timothy Hofer, M.D.
Reference: Potter, P et. al. An analysis of nurses’ cognitive
Reference: Collard, HR, et. al. Prevention of ventilator-
work: a new perspective for understanding medical errors. In: associated pneumonia: an evidence-based systematic review.
Battles J, et al. (Editors). Advances in Patient Safety; Vol. 1— Ann Intern Med. 2003 Mar 18;138(6): 494-501.
Research Findings (AHRQ Publication No. 05-0021-1).
Rockville, MD: February 2005; p. 39-51.
Project Title: Malpractice Insurers’ Medical Error Prevention
Study
Principal Investigator: David M. Studdert, M.D.
Reference: Gawande, AA, et. al. Risk factors for retained
instruments and sponges after surgery. N Engl J Med. 2003
Jan 16;348(3):229-35.
Project Title: Intensive Care Safety Reporting System
Principal Investigator: Peter Pronovost, M.D.
Reference: Needham, DM, et. al. A systems factors analysis
of airway events from the Intensive Care Unit Safety Reporting
System Crit Care Med. 2004 Nov;32(11): 2227-33.

Source: http://www.hourswatch.org/storage/documents/10tips.pdf