Alarm Fatigue

According to a news article published by The Joint Commission, the constant beeping of alarms and the overabundance of information transmitted by medical devices are causing “alarm fatigue” and is putting patients at risk.

Over a four-year period, The Joint Commission sentinel event database reported 80 alarm-related deaths and the U.S. Food and Drug Administration database reported more than 560 alarm-related deaths.

Alarms in patient rooms are there to alert caregivers of potential problems, but if they are not properly managed, safety can be compromised. Warning noises tend to desensitize caregivers and can cause them to ignore alarms or even disable them. Sometimes there are too many medical devices with alarms or individual alarms can be difficult to hear.

The Joint Commission recommends that health care organizations take the following actions:

• Ensure that there is a process for safe alarm management and response in areas identified by the organization as high risk.
• Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.
• Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.
• Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.
• Inspect, check and maintain alarm-equipped medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability. Base the frequency of these activities on criteria such as manufacturers’ recommendations, risk levels and current experience.

Since this is a growing issue, The Joint Commission is also considering creating this as a National Patient Safety Goal so health care organizations can be more educated on the matter.  

Product Recall






Photo Credit: CPSC.gov



Approximately 9,000 Imaginarium Activity Walkers have been recalled from Toys R Us due to a choking hazard.

Currently, the company has received five reports of the front wheels detaching, which can pose a risk to children. The recalled product has a model number of 5F5E972 which is located on the bottom.

No injuries have been reported as of right now. Consumers can return the product to an Toys R Us store and get a full refund or store credit.



Hand Hygiene

Taken from Becker's Hospital Review:
Here, Gina Pugliese, RN, MS, vice president of the Premier healthcare alliance's Safety Institute, explains why hand hygiene should be a patient safety priority, and how healthcare organizations can succeed in improving hand hygiene compliance.
Question: Patient safety includes a wide range of issues, from patient falls to medication errors and hospital-acquired infections. What one patient safety issue do you think should be a priority in hospitals and health systems?    

Gina Pugliese: Hand hygiene is one of the most important patient safety issues today. And, it is the single most important factor in preventing the spread of pathogens and healthcare-associated infections. Low compliance with this basic patient safety measure may represent a lack of compliance with other patient safety practices. Despite attention to public reporting, reduced reimbursement initiatives for certain healthcare-associated infections, and international attention by public health, professional and accreditation organizations, it has been a challenge to reach and sustain hand hygiene rates over 80 percent in many healthcare facilities.

Q: What are the biggest barriers to improving hand hygiene?
GP: All the systems must be in place to support hand hygiene and make it easy for staff to adhere. This includes staff education on the importance and indications for hand hygiene; convenient location of sinks and dispensers; all dispensers in working order and filled with hand hygiene products that are not drying or irritating to the skin and [that are] acceptable to staff. 

Q: What are the biggest opportunities for improving hand hygiene?
GP: The organizational culture must have the right balance between no-blame and individual accountability for noncompliance with safety practices. In most high reliability industries, such as the airline industry, once a reasonable safety rule has been scrutinized for strong evidence to support it, found to have no unintended consequences and then becomes implemented, a worker who fails to follow the rule becomes accountable for failure to comply. There needs to be a consistent, fair and transparent method to monitor adherence to recommended practices for hand hygiene and the behaviors for which staff will be held accountable.  

Some hospitals have been very successful with incentives and rewards to improve hand hygiene compliance. Any penalties for failure to adhere to patient safety standards must be understood by all staff and applied fairly and proportional to the infraction. Penalties are not intended for a busy or distracted caregiver that may forget to wash their hands, but rather habitual and intentional failure to perform hand hygiene despite education, repeat counseling and corrections of any identified systems issues. Penalties for failure to adhere to appropriate hand hygiene vary, and have included the linking of compliance to merit increases for salaried staff and temporary loss of clinical privileges for physicians.

Patient Safety App

After a mother died from a preventable medical error, her family took action into their own hands.

After getting knee surgery, Louise Batz was given two narcotics and a sedative; once the combination of medicine was in her system, she stopped breathing and suffered irreversible brain damage. Eleven days later, she was taken off life support and died. Because Batz displayed signs of sleep apnea, she should not have been given that combination of drugs. Her death was completely preventable.

After Batz’s death, her family co-founded the Louise H. Batz Patient Safety Foundation so other families wouldn’t have to endure the same traumatic experience of losing a loved one. With the help from a medical advisory board, they created The Batz Guide for Bedside Advocacy.

This guide is now an iPad app that allows patients and their loved ones a way to monitor medical care to improve safety. They can log medications, look up medical terms, track vital signs and more. The app can be downloaded for $2.99. The goal of the app is to facilitate communication by helping patients and families know which questions to ask in order to help prevent errors.

To read more, click here.

Johnson & Johnson Recall

Due to a failure to operate properly at extremely high glucose readings, Johnson & Johnson is recalling and replacing approximately two million meters used to measure blood glucose levels in diabetics.

Here in the United States, about 90,000 OneTouch Verio IQ meters were sold. The units have failed to provide a warning of dangerously high blood sugar as well as high glucose readings of 1024 mg/dl and above and will shut off, which can delay proper treatment.

The company is also recalling about 4,000 of the OneTouch Verio Pro meters found in the Middle East, Europe and the Asia/Pacific Region, as well as 670,000 of the meters in Europe.

No patient injuries have been reported in the U.S. due to the malfunction. The company stated that patients should continue using the Verio IQ model until replacements arrived.

Calcium

According to an article published in The Washington Post, a 2012 study found that calcium supplements may raise your risk of a heart attack.

However, calcium is an important role when it comes to your health: your body needs it to maintain nerve and heart function and to keep bones strong. Adults should be getting 1,000 to 1,200 milligrams a day.

For deciding whether or not to meet your daily requirement in whole or in part by taking supplements, there is a lot of conflicting evidence. Some studies suggest links between calcium intake and heart attacks, while others found that getting too little calcium can contribute to heart disease.

It can be confusing whether or not to take supplements or how you should care for your bones, but many physicians are bringing their focus back to what their patients are eating, as the studies showed that no heart risks were associated with calcium from food.

According to the article, there are multiple calcium-rich foods available, so you shouldn’t take a calcium supplement if you can get the calcium you need through diet.

Since caring for your bones can be complicated, you should have your bone density tested. The Preventive Task Force recommends getting tested if you’re a woman over age 65 and many physicians recommend that men should be tested after age 50.

However, these basic tips for bone health still count: eat a healthful diet rich in calcium, get plenty of exercise and avoid smoking.

 

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At Snyder & Wenner, we strive to keep the community safe when hospital care is involved. We have become patient safety advocates by representing patients who have been harmed from hospital error. If you know someone who has been seriously injured from a hospital error, please contact us. 

Snyder and Wenner, P.C.

2200 E. Camelback Road

Suite 213

Phoenix, AZ 85016

602-224-0005
www.azmedicalmalpracticelaw.com

 

Superbugs

The Centers for Disease Control and Prevention (CDC) recently warned that “nightmare bacteria” are increasingly resistant to even the strongest of antibiotics.  

According to an article published in The Washington Post, these superbugs are posing a growing threat to hospitals and nursing homes nationwide.  

Since the strongest antibiotics don’t work, patients are left with a possibility of having an untreatable infection, so health officials and doctors need to work together to stop these deadly spreads.

The bacteria, known as Carbapenen-Resistant Enterobacteriaceae, is called a “triple threat:” it’s resistant to nearly all antibiotics, it kills up to half of patients who get bloodstream infections, and it can transfer their antibiotic resistance to other bacteria within the family, which can make other types of bacteria untreatable.

In 2001, the percentage of these bacteria resistant to antibiotics was 1.2 percent. In 2011, the percentage was 4.2 percent. During the first six months of 2012, almost 200 hospitals treated at least one patient infected with the superbug.

Most infections occur in patients who are receiving care for serious conditions or are in nursing homes, and who often have catheters or ventilators which allow the bacteria to get deep in a patient’s body.

Since the germs spread from person to person, it can be controlled with proper precautions and better practices. According to the CDC, standard infection control precautions include washing hands and prescribing antibiotics wisely, which can reduce the problem.  

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At Snyder & Wenner, we strive to keep the community safe when hospital care is involved. We have become patient safety advocates by representing patients who have been harmed from hospital error. If you know someone who has been seriously injured from a hospital error, please contact us.

Snyder and Wenner, P.C.

2200 E. Camelback Road

Suite 213

Phoenix, AZ 85016

602-224-0005

www.azmedicalmalpracticelaw.com