# Presentation: 510816

## How Can States and Institutions Work Together to Create a Culture of Safety?Concrete Actions to Improve Patient Safety

**Marge Keyes, M.A.**
**Health Scientist Administrator, **
**Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ) Rockville, MD**

## Building the Business Case for Patient Safety– an AHRQ-JCAHO Invitational Conference

- Architecture:  more than just a financial argument
- Foundation
- Defining and measuring ROI
- Examining the impact of reimbursement and purchasing policies
- Roughing in the structure
- Raising the roof
- Customizing the options
- Passing inspection

## Evidence-based Practices to Improve Patient Safety

**Evidence-based Practices to Improve Patient Safety**

- Making Health Care Safer:  A Critical Analysis of Patient Safety Practices (July 2001)
- Patient safety practices:  those that reduce the risk of AE related to exposure to medical care across a range of diagnoses or conditions
- 40 researchers (expertise in patient safety, EBM, and clinical medicine, nursing, and pharmacy)
- Primarily hospital care but included some nursing home and ambulatory care practices
- Selection of practices relied on
- Inclusion criteria
- Structured evaluation of the evidence

## Top Evidence-based Safety Practices

- 11 of 79 practices rated highest
- Appropriate prophylaxis to prevent thromboembolism
- Perioperative beta-blockers
- Maximum sterile barriers when placing central IV catheters
- Antibiotic prophylaxis in surgical patients to prevent perioperative infection
- Antibiotic-impregnated central venous catheters to prevent catheter-related infections
- Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia

## Top Evidence-based Safety Practices

- Pressure relieving bedding to prevent pressure ulcers
- Real-time ultrasound guidance during central line insertion
- Appropriate provision of nutrition (emphasis on early enteral nutrition for critically ill or surgical patients)
- Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications
- Patients to recall and restate informed consent information

## Response to the EPC Report on Patient Safety Practices

- JAMA – July 24/31, 2002 Leape, Berwick, Bates
- Acceptance of a practice does not always rely on evidence from a randomized trial
- Reasonable judgment based on best “available” evidence may be acceptable approach

## Response to the EPC Report on Patient Safety Practices

- JAMA – July 24/31, 2002 Shojania, Duncan, McDonald, Wachter
- Charge was to *identify evidence-based safety practices*
- General insistence on evidence should not prevent implementation of practical, low-risk, understudied interventions that seem likely to work

## Response to the EPC Report on Patient Safety Practices

- Gap between standards considered acceptable by academics and standards of evidence considered acceptable by those in business
- NQF consensus development process

## Patient Safety Improvement Corps

- Goal:  develop and maintain “front line” capacity for patient safety improvement at the community, regional, and state level
- Objective:  By 2004 have on-site experts and technical assistance in 10 states/health care organizations to improve patient safety

## Patient Safety Improvement Corps

- Initially considered two models
- CDC’s EIS model
- Department of Agriculture cooperative state research, education, and extension service model
- Feasibility study
- Diverse needs and opinions

## Patient Safety Improvement Corps

- Future users/participants
- AHA representative conference calls
- NASHP state representative conference calls
- Common needs
- Leadership buy-in
- Core content with short, practical courses
- Train together

## Criteria Used to Evaluate Evidence-Based Practices

**If I wanted to improve patient safety at my institution over next 3 years and resources were not a significant factor, how would I grade this practice?**
**4-person editorial board independently rated each of the 79 practices**
- Find the best available evidence
- 3 major categories for rating

## Clear Opportunities for Research

- Preventing infections
- Perioperative glucose control
- Use of supplemental perioperative oxygen
- Silver alloy coated urinary catheters
- Prophylactic antibiotics  to prevent perioperative infection
- Limited antibiotic use to prevent antibiotic resistance
- Use of analgesics in patients w/acute abdomen (w/o compromising diagnostic accuracy
- Localizing surgery/procedures to high volume centers
- Hand washing compliance

## Clear Opportunities for Research (cont’d)

- Appropriate enteral nutrition
- Post-surgical
- Critically ill
- Appropriate use of prophylaxis to prevent venous thromboembolism in at-risk patients
- Nurse staffing
- Technology/Informatics
- CPOE with DSS to decrease medication errors and AE related to the drug ordering process