Patient Safety Week

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The Collaborative Healthcare Patient Safety Organization (CHPSO) and the Hospital Quality Institute (HQI) celebrated Patient Safety Awareness Week with a series of very well attended and highly informative webinars. Many organizations took advantage of these educational offerings as opportunities to bring multidisciplinary teams together to learn more about these important patient safety and quality improvement topics. If you missed these sessions, we encourage you to take advantage of the recordings and associated materials. Here are recaps of each of the five webinars: 

Prescription for Safety: Just What the Doctor Ordered – Simple Strategies to Promote Safe Medication Use 

Summary

HQI and CHPSO kicked off Patient Safety Awareness Week with a presentation on medication safety. The panelist for this webinar was Katayoon Kathy Ghomeshi, PharmD, MBA, BCPS, CPPS, medication safety officer at UCSF Health and assistant clinical professor with UCSF School of Pharmacy. She also is an appointed member of the American Society of Health-System Pharmacists Advisory Group on Medication Safety, an appointed member of the California Hospital Association Medication Safety Committee, an appointed Specialty Council member for the Board of Pharmacy Specialties and serves on the Board of Directors for the California Society of Health-System Pharmacists.   

Dr. Ghomeshi  described an 11-step Medication Use Process that she suggests caregivers (physicians, nurses, pharmacists, and respiratory therapists) use collaboratively to ensure all steps are being performed safely and correctly. These processes should have workflows for each step that are designed to prevent medication errors, make errors more detectable, and mitigate potential for harm when an error occurs.  

Unfortunately, even with solid medication use processes in place, errors —  wrong time, wrong patient, wrong route, wrong drug, and wrong dose — can occur. Dr. Ghomeshi said these errors are always considered preventable and may result in no harm or Adverse Drug Events.  Incorporating standard checklists that analyze root causes when evaluating medication errors can improve processes that help prevent or reduce error occurrence. Dr. Ghomeshi introduced several risk-reduction strategies that ranged from low-level (people-based) strategies to high-level (system-based) strategies. Some of these strategies included having a default maximum dose, barcode scanning, and two RN independent checks.

Dr. Ghomeshi touched on high-alert medications, such as anticoagulants, opioids, and insulin, and discussed the importance of establishing safeguards and implementing system-based risk-reduction strategies to prevent errors, make them detectable, and mitigate the chance of harm. It is also important to educate staff on the nature of harm associated with each of the high-alert medications. She added that Medication Reconciliation is important step to reduce inaccurate and incomplete medication histories. Obtaining an accurate medication history using reliable sources of information can eliminate medication errors for hospitalized patients. This also allows for identification of appropriateness of prior therapies at transitions of care (admissions, changes in level of care, and discharges). 

Technology can play a large role in promoting safety. Some examples of this are order sets, dose alerts, barcode scanning, automated dispensing cabinets, and smart pump libraries. It must be kept in mind that technology is only as reliable as the humans who develop, implement, and utilize it. Technology cannot replace critical thinking, situational awareness, and proper training. 

The high-stress, fast-paced nature of the health care environment may cause health care team members to feel pressured to cut corners and engage in high-risk behaviors because they want to accomplish more,  making potential safety risks difficult to see. When cutting corners becomes a normal behavior, it can lead to a flawed system or process. When following up with staff involved in reported errors, identify and coach or counsel staff about the error, but do not stop there. The underlying condition may continue to recur and may be the source of risky behavior, or it could be a signal to a different issue that needs to be fixed.  Knowledge of potential failure points and effective prevention strategies can promote a safe medication use program. 

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Transgender Healthcare: Safety Considerations for Both Patient and Institution

Summary

Patient Safety Awareness Week continued with a review of safety considerations when caring for transgender patients. The panelist for this webinar was Maurice Garcia, MD, MAS, Director of Transgender Surgery and Health Program at Cedars-Sinai Medical Center and Associate Clinical Professor of Urologic Surgery at Cedars-Sinai Medical Center. Dr. Garcia explained the importance of what terminology is used. “Gender” is a complex internal sense of being male, female, or other. “Gender identity” is not the same as “sexual orientation.” He used the example of sexual identity being who you go to bed with, whereas gender identity is who you go to bed as. “Transgender” describes individuals whose identity, expression, behavior, and general sense of self does not conform to the sex they are assigned at birth. The incidence and prevalence of individuals who identify as transgender is grossly underestimated. Most studies only count people who have presented to gender clinics. In 2016, 0.6-0.7% of the population in the United States stated that they identify as transgender. That is 1.4-1.63 million people.  

“Gender dysphoria” means the discomfort or distress caused by the discrepancy between the person’s gender identity and their sex assigned at birth.  Available treatments for gender dysphoria include non-invasive and invasive therapies such as behavioral therapy, hormones, and surgery. Treatment should always be individualized and focus on helping the patient explore and become comfortable in their gender identity. The World Professional Association for Transgender Health (WPATH) has defined specific criteria for referring patients for hormone therapy and gender affirming surgeries. 

When caring for transgender patients, it is important to provide culturally competent care and remember to consider the patient as a whole. This includes being respectful, having a basic understanding of transgender care options, utilizing patient-centered language, and correctly using the patient’s desired pronouns. In the context of transgender care, cancer screenings, and sexual health screenings are often negatively impacted depending at what stage of gender transition the individual may be. 

Some common pitfalls in caring for transgender patients are misgendering patients and lack of inclusive signage in health care settings, and, when providers fail to use the person’s correct pronouns based on how the patient identifies, it causes the patient to feel invalidated, rejected, hurt, angry, unwelcome, and unsafe. This can be addressed through cultural competency training for all staff. Non-inclusive signage makes patients feel unacknowledged and unwelcome. Putting signage on the patient’s chart or on their hospital door to have visitors speak with the nurse first to be informed about the patient’s preferred name and gender can assist in decreasing the incidence of misgendering these patients. The third common issue is intake forms that are cisgender-normative and heteronormative. This can be addressed by having intake forms that include the patient listing their gender identity separately from their sex assigned at birth and listing their preferred name as well as their legal name if they are different.  

Care for transgender patients enriches the entire health care environment   calls on skills associated with being a good doctor — compassion, advocating for patients, and innovation. Surgeries for transgender patients lead to innovation that can in turn help non-transgender patients (e.g., intestinal vaginoplasty for vaginal replacement after vaginal or uterine cancer surgery or radiation). Lastly, transgender care channels an institution’s commitment to diversity and acceptance.  

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Patient Safety Culture Change

Summary

For the third webinar offering of Patient Safety Awareness Week, we  shared the groundbreaking new partnership of Inland Empire Health Plan (IEHP), BETA Healthcare Group (BETA), and Hospital Quality Institute (HQI) that rewards hospitals for participating in HQI Cares: Implementing BETA HEART® (HQI Cares), a comprehensive, multi-year program aimed at transforming patient safety and caregiver well-being. The panelists for this webinar included Deanna Tarnow, RN, B.A., CPHRM, Senior Director of Risk Management and Patient Safety at BETA Healthcare Group; Tim McDonald, M.D., J.D, Chief Patient Safety and Risk Officer for RLDatix and BETA HEART Lead Faculty; and Genia Fick, Vice President of Quality at IEHP. 

Through developing a comprehensive approach to the prevention and response to patient harm, an organization can provide effective communication rapidly following all serious harm events; apologize and fairly and rapidly resolve all causes of inappropriate care; learn from their mistakes; and support patients, families, and caregivers throughout the process.  

HQI Cares: Implementing BETA HEART® has its roots in CANDOR.  

The goals of the HQI Cares: Implementing BETA HEART® program are: 

  • Develop accountable and reliable systems that support provision of safe care; 
  • Develop empathic and clinically appropriate processes that support healing of both the patient and clinician after an adverse event; 
  • Develop mechanisms for early, ethical resolution of hardship caused by medical error or inappropriate care; and 
  • Instill trust between clinicians and patients. 

The program’s five domains are:  

  1. “Culture Measurement.” This includes administering a validated and integrated culture of safety surgery to measure staff perceptions of safety and engagements, teaching to debrief data for improved learning and understanding the drivers, adopting Just Culture principles of accountability across the organization, and broadly disseminating lessons learned.  
  2. “Rapid Event Response and Analysis.” This includes incorporating timeliness, applying human factors science to event investigations, collecting information utilizing cognitive interviewing tactics, applying Just Culture principles of accountability when evaluating individual behaviors and choices, and incorporating input from patient and families.  
  3. “Communication and Transparency.” This includes incorporating timeliness measures, utilizing Communication Assessment to identify individuals with greater cognitive complexity who will staff the communication resource team, training with standardized persons via simulation-based learning, and starting communication early and continuing communication through the point at which there is understanding as to what occurred. 
  4. “Care for the Caregiver.” This includes proactively responding to frontline clinicians and staff, training peer supporters to respond to providers and staff involved in harm events, measuring personal burnout to identify staff resilience utilizing SCORE measurement, and including timeliness features and monitoring for continued follow-up. 
  5. “Early Resolution”. This includes, when care is deemed inappropriate, timely resolution achieved absent of a lawsuit, which avoids costly litigation. This may include financial resolution or non-financial resolution (i.e., inclusion in patient safety efforts).  

Joining HQI Cares: Implementing BETA HEART® begins with your organization signing a participation agreement which sets forth commitment of HQI CARE/BETA Healthcare Group and attestation of organization leaders to provider support and resources. The HQI Cares and BETA HEART Guideline serves as a roadmap to success. After senior leadership is signed off, your organization can begin the onboarding process, which includes a Readiness Assessment and Gap Analysis. The Gap Analysis is a crucial step that will serve as a qualitative measure and provide a lens into the organization’s culture and help determine where HQI Cares must “meet” the organization in its level of development and readiness. HQI Cares, in collaboration with participating organizations, will review the Gap Analysis findings and identify initial areas of focus and develop a plan for next steps and implementation.

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Addressing Racial Inequity in Health Care Outcomes with a Focus on Cherished Futures for Black Moms and Babies

Summary

For our fourth day of Patient Safety Awareness Week, we hosted a webinar addressing racial inequity in health care. We had panelists from Cherished Futures for Black Moms and Babies, an organization that helps participating hospitals evaluate their data, collaborate with community partners, and implement institutional changes to improve care for Black women, birthing people, and families. Our panelists included Esther Ebuehi, MS, birth equity impact analyst and Asaiah Harville, IBCLC, birth equity coordinator. 

Cherished Futures is a multi-sector collaborative effort to reduce Black infant and maternal inequities and improve patient experiences for Black birthing people in Los Angeles County. The county has approximately 10 million residents, approximately 114,000 births on average each year, and 46 delivery hospitals. Cherished Futures is a two-year cohort experience. In year one, capacity building is done through a “getting grounded” approach in a series of workshops to build the knowledge and understanding of inequity among Black babies, mothers, and birthing people. By the end of the first year, all teams develop an implementation plan. In year two, hospital plans are implemented, continued coaching and assistance is provided, collaborative meetings are held at least three times, and the organization is evaluated. The goal of this program is to reduce Black maternal and infant health inequities and improve the Black patient experience in Los Angeles County.  

Research supports that racism is the root cause of maternal and infant health inequities in the United States. The overexposure to racism and discrimination throughout Black women’s lives contributes to the physical weathering of Black bodies. This phenomenon is seen in Black women across lines of class, education, maternal attitudes, and behaviors. “Equality” is the condition under which all individuals receive uniform treatment, resources, and opportunities. “Equity” is acknowledging that we do not all start from the same place, and therefore, we need different resources and opportunities to thrive. “Justice” is changing systems in ways that lead to sustained equitable access for all. Just, equitable systems result in people who do not need additional support because the cause of the inequity is addressed — the system is changed. Birth equity is defined as the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort.  

In the 21st century, maternal and infant health inequities persist:  

  • The rates of pregnancy-related death for Black and American Indian/Alaska Native women over the age of 30 are four to five times higher than their white peers.  
  • Black women are 27% more likely to experience severe pregnancy complications than White women. 
  • A Black woman with a college degree is nearly twice as likely to experience pregnancy complications compared to a white woman who has not completed high school. 

Structural racism has a major impact on birth inequities. Disrespect, abuse, and discrimination within the health care system play a significant role in how women of color access and experience care during pregnancy, birth, and postpartum, which contributes to adverse outcomes for mother and baby. The suboptimal care received by some Black women may result in part from the legacy of racist treatment during the antebellum period and in the afterlife of slavery. Research has found that Black women bear a larger burden of allostatic load than men and women of all other ethnicities. Black women find that they must spend significant time, thought, and emotional energy watching every step they take, managing an array of feelings, and altering their behavior to cope with it all. This study found that in order to fit in, keep the peace, and move forward, many of the women had to censor their conversations and funnel their ideas.   

The panelists discussed the importance of disaggregating birth data in order to identify underlying trends and patterns, including social determinants of health, and see which populations are experiencing disproportionate rates of certain clinical outcomes. Based on these results, initiatives that are grounded in data and tailored to the communities most in need may be developed and implemented. When needs of the communities most impacted by disparities are addressed, everyone benefits.  

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Recent CDC Studies about COVID in California: An Epidemiological Review and Critique

Summary

On our last day of Patient Safety Awareness Week, we examined new studies about various aspects of the COVID-19 pandemic. This webinar was presented by Scott Masten, PhD, vice president of measurement science and data analytics, at Hospital Quality Institute. In this webinar, HQI’s epidemiologist provided a historical perspective of the pandemic in California and reviewed the findings, pointed out strengths, and critiqued the methodologies used in several recent COVID-19 studies based on California data. 

Dr. Masten first reviewed recent California data regarding COVID-19 cases, testing, and deaths.  

He reviewed a study conducted at Cedars-Sinai Medication Center on the clinical characteristics and outcomes among adults hospitalized with laboratory confirmed SARS-CoV-2 infection from July 15 to September 23, 2021 (delta) and December 21, 2021-January 27, 2022 (omicron). This study included 1,076 individuals who were hospitalized during the previously stated time periods. The study further looked at the difference in the number of hospitalizations between vaccinated and unvaccinated individuals during both delta and omicron. The study found that there was a higher vaccination prevalence among hospitalized patients during omicron. Findings also indicated that omicron was less severe than delta, regardless of vaccination status. Furthermore, vaccination was associated with lower ICU admission and lower death.  

The limitations of this study were that it was only done within one hospital, low statistical power for detecting differences across vaccination status, possible undercount of death during omicron due to patients still being hospitalized when the study was completed, and potential confounding by ignoring immunity from prior COVID-19 infection. 

Dr. Masten then reviewed a study done on all SARS-CoV-2 infections and hospitalizations, by vaccination status, in Los Angeles County before and during omicron (November 7, 2021-January 8, 2022). This study included 422,966 individuals who were hospitalized during the previously stated time. The study examined the difference rates of hospitalization, admittance to an ICU, requirement of mechanical ventilation, and death in those who were fully vaccinated (with and without booster) and those who were unvaccinated. The study found that illness severity decreased monotonically with increased vaccination status and showed a clear indication of lower hospitalization risk if vaccinated.  

The limitations of the study were that hospitalization for COVID-19-positive was assumed based on positive test results and hospital admission dates being contemporaneous, and the study measured prior COVID-19 disease, but did not use this to stratify groups. Effects of the vaccine and booster were possibly confounded by natural immunity, which would bias against the vaccine with booster benefit.  

The final study reviewed all positive cases and hospitalizations by vaccination status and previous diagnosis in California and New York. Dr. Masten only discussed the California data, which included 752,781 individuals with laboratory-confirmed COVID-19 and 56,177 individuals out of the 752,781 who were hospitalized during May 30, 2021-November 20, 2021. The incidence of a second diagnosis was least in those who were vaccinated and had a prior diagnosis, and highest in those who were neither vaccinated nor had a prior diagnosis. Hospitalization was lowest in both those who were vaccinated and had prior diagnosis and those who were unvaccinated with previous diagnosis, and highest in those who were neither vaccinated nor had prior diagnosis.  

The limitations of this study were possible misclassification bias when individuals had non-matches. They may have been assumed to be unvaccinated or COVID-19-naive. Also, it is likely that many people with COVID-19 never tested and were incorrectly categorized.  

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