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Hospital changes stroke care to improve safety
The quality and safety of stroke care in U.S. hospitals can be vastly improved if risk managers first understand how patients may be injured as a result of medical mishaps, according the experience of Strong Memorial Hospital in Rochester, NY. There has been plenty of attention to quality in stroke care, but not enough focus on safety issues, according to researchers there.
Strong Memorial revamped its stroke care after conducting a study that revealed an alarming number of medical errors in its stroke unit. The study looked 1,440 stroke patients hospitalized at Strong between July 1, 2001, and Dec. 31, 2004. By analyzing incidents reported by staff, the study details the frequency, types, and preventability of various adverse events.1
Associate professor of neurology and lead author Robert G. Holloway, MD, says he hopes that analyzing and sharing Strong's experience will prompt physicians and risk managers across the country to improve the safety of the care provided in their institutions.
"Learning about what caused these events in our stroke patients is the only way to keep them from happening again," Holloway says. "Over the last two decades, much attention has been given to improving the quality of stroke care in U.S. hospitals by establishing dedicated stroke centers and units, evidence-based guidelines, and performance measures. While these steps have been useful, most hospitals have yet to fully understand and address the safety of stroke patients."
12% of patients had adverse event
Over a 3½-year period, Holloway studied the experiences of patients who were treated for strokes caused by blood clots or spontaneous bleeds in the brain. Of the 1,440 patients studied, 12% (173 patients) experienced an adverse event. A total of 201 events were reported for the 173 patients, although 18 events were considered "near misses," meaning that the error did not reach the patient. Of the 183 remaining adverse events, 86 were considered to be preventable, 37 were not preventable, and 60 were indeterminate. Preventable events included transcription/documentation errors, failure to perform a clinical task, communication/handoff errors between physicians and/or staff, and failed independent checks or wrong calculations.
"Although few patients who experienced a preventable adverse event were seriously harmed, adverse events do lead to temporary discomfort, longer hospital stays, and in some cases, serious injury or the potential for legal action," Holloway says. In the years since the study, Strong has concentrated on reducing medication errors and preventing complications such as blood clots and falls, he says.
Safety checks for meds
Strong has implemented a hospitalwide effort to reduce medication errors by implementing safety checks at the points that medications are prescribed, dispensed, and administered, says Strong Memorial chief quality officer Robert Panzer, MD. For example, computerized order entry systems have eliminated the need for handwritten prescriptions and screen medication orders for potential dosing errors, interactions, allergies, and more.
Robotic dispensing systems in the hospital's pharmacy ensure that the right medications are delivered to patient care units. Three years ago, Strong replaced all of its intravenous medication pumps with new smart-pump technology that checks the type and dosage of a drug just before it is administered.
Improved communication is a major focal point for reducing errors in the stroke care unit, Holloway and Panzer say. To improve communication, the hospital revised some policies and procedures to encourage staff to exchange information in a more organized, prescribed manner. At transfer points, such as when moving a patient in or out of the stroke care unit, staff are required to communicate in a systematic manner that ensures crucial information is conveyed correctly. For example, unit transfers include a check sheet that covers all important information. Supervisors hold staff accountable for following the procedures correctly and consistently, and failure to do so will affect their performance reviews.
"We're trying to improve the transfer of communication hospitalwide, using more systematic ways of transferring information from one person to another or one unit to another," Holloway says. "So what we're doing in the stroke care unit is consistent with what we're doing in a broader way to improve our culture of patient safety, but the study on this unit revealed some of the particular needs that could be addressed."
More attention to risk of falls
In addition, Strong has taken steps to prevent patients recovering from strokes from falling. This effort includes more consistent use of bed alarms on its inpatient stroke unit that alert staff when a patient who is unstable has gotten out of bed. Laminated signs hang outside of patient rooms to remind staff to check to make sure that alarms are always active and similar signs remind staff not to leave the patient alone in the bathroom.
"One way that stroke patients improve is by getting up and moving, so we have to balance that against wanting to reduce falls," Holloway says. "We want them up, but we also want to constantly remind staff to watch them and to use all the safeguards we have in place."
Though data on reduced falls are not yet available, Holloway says he is confident that the aggressive fall prevention measures are having a significant effect. The effort to reduce falls and adverse events dovetails well with Strong Memorial's overall efforts to use clinical best practices for stroke care, such as for prevent hospitalized patients from developing blood clots (thrombosis), a complication to which stroke patients are particularly prone. Other efforts include getting patients up to walk whenever possible, using compression stockings or pads, and requiring the use of blood thinning drugs, such as heparin, at appropriate levels, Holloway explains.
Results from the improvements still are being compiled, but Holloway says it is clear that safety has been improved on the stroke care unit.
"Medication errors like heparin or insulin errors, the kind that we saw frequently in the beginning of this study, have essentially been eliminated," he says. "We're continuing to track our communication errors across transfer points and we think we're going to see excellent results there also."
1. Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology 2007; 68:550-555.