Kristina Weeks

Reducing Medical Errors and Adverse Events

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Healthcare-associated infections are common, costly, and often lethal. Although there is growing pressure to reduce these infections, one project thus far has unprecedented collaboration among many groups at every level of health care. After this project produced a 66% reduction in central catheter-associated bloodstream infections and a median central catheter-associated bloodstream infection rate of zero across >100 intensive care units in Michigan, the Agency for Healthcare Research and Quality awarded a grant to spread this project to ten additional states. A program, called On the CUSP: Stop BSI, was formulated from the Michigan project, and additional funding from the Agency for Healthcare Research and Quality and private philanthropy has positioned the program for implementation state by state across the United States. Furthermore, the program is being implemented throughout Spain and England and is undergoing pilot testing in several hospitals in Peru. The model in this program balances the tension between being scientifically rigorous and feasible. The three main components of the model include translating evidence into practice at the bedside to prevent central catheter-associated bloodstream infections, improving culture and teamwork, and having a data collection system to monitor central catheter-associated bloodstream infections and other variables. If successful, this program will be the first national quality improvement program in the United States with quantifiable and measurable goals.

Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.

Abstract: Central‐line–associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit‐based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN‐defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

Prevention of Central Line–Associated Bloodstream Infections: A Journey Toward Eliminating Preventable Harm

Central line–associated blood stream infections (CLABSI) are among the most common, lethal, and costly health care–associated infections. Recent large collaborative quality improvement efforts have achieved unprecedented and sustained reductions in CLABSI rates and demonstrate that these infections are largely preventable, even for exceedingly ill patients. The broad acceptance that zero CLABSI rates are an achievable goal has motivated and stimulated diverse groups of stakeholders, including public and private groups to develop policy tools and to mobilize their local constituents toward achieving this goal. Nevertheless, attributing reductions in CLABSI rates achieved by multifaceted quality improvement efforts solely to the use of checklists to ensure adherence with appropriate infection control practices is an easily made but crucial mistake. National CLABSI prevention is a shared responsibility and creating novel partnerships between government agencies, health care industry, and consumers is critical to making and sustaining progress in achieving the goals toward eliminating CLABSI.

Associations between Home Remedy Use and a Validated Self-Reported Adherence Measure in an Urban African-American Population with Poorly Controlled Hypertension

OBJECTIVE To determine associations between home remedy use and self-reported adherence among urban African Americans with poorly controlled hypertension. METHODS A cross-sectional structured interview of African Americans admitted to medical units for uncontrolled hypertension at an urban academic hospital from 1999-2004. Logistic regression was used to test associations between home remedy use and self-reported adherence. RESULTS One-hundred-eighty-three of 272 participants completed the study (67%); 39 (21%) reported using home remedies for hypertension. In a multivariate model, home remedy use was independently associated with greater medication adherence (OR for nonadherence=0.32, 95% CI: 0.14-0.75; p<0.01) and dietary adherence (OR for changing diet=3.28, 95% CI: 1.10-9.81; p=0.03), but not lifestyle or appointment adherence. These associations remained strong while controlling for age; sex; employment status; and key covariates, including greater medication side effects (OR=4.31; 95% CI: 1.64-11.3; p<0.01), greater difficulty paying for medications (OR=2.94, 95% CI: 1.25-6.92; p=0.01) and longer duration of diagnosis (OR for log years=1.53; 95% CI: 1.02-2.33; p=0.045). CONCLUSION Home remedy use may be a marker of positive self-care for some hypertensive African Americans and not a promoter of nonadherence.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

Background Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans. Objective To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension. Design and Participants A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999–2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence. Main Outcome Measures Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime. Results Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR] = 3.23 95% confidence interval [CI] (1.33–7.69), hypertension knowledge ([OR] = 1.20 95% CI: 1.01–1.42), lack of insurance ([OR] = 6.02 95% CI: 1.83–19.88), insurance with no medication coverage ([OR] = 5.08 95% CI: 1.05–24.63), cost of discharge medications ([OR] = 1.20 95% CI: 1.01–1.42), belief that anti-hypertensive medications do not work ([OR] = 3.67 95% CI: 1.16–11.7), experience of side effects ([OR] = 3.63 95% CI: 1.24–10.62), medication non-adherence ([OR] = 11.31 95% CI: 3.87–33.10). Substance abuse was not associated with appointment non-adherence ([OR] = 1.05 95% CI: 0.43–2.57). Conclusions Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative

BACKGROUND We sought to examine self-reported compliance with 5 evidence-based central line-associated bloodstream infection (CLABSI) prevention practices and link compliance to CLABSI rates in a national patient safety collaborative. METHODS We analyzed data from a national CLABSI prevention program. Adult ICUs participating in the program submitted their CLABSI rates and a Team Checkup Tool (TCT) on a monthly basis. The TCT responses provided self-reported perceptions about how reliably the unit team performed the evidence-based practices in the previous month. Monthly data were aggregated into quarters for the analysis. We analyzed a total of 2775 ICU quarters during the program. RESULTS Chlorhexidine skin preparation and hand hygiene had the highest adherence. Avoidance of the femoral site and removal of unnecessary lines had the lowest compliance. Regression results showed that consistent performance of all practices was significantly associated with lower CLABSI rates. In terms of each practices independent effect, femoral site avoidance for line placement and removal of unnecessary lines were independently associated with lower CLABSI rates after controlling for other factors. CONCLUSION Our findings suggest that uptake of the 2 low-compliance practices, avoidance of the femoral site and removal of unnecessary lines, is important for reducing CLABSI rates in conjunction with other practices.

Reducing preventable harm: observations on minimizing bloodstream infections

Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions. Practical implications This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms. Originality/value Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

Access to Care, Treatment Ambivalence, Medication Nonadherence, and Long-Term Mortality Among Severely Hypertensive African Americans: A Prospective Cohort Study

African Americans living in poor neighborhoods bear a high burden of illness and early mortality. Nonadherence may contribute to this burden. In a prospective cohort study of urban African Americans with poorly controlled hypertension, mortality was 47.6% over a median follow‐up of 6.1 years. Patients with pill‐taking nonadherence were more likely to die (hazard ratio, 1.80; 95% confidence interval [CI], 1.18–2.76) after adjustment for potential confounders. With regard to factors related to nonadherence, poor access to care such as difficulty paying for medications was associated with prescription refill nonadherence (odds ratio [OR], 4.12; 95% CI, 1.88–9.03). Pill‐taking nonadherence was not associated with poor access to care; however, it was associated with factors related to treatment ambivalence including lower hypertension knowledge (OR, 2.97; 95% CI, 1.39–6.32), side effects (OR, 3.44; 95% CI, 1.47–8.03), forgetfulness (OR, 3.62; 95% CI, 1.78–7.34), and feeling that the medications do not help (OR, 2.78; 95% CI, 1.09–7.09). These data suggest that greater access to care is a necessary but insufficient remedy to the disparities experienced by urban African Americans with hypertension. To achieve its full promise, health reform must also address treatment ambivalence.

1091: Impact of Comprehensive Unit-Based Safety Program (CUSP) on central line days and CLABSIs in ICUs

Introduction: While central venous catheters can be life saving, they can also act as a superhighway for transmission of infections. Changes in practice can prevent the occurrence of central line associated bloodstream infections (CLABSI). Removing unnecessary central line catheters decreases the ri