Recent Patient Safety Bulletins
 Bulletin 1: Changing Technology, Changing Risk - Upgrading from 1.5 to 3.0 Tesla MRIs
Bulletin 2: A Serious Kink in the System
Bulletin 3: Changing Technology, Changing Risk II - Patient Sandbags in the MRI Environment
Bulletin 4: Technology and Risk - Implanted Pain Pumps
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Update on Implementation of: Color-Coded Wristbands in Oregon
On June 1, 2007, over twenty Oregon hospitals and health systems came together to discuss implementation of color-coded wristbands for hospital patients.
In Oregon, four colors have been adopted for use in patient wristbands. Besides having the standardized colors, the meaning for each band is embossed on the wristband itself. They include:
- Red to indicate Allergy
- Yellow to indicate Fall Risk
- Purple to indicate DNR
- Pink to indicate Restricted Extremity
January 1, 2008 was the decided implementation date.
At this time, the majority of Oregon hospitals have standardized their use of color-coded alert wristbands.
Implementation Tool Kit
Memo: Use of Colored Wristbands for Hospital Patients in Oregon - November 3, 2006 (PDF)
Form: Staff Sign-In Sheet (PDF)
Form: Staff Competency Checklist (PDF)
Staff Brochure: Color-Coded "Alert" Wristbands (PDF)
Patient Brochure: Understanding What Your Color-Coded "Alert" Wristband Means ENGLISH (PDF)
Patient Brochure: Understanding What Your Color-Coded "Alert" Wristband Means SPANISH (PDF)
FAQs About Color-Coded Alert Wristbands (PDF)
Presentation: Color-Coded Wristband Standardization in Oregon (Microsoft Power Point)
Template: Policy and Procedure (Microsoft Word)
Template: Patient Refusal to Participate in the Wrist Band Process (Microsoft Word)
Poster 1 (PDF)
Poster 2 (PDF)
Poster 3 (PDF)
For additional information/questions, please contact Diane Waldo at 503-479-6016 or diane.waldo@oahhs.org.
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Preventing central line infections
Dr. Peter J. Pronovost, a physician-researcher at Johns Hopkins, is a tireless advocate for reducing hospital-acquired infections. He has trialed a change process and has had remarkable results. In fact, in 18 months the average ICU using this change process reduced its infection rate to zero, from 4 percent. All told, it saved more than 1,500 lives and nearly $200 million. The program itself is not without cost, but can be considered to be money well spent. The cost for implementing the program first at Johns Hopkins was $500,000. Later, the program was implemented in 108 intensive-care units in Michigan. This simple change brought success beyond anyone’s wildest dreams in saving lives and reducing costs for patients. What was the change?
A five-item check list when inserting a central venous catheter.
Dr. Pronovost distilled the five steps from a 64-page federal document on controlling hospital-acquired infections. When inserting a central venous catheter, doctors should do the following:
1. Wash their hands with soap.
2. Clean the patient’s skin with chlorhexidine antiseptic.
3. Put sterile drapes over the entire patient.
4. Wear a sterile mask, hat, gown and gloves.
5. Put a sterile dressing over the catheter site.
This list may seem like a no-brainer. But in the crush of crisis medicine, one or more of these steps is often neglected. Sometimes there is a breach in practice or a casual compliance because it is such a simple process - but that often leads to disastrous results. The hospitals in Michigan say what made the program work was continuous — and anonymous — collection of data. The hospitals were monitored on their use of the list, their rates of infection and their feedback to medical personnel to show what was working and where gaps remained in quality care. If you are considering a checklist like this, you will no doubt save lives, prevent infection and avoid unnecessary healthcare expenses due to infections. If you are considering a process that includes monitoring compliance with the checklist, read the following article to understand the full implications.
To view the original news article this was developed from, go to:
http://www.nytimes.com/2008/01/22/health/22brod.html
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Join the OAHHS Hand Hygiene Project is one way to tackle MRSA
Treating methicillin-resistant staphylococcus aureus (MRSA) can be a challenge, but the best prevention measure, according to the Centers for Disease Control and Prevention (CDC), is quite simple. Because MRSA is spread by hand-to-hand contact, proper handwashing and other hygiene tips are key to preventing this “super bug.”
To get started with your own hand hygiene compliance project, please call Diane Waldo at 503-479-6016 or email at diane.waldo@oahhs.org
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Magic Wands and Bar-Coding in the OR
It’s never going to happen on your watch. That’s what everyone thinks – until it happens. According to a 2003 New England Journal of Medicine study, sponges and other foreign objects were left behind after abdominal surgeries at a rate of 1 for every 1,000 to 1,500 such operations. The financial cost to retrieve a sponge in a redo surgery can cost $50,000 or more. Worse than that is the pain and suffering to the patient and their family. And of course, there is the cost of litigation and the tremendous impact on the healthcare providers who were involved.
Several medical-products companies say sponges are the most common foreign objects left behind in surgeries. Technology is coming to the rescue of doctors and nurses, who for decades have kept track of sponges by manually counting them. But now, several types of modalities are available to keep track of the sponges, such as a bar coding type of inventory process. Another company uses a radio frequency system that alerts staff when sponges are still in the patient before the doctor closes. Sponges, tagged with a radio frequency detection system, can be found after a wand-like device is waved over the wound.
How costly are these products? It appears the costs are somewhat reasonable. Cardinal Health, a vendor that offers the bar-coding system, says the SurgiCount system costs about $12 to $15 a procedure. Medline Industries, who used the radio frequency product, RF-Detect, says the product adds $50 to $60 per thoracic procedure.
This may be something to look into, especially with the onset of CMS’s non-payment for select Never Events, which includes the retention of a foreign object in a patient after surgery or other procedure.
To view the original news article this was developed from, go to:
http://www.chicagotribune.com/news/chi-wed_sponges_0102jan02,0,2362713.story
Oregon Patient Safety Reporting Program
What is it? The Oregon Patient Safety Reporting Program was passed by the Oregon Legislative Assembly during the 2003 session. Program participants include hospitals, long term care facilities, pharmacies, ambulatory surgical centers, outpatient renal dialysis facilities and freestanding birthing centers. Participants will report serious adverse events, root cause analysis, actions plans established to prevent similar serious adverse events and patient safety plans to the Oregon Patient Safety Commission, a semi-independent state agency. The Commission will analyze reported data to develop and disseminate information to improve the quality of care with respect to patient safety. No patient safety data will be reported or disclosed to a regulatory body. Patient safety data is confidential.
Is it voluntary? Yes, but the Commission must submit a report to the 2007 Legislative Assembly regarding whether performance goals have been met and offering any recommended changes to the program, including whether the program should become mandatory.
Are the results available to the public? Patient safety data identifying an individual hospital or patient will not be available to the public. The Commission will distribute written reports to the public using aggregate, de-identified data to describe statewide serious adverse event patterns. The Commission will maintain a Web site to facilitate public access to reports, as well as a list of names of participants. Click here to download the January 2007 Evaluation Results
When does it go into effect? The legislation was signed by the Governor in August, 2003 and is in effect. The Commission has not been appointed, however, and any reporting likely will not begin until 2005.
How do I report? To be determined by the Oregon Patient Safety Commission Board of Directors.
What resources does OAHHS provide?
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