VHIG Digest: Vol. 3, No. 6
This Week’s Top 3 Stories in Patient Safety and Quality Improvement in Healthcare
By Tim Lockney, School of Medicine, Class of 2013
1. “Global Trigger Tool” Shows Adverse Events May Be 10 Times Greater Than Previously Measured
An article published in Health Affairs journal April 2011 used the Institute for Healthcare Improvement’s Global Trigger Tool to look at 795 patient records at 3 tertiary care hospitals in October 2004. The study found that the adverse event detection methods commonly used to track patient safety in the U.S. today, voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators, missed 90 percent of the adverse events. The Global Trigger Tool found at least ten times more confirmed, serious events. Overall, adverse events occurred in one-third of hospital admissions.
2. Adherence to Guideline-Directed Venous Thromboembolism Prophylaxis Among Medical and Surgical Inpatients at 33 Academic Medical Centers in the United States
A study published in the American Journal of Medical Quality collected data describing compliance with established venous thromboembolism prophylaxis guidelines in medical and surgical inpatients at 33 US academic medical centers. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. Despite guidelines, venous thromboembolism prophylaxis remains underutilized in these centers, with only 48% of patients receiving guideline-directed prophylaxis—59% of which were medical and 41% of which were surgical patients. The study remarked: “Because academic medical centers provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.
3. “Clean Spaces, Healthy Patients” Initiative
The Association for Professionals in Infection Control and Epidemiology and the Association for the Healthcare Environment have partnered in a joint campaign “Clean Spaces, Healthy Patients: Leaders in Infection Prevention and Environmental Services working together for better patient outcomes” to improve the relationship between infection prevention and environmental services in reducing the incidence of healthcare-associated infections. Daily cleaning and disinfecting of an occupied patient room with attention to bedrails, knobs, call buttons, etc. will take 25-30 minutes per room, while a post-discharge cleaning may take 40-60 minutes. Well-established guidelines for proper cleaning exist, and should be made available. Results of a survey indicated that 51% of infection prevention and environmental services professionals find it difficult to locate resources about proper cleaning and disinfection, and 54% believe other staff should be educated about their role in cleaning.