By Christopher Cheney
A health system can not only slash patient harm incidents but also sustain the reduction efforts over time.
Medical errors are a leading cause of death in the United States, with estimates of the lives lost annually ranging as high as 440,000. Nonlethal but serious errors such as incidents that lead to permanent harm are estimated to impact as many as 4 million patients annually.
In 2008, St. Louis-based BJC HealthCare launched a patient safety and quality improvement initiative that was designed to dramatically reduce patient harm events over a five-year period and sustain the reductions for an additional five years.
“A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress,” BJC staff members wrote this month in The Joint Commission Journal on Quality and Patient Safety.
The initiative achieved eye-popping results. During the intervention period from 2009 to 2012, total harm events fell 51.6%. An additional 2,600 harm events were avoided from 2013 to 2017, realizing a 74.9% reduction in harmful incidents through the entire course of the initiative.
BJC, which features 15 nonprofit hospitals, focused on five classes of harm events to garner these gains, according to The Joint Commission journal article.
1. Pressure ulcers
Before the initiative was launched, the top cause of patient harm at BJC was pressure ulcers.
To help reduce the incidence of pressure ulcers, BJC developed an electronic health record-based surveillance system for the condition that tapped data in nursing documentation. Best practices were adopted across the health system, including pressure redistribution and patient turning, skin care and moisture management, listing of pressure ulcer events on medical unit display boards, and educational efforts to enlist patients and families in detection and prevention.
2. Adverse drug events
At BJC, hypoglycemia accounted for 75% of adverse drug events, with over-sedation accounting for the next highest percentage of ADEs at 16%.
The health system investigated the causes of severe hypoglycemia through examination of nursing data collected on an online portal after adverse events. The investigative effort led to the development of a pioneering benchmark for severe hypoglycemia.
Hypoglycemia interventions included limiting bedtime snacks, which data analysis showed increased risk of early morning hypoglycemia. The health system also used a locally developed clinical decision support tool—the Pharmacy Expert System—to deploy an algorithm that identified patients at high risk for severe hypoglycemia. When patients were identified at high risk, a diabetes nurse educator, charge nurse, or pharmacist would adjust diet and medication as necessary.
Efforts to avoid over-sedation followed a similar roadmap, with initial efforts aimed at identifying causes such as inappropriate dosing based on a patient’s health history or condition. Interventions included changing narcotic dosages in order sets and engaging clinicians who were prescribing medications in excess of guidelines.
3. Healthcare-associated infections
Before launching its harm reduction initiative, BJC had conducted a decade-long effort to reduce healthcare-associated infections (HAIs), but there were still gains to be made. The health system focused on the three most common HAIs at the organization’s hospitals: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI).
For CLABSI, a standardized central line insertion kit and insertion checklist was deployed throughout the health system. For CAUTI, efforts focused on removing indwelling urinary catheters as soon as medically possible.
For CDI, housekeeping procedures were developed for cleaning isolation rooms as well as daily and discharge patient rooms. When CDI was detected, an intervention was conducted featuring core cleaning standards, hand hygiene, and presumptive isolation.
From 2009 to 2017, BJC achieved a 40.6% reduction in HAIs.
4. Falls with injury
Surveillance for falls with injury was conducted with an online reporting tool crafted at BJC. The surveillance data revealed variation in falls, with some medical units showing significantly higher rates of falls than others. The high-fall units were targeted for interventions such as increased use of electronic health record-based fall risk assessment tools and deployment of core prevention standards.
5. Venous thromboembolism
Efforts to prevent venous thromboembolism centered on making sure patients got appropriate VTE prophylaxis. The primary intervention was mandatory order sets in the EHR, including alerts when VTE prophylaxis was not ordered.
Keys to success
Sustaining harm reduction after the five-year intervention period required concerted effort, the BJC staff members wrote in The Joint Commission Journal on Quality and Patient Safety article.
“Each subteam developed a transition plan that designated a specific system-level group to oversee ongoing improvements in that area (for example, the system chief nursing officers’ council provided ongoing oversight for falls with injury and pressure ulcers). Surveillance for each harm event continued, and detailed reports were available to the hospitals and responsible groups. Overall reporting of preventable harms was moved to the system quality best-in-class report card, with progressive reduction targets set each year.”
Several elements contributed to the overall initiative’s success, they wrote. “A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress.”