# NCPS TIPS -- May/June 2001

### Contents: 1. VA/QuIC Patient Safety Summit

> 2\. What is QuIC?
>
> 3\. Dental X-Ray Film Warning
>
> 4\. Facility Feedback
>
> 5\. Safety Spotlight
>
> 6\. Nitrogen or Nitrogen NF
>
> 7\. Learning Links

### 

### 1. VA/QUIC PATIENT SAFETY SUMMIT

##### From the VA National Center for Patient Safety

Under the auspices of QuIC (see related article), the VA National Center
for Patient Safety (NCPS) is organizing and convening the Summit on
Effective Practices to Improve Patient Safety. The symposium will
present information on findings, methods, and systems that can be used
to improve patient safety, which participants can put to rapid and
widespread use in health care settings. This will be held September 5-7,
2001, at the Washington (DC) Hilton and Towers. Including VA and non-VA
participants, the summit can accommodate up to 500 participants. We
expect that about 200 participants will be from VA, with the rest coming
from other QuIC member agencies, state and local governments, and the
private sector.

NCPS staff are in the process of organizing the details of the
conference. Key speakers at the summit will include Dennis O'Leary,
President of the Joint Commission on Accreditation of Healthcare
Organizations, Donald Berwick, M.D., M.P.P, CEO and President of the
Institute for Healthcare Improvement, and Michael Cohen, Pharm D,
President of the Institute for Safe Medication Practices.

The topics and presentations planned (some for plenary sessions, some
for breakout sessions) will include:

• Patient Safety Obstacles and Solutions/Lessons Learned by the VA

• Failure Modes Effects and Analysis (FMEA) as Applied to Patient Safety

• Root Cause Analysis (RCA) Teams Presentation

• NCPS RCA Tools and Safety Assessment Code

• Report from AHRQ Evidence-Based Practice Patient Safety Study

• New JCAHO Patient Safety Standards

• VA/NASA Patient Safety Reporting System

• Using Human Factors and Usability Testing to Improve Patient Safety

• New NCPS RCA Software Demos

• Patient Safety Alerts and Advisories

• Effective Management of Medical Teams

• Methods to Reduce Falls

• Health Care Provider Performance and the Effects of Fatigue

• Use of Simulations and Simulators to Improve Patient Safety

• Methods for Increasing Medication Safety

• Results of the VA Survey on Patient Safety Attitudes

• Improving Quality: The Rest of the Iceberg

The sessions will be organized so that those new to patient safety as
well as those with experience in the field can both benefit from
attending. We expect the conference to be especially valuable to staff
newly hired or reassigned as patient safety managers.

Registration for the VA/QuIC Summit on Effective Practices to Improve
Patient Safety is available via the NCPS intranet website
(vaww.ncps.med.va.gov) or go directly to
vaww.rev.lrn.va.gov/conferences/safety/index.cfm. Please coordinate your
registration in cooperation with your VISN as soon as possible to ensure
that you get one of the slots assigned to VA. If you are unsure of who
to contact in your VISN, a list of contacts for the symposium is
available at the registration website.

### 2. WHAT IS QUIC?

##### From the VA National Center for Patient Safety

The Department of Veterans Affairs (VA) is one of 11 members of the
federal government's Quality Interagency Coordinating (QuIC) Task Force
(see www.quic.gov). QuIC was established in 1998 with the goal to ensure
that all Federal agencies that purchase, provide, study, or regulate
health care services are working in a coordinated way toward the common
goal of improving the quality of health care.

QuIC seeks to provide information to help people make choices, to
improve the care purchased and delivered by the government, and to
develop the infrastructure needed to improve the health care system.
QuIC was responsible for the 2000 report [Doing What Counts for Patient
Safety: Federal Actions to Reduce Medical Errors and Their
Impact]{.underline}, which presented the federal government's response
to the Institute of Medicine's 1999 report [To Err Is Human: Building a
Safer Health System]{.underline}, which raised the public's awareness of
the need for major improvements in patient safety.

### 3. DENTAL X-RAY FILM WARNING

##### From the VA National Center for Patient Safety

The FDA has issued a Public Health Notification warning of the potential
for harmful lead exposure from dental film stored in tabletop containers
lined with unpainted or coated lead. These containers are usually the
size and shape of a shoebox, are made of wood, and are lined with lead
that has apparently not been painted or coated.

Film stored in these containers has been found to be coated with a
whitish film that is about 80% lead. These highly dangerous lead levels
are enough to potentially cause serious adverse health effects \--
including anemia and serious neurological damage \-- in patients and
healthcare professionals.

The FDA recommends the following:

• Discard any dental film that has been placed in these containers. None
of this film should be used. Wiping the film does not significantly
reduce the lead levels.

• Remove the containers and dispose of them properly.

For more information on this contact your facility Industrial Hygienist.

### 4. FACILITY FEEDBACK

##### From the VA National Center for Patient Safety

(Patient safety feedback from throughout the VHA. Please send any
comments you'd like to share with us to ncpstips@med.va.gov.)

#### Unannounced JCAHO Survey

We recently had our first random, unannounced Joint Commission survey
for Home Care/Durable Medical Equipment. From the patient safety
perspective, we were scored on Improving Organization Performance Home
Care Standards, specifically aggregation and analysis.

This was where we had the opportunity to "brag" about our RCA process
and walked the surveyor through the SAC score process of all incidents,
including close calls and the RCA format. The surveyor was very
impressed with our front line staff and senior management involvement.

We also pulled our current storyboard circulating to staff regarding
"Lessons Learned" from RCA's, listing all staff who participated,
whether it was a close call or actual event (over half of our RCA's are
close calls), what the RCA incident was, and then the improved outcome
(all sanitized of patient identifiers, of course).

We scored "substantially compliant" for standards PI.4.3 (undesirable
patterns of trends in performance and sentinel events are always
evaluated) and PI.4.4. The organization uses the information from the
evaluation to develop an action plan that will improve performance or
reduce the risk of future sentinel events.

Needless to say, we impressed the surveyor with having all this info
available on a random, unannounced survey. (I think we knocked his socks
off).

Thank you to you and your staff for helping us "shine" during this
survey --- especially a random, unannounced survey --- and wanted you to
share in our success.

P.S. We're actually getting good at RCA's and we have several that have
been completed in 20 hours or less that are excellent. Thanks again.

\-- Sandy Brestowski

Wilkes-Barre VAMC

### 

### 

### 5. SAFETY SPOTLIGHT

##### From the VA National Center for Patient Safety

(On a regular basis we will feature teaching examples pulled from
medical literature and similar RCAs that we feel are applicable and of
interest to the entire VHA healthcare system. These cases are intended
to be used for learning purposes only.)

### Failure to obtain consent for surgery

#### Description

A patient was scheduled to receive a paracentesis, and the resident
discussed with the patient the procedure along with the incumbent risks.
The veteran, who had experienced relief before with this procedure, was
seeking this treatment and consented verbally. The resident had been
working a long shift, and failed to receive the written consent. At the
time of the procedure, the resident explained to the attending physician
that verbal consent had been obtained, and the resident went and got a
procedure tray from the open supply room. They performed the surgery
without incident, and following the surgery the resident documented that
verbal consent had been given.

Upon discussion, the resident confirmed that she knew that you should
get informed consent, but couldn't remember any orientation regarding
the policy and described the atmosphere as relaxed regarding informed
consent.

#### Vulnerabilities

The following vulnerabilities and system weaknesses were identified:

A cultural norm (especially among the residents) of a lax approach to
informed consent

Non-enforcement of existing policies

No training or discussion of the informed consent process and its
value were built into the orientation

A lack of incentives or dis-incentives to change the current behavior

Lack of barriers in the environment as the procedure kits/trays can be
retrieved from an unlocked supply room regardless of patient consent
status, and no individual to verify that the consents have been received

Fatigue on the part of staff

The process often breaks down during off tour times

Insufficient alerts to remind of policy

#### Actions To Consider

The following actions were recommended:

Brightly colored sticker placed on each tray stating "STOP---an
informed consent must be completed for this procedure"

Included informed consent on procedure tray

Supply room locked so that supply/procedure trays cannot be taken

Procedure tray will not be issued until signed consent obtained

Eye-catching promotional literature in team conference room about
informed consent

Additional resident and staff educational sessions

### 

### 6. NITROGEN OR NITROGEN NF?

##### From the VA National Center for Patient Safety

Do you use nitrogen to power operating room surgical equipment or dental
office tools? If you answered "yes" to this question, is the nitrogen
medical gas grade or industrial, non-medical grade? Does it make a
difference? YES!!

The Compressed Gas Association (CGA) identified two patient related
incidents involving gaseous nitrogen that was used to power tools. These
incidents involved the presence of a substance in non-medical grade
Nitrogen that gave a strong odor. In one case a patient in a dentist's
office required hospitalization. In both cases the odorizing substance
was found to be toxic in nature.

FDA does not specifically require that nitrogen used to power surgical
or dental equipment be listed as either a Medical Device or be Nitrogen
NF (medical grade). However, based on these two events CGA recommends
that only Nitrogen NF be used.

Medical grade Nitrogen NF production procedures require testing for odor
prior to distribution, and industrial non-medical grade nitrogen does
not.

It is recommended that you review the type of Nitrogen gas you use to
power this equipment in your hospital **and switch to Nitrogen NF if it
is not currently being used.**

If you would like more information on this issue please refer to CGA
Safety Alert SA-6-1998.

### 7. LEARNING LINKS

##### From the VA National Center for Patient Safety

We have recently come across interesting articles and websites on
patient safety issues that we want to pass on to you.

[The British Medical Journal]{.underline}

The British Medical Journal recently published an article titled
"Adverse Events in British Hospitals: Preliminary Retrospective Record
Review" ([http://bmj.com/cgi/content/full/322/7285/517]{.underline}).
This article highlights preliminary findings from a pilot study
conducted in the United Kingdom that examined the feasibility of
applying U.S. and Australian adverse event reporting methods in the U.K.

[FDA Bulletin]{.underline}

The Food and Drug Administration publishes a quarterly bulletin called
"User Facility Reporting"
([http://www.fda.gov/cdrh/fusenews.html]{.underline}). The purpose of
this publication is to assist hospitals and other medical device user
facilities in complying with their statutory reporting requirements
under the Safe Medical Devices Act of 1990 and the Medical Device
Amendments of 1992.