Wrong-Site Surgeries in Pennsylvania Decrease Significantly Since Prevention Program Began in 2007

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Pennsylvania Patient Safety Authority

Jun 06, 2012, 08:00 ET

A Southeastern Regional Falls Reporting Initiative Shows Steady Decline in Harmful Falls during the Two-Year Program

HARRISBURG, Pa., June 6, 2012 /PRNewswire-USNewswire/ -- Wrong-site surgery and falls prevention programs within Pennsylvania healthcare facilities appear to be working, with significant declines in wrong-site surgeries and harmful falls, according to the June Pennsylvania Patient Safety Advisory released today.

The Patient Safety Authority's program to prevent wrong-site surgery began in December 2007 after an Advisory article revealed that Pennsylvania healthcare facilities were submitting approximately two and a half wrong-site surgery reports (Serious Events and near misses) per week.

Since the prevention program began, wrong-site surgeries in Pennsylvania have decreased by 37 percent from an average of 19 reports per quarter to an average of 12 reports per quarter. Adjusting for the increase in procedure volume over the past several years, the decline is more pronounced. The rate of wrong-site surgery has dropped by 40 percent, from 2.4 per 100,000 procedures (2007-2008) to 1.4 per 100,000 procedures (2010-2011).

"Although the decline in wrong-site surgeries is happening slower than we'd like, it's nice to see the numbers going down each year," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "We've learned a lot from our analysis of the reports and from our visits to Pennsylvania healthcare facilities throughout the program that we can now take to help those facilities that are still struggling with wrong-site surgeries."

Clarke said the Authority's wrong-site surgery prevention program has garnered its own webpage with 20 Advisory articles, 13 prevention program tools, seven educational tools (i.e., brochures, presentations) and 11 snapshots that include wrong-site surgery breakdown reports and key best practice principles.

"The most notable trait in facilities that have significantly improved their wrong-site surgery rates is that they have made a serious commitment to implement wrong-site surgery prevention programs, including evidence-based best practices," Clarke said. "Everyone agrees wrong-site surgeries are horrific events, but to eliminate them everyone must also make the commitment to prevent them."

Clarke added that in April the Authority began another wrong-site surgery initiative with 26 Pennsylvania healthcare facilities that have made the commitment to reduce and eliminate wrong-site surgeries. The initiative is led by the Authority as part of the Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Engagement Network (HEN) funded by the Centers for Medicare and Medicaid Services (CMS). The Authority will receive about $1.6 million of $5.2 million awarded to HAP through the federal contract with CMS. The Authority is using the federal funds for three statewide projects that include WSS, falls and adverse drug events.

For more information about the project success to prevent wrong-site surgery, go to the June Patient Safety Advisory article, "Quarterly Update on Preventing Wrong-Site Surgery" on the Authority's website at www.patientsafetyauthority.org.

Another Authority initiative that is funded by the CMS contract is a falls prevention project that was undertaken after previous success in the southeastern region of Pennsylvania. More than 80 Pennsylvania healthcare facilities are participating in the statewide falls project.

In October 2008, 25 southeastern Pennsylvania hospitals committed to reporting falls and falls with harm using standardized definitions. The falls project lasted two years with reports showing five uninterrupted quarters of steady decline in rates of falls with harm. The Authority and the Health Care Improvement Foundation (HCIF) partnered to help the hospitals in their falls prevention efforts.

"The Authority and HCIF discussed the results of the two-year study and approached those facilities that showed the most improvement in reducing falls with harm," Denise Barger, Patient Safety Liaison for the southeast region said. "We found that several regional hospitals had implemented effective and innovative strategies as a result of the data given to them from the two-year project which boosted their existing falls prevention strategies."

During the total reporting period, the participating hospitals reported 14,571 falls events to the Authority. Of those, 97.4 percent (14,192) were falls events without harm and falls with harm comprised 2.6 percent (379) of these events. Four events resulted in the patient's death; however, one of those deaths was not directly related to the fall.

Barger said on-site hospital visits showed that there were core elements common to nearly all of the assessed falls prevention programs. These include: establishment of a multidisciplinary team focused on falls; review and analysis of falls data; performance of falls risk assessment on admission and reassessment at prescribed intervals; use of visual cues to communicate falls risk; use of bed-exit alarms; implementation of one-to-one observation or sitters; enforcement of patient rounding; and promotion of patient education.

"Along with these core elements, it was also apparent that hospitals with better than average performance were implementing additional strategies and innovations that allowed for them to maintain their success in the program," Barger said. "At the end of the project, the Authority chose six hospitals with the most innovative strategies to present at a full day conference to help others learn from their success."

Barger said the Authority also surveyed Pennsylvania healthcare facilities to determine if they were interested in participating in a statewide rollout of the falls prevention project. Over 80 percent of the respondents were interested in participating in a statewide falls project which the Authority kicked off in May through the HEN contract.

For more information on the falls project and survey, go to the 2012 June Advisory article "Falls Rates Improved in Southeastern Pennsylvania: The Impact of a Regional Initiative to Standardize Falls Reporting" and "Standardizing Reporting of Patient Falls: A Survey of Pennsylvania Hospitals," at the Authority's website www.patientsafetyauthority.org.

The Authority's 2012 June Advisory also contains other clinical articles with strategies to improve patient safety and new consumer tips. Highlights include:

Patients Taking Their Own Medications While in the Hospital: Pennsylvania facilities submitted 879 medication error reports from July 1, 2004, through January 31, 2011, to the Authority involving patients taking their own medications while in the hospital. Over 77 percent of the events reached the patient and over 2 percent of the events resulted in patient harm. More than 25 percent of the reports mentioned a medication considered to be a high-alert medication. This article discusses prevention strategies healthcare providers can implement to improve patient safety. Consumer tips are also available for patients and their families.
Reducing Risk of Air Embolism Associated with Central Venous Access Devices: Air embolism is a rare but potentially lethal complication of certain medical and surgical procedures. Between June 2004 and December 2011, the Authority received 74 reports related to air embolism. The majority of confirmed or suspected air embolisms were attributed to central venous access devices. Hospitals can decrease the risk for air embolism by establishing policies and procedures that contain specific air embolism prevention protocols for central venous access device insertion, management and removal. Risk reduction strategies to prevent central venous access device embolism are given in this article.
Feature Articles: The 2012 June Advisory contains two feature articles on (1) the need for national violence prevention training standards for hospital security officers and (2) the opportunities available for healthcare providers to receive more patient safety education.