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Infection Control & Patient Safety

Are Your Patients Safe?

Published March 11, 2014 3:33 PM by Barbara Smith
March 2 through 8, 2014 was National Patient Safety Awareness week. This annual event is hosted by the National Patient Safety Foundation, a not -for -profit organization whose aim it to help create a world where patients AND health care workers are from harm. (http://www.npsf.org/)

As an infection preventionist, my primary focus is preventing harm by reducing health care acquired infections (HAIs) and occupational exposures to infectious agents. The Joint Commission continues to emphasize this measure as part of National Patient Safety Goal number 7 that applies to hospitals, behavioral health and ambulatory care. I aim to make my priority align with the other members of the health care team.

In reality, there are many competing demands for the nurse and the NPSF's aim is much broader than infection prevention. The larger umbrella of patient harm includes medication errors, falls and wrong site surgery. This year, NPSF focused on prevention of diagnostic errors. They estimate that 40, 000-80,000 deaths occur annually due to incorrect, missed or delayed diagnosis. While some of these events seem more like medical issues, nurses are patient advocates and can play a key role in averting many of these adverse occurrences.

What do you see as the most dangerous harm to your patients and more importantly, how can it be rectified?

posted by Barbara Smith


I agree that  hand washing,or the lack thereof is the number one practice to keep patients safe.%0d%0aAfter that I would say nurses who are under pressure to get out on time is another danger. It is too easy to bow down to pleasing supervisors by rushing through tasks. Skipping the 5 rights for medication administration, or getting the dressing change done before the next admit.%0d%0aI would also say that inconsistency in allowing patients leave whatever unit you work on is a major risk. Most of the time they want to leave to go smoke. I think it would be better to tell them they cannot leave period or go AMA. There isn't enough staff to monitor smokers. Why would anyone condone bad habits anyway ? I get stressed out being a patient,but my method off dealing with stress would be to overeat or go shopping, neither of which would I hear anyone say"Oh,let's just allow her to go shopping and come back later for more testing, etc.."%0d%0a

Theresa Abaldo, Postpartum - RN, VVGMC March 22, 2014 12:53 PM

What do I see as a significant threat to patient safety?  Many facilities have protocols in place, reducing falls, preventing medication, surgical and testing errors.  Still, it baffles me as to how unaware health care facilities and workers are in maintaining the simplest measures in preventing the spread of infection.  Dating back to Florence Nightingale, “low tech” techniques such as hand washing and aseptic techniques are simple but effective measures to reduce hospital acquired infections.  On a recent visit to a friend in a local hospital, the medical personnel were wearing the “Ask me if I’ve washed my hands” button.  Not surprisingly, none of them washed upon entering the room, which was nicely equipped with a sink located just inside the entrance.  In some clinical settings, it’s not unusual that paper towels and soap and alcohol based cleansers are not always as available.  Hand hygiene dispensers are on the walls but too often, they are empty, creating a challenge to clean hands before entering the room, while within the room and during care.  Even on the busiest of units, it’s easy to become complacent to get things done.  Even with time constraints, the use of a sterile field to change a dressing is still a “best practice”; opening a sterile wound dressing package, removing the dressing and leaving it on a bedside stand for later application is an invitation to a hospital acquired infection. Wound dressing changes done with this laxness and ineptness is surprisingly common even in this age of advanced knowledge.  Some simple overlooked tasks to decrease the spread of infection: refrain from placing articles that have been on the floor back into the patient’s bed; this includes call bells, bed controls, TV remotes, equipment plugs (vital signs machines, pumps, etc.) and oxygen tubing should not be put back on the patient after it has contacted the floor.  Hospital acquired infection can be debilitating or deadly to patients, often unintentionally transmitted by those entrusted with keeping them safe. There are so many safety issues to be addressed in the hospital, with the exception of falls, preventing infection is the major safety threat is ongoing for every patient throughout their stay, involves all members of the health care team and remains a priority even in the OR.  

Patricia, Education - RN, NYCCT March 20, 2014 11:33 PM
Brooklyn NY

too many requirements with focus on documentation have left us w/ the focus on all the wrong things. I find that I spend 70-80% of my bedside time on trying to meet the ever increasing documentation requirements and not on actual care of pts and education of families. add to this the ever increasing 'open visitation' policies that allow for anyone and everyone to visit bringing w/ them all their germs and a very busy staff that often forget to mention the importance of hand washing. the hospital cut backs on areas such as housekeeping w/ the slack being reassigned to nursing staff to complete. the focus of care needs to be placed back on the delivery of care, all systems put into place need to support not take away from this concept so that nurses can focus on SAFE care. that would include everything from the basic washing of hands to the correct delivery of meds. having the time to actually think through a situation and ask when something doesn't make sense rather than just passing on the things that don't make sense

anna, surgical icu - rn March 20, 2014 9:14 AM
riverside CA

Sheila , Catherine and K- glad  you raised these issues - we can all learn from each other and we can't assume we already know it - as K points out

thanks for joining in


Barbara Smith March 20, 2014 12:59 AM

The most dangerous threats I see as an educator is that there are so many patient safety threats under increasingly stressful working conditions within the ever changing healthcare environment. As if this is not risky enough the staffing mix disparities coupled with more complex patients and tighter administrative and government standards changing constantly is leading to nurses that are disengaged, undertrained, and on info overload from the usually substandard endless web-based training modules and signage used to teach patient safety updates.

The ability to learn on the job because cutbacks don't allow for enough additional pay for amount of education days needed to train competency on these topics is such a disservice because it's next to impossible to absorb the mass quantities of information we're throwing at these nurses while they are trying to manage patient loads beyond the usual acuity and staffing standard. It's no secret that people cannot learn in such environments in the leadership world and yet it's the mainstay of educational efforts these days. And there's three broad categories of the working nurse: novice nurses; nurses at the prime of their practice that feel they don't need to learn anything else, but if they did they will go get it them selves; or burnt out seasoned nurses. Occasionally, there is the best practice nurse, but they usually transfer from the bedside at some point...just generalizing for humor to break up my rant :)

This is why I see change not occurring as quickly as it needs to. This is why the messages are not received. Don't even get me started on how difficult it is to meet TJC standards under substandard working conditions-when you're working with scare resources at organizations lacking accountability at every level. The time has come where we HAVE to shift gears and use IT such as electronic health records and other analytical strategy to be more proactive and less reactive. There are too many people in power positions unwilling to learn to use these programs to monitor outcomes to assess the issues and see where opportunities exist and meet issues before they're catastrophes. I'm not even talking about major HIM programs, I'm talking about simple programs like excel.

It's also not as "just" a culture as they say it is. People still fear reporting their errors, which is horrifying to me. Incident reports and root cause analyses are important pieces of wisdom that are not just notes for your employee file that will get you fired, but they could very well explain major flaws in the system and can prevent future patient serious safety events.

It's time we value learning from each other and stop taking insight and suggestions so personally. We are all a team, and we're aiming for improving patient outcomes and saving lives. If someone has an idea it's not because they think another person's idea is not working or wrong, they just have an idea. Period. Maybe their idea will be a safer one, or a more fiscally responsible one, or save nurses 20 extra processes for a mundane task; but it's just something no one mentioned before. That's all. It might sound crazy at first but just respect them and hear them out. Thank them for caring enough about their job, organization, and patients to where they wanted to contribute to sharing an idea no matter how different it was. Maybe you'll use it maybe you won't, but don't reprimand participating in shared go dr nance, that goes against basically every organizations principles these days. That's typically ground upon. Maybe their idea will save a life. They should not feel scared or intimidated to mention patient safety suggestions, report errors. On a similar note, they should know WHERE they can share.

These are the threats to patient safety, IMHO.

Thank you for allowing for an open forum to share thoughts:)

K, Nursing - RN educator, Undisclosed March 19, 2014 10:59 PM
Louisville KY

As a nurse leader, I am ignorant of the basics on blood draws.  I have been a member of the Nurse-Lab Team, but the focus was on quality processes such proper blood culture draws or how to utilize lab supplies provided by the hospital. Thank you Catherine Ernst for sharing your knowledge.  This information will be utilized for my staff's 2014 competency testing.

Sheila, Nursing - Director, Acute Care Hospital March 19, 2014 8:41 PM
Chicago IL

I am glad you posted this question. Physicians rely on the results of laboratory testing for diagnosis and management of their patients. There is a lot that can be done incorrectly during a blood sample collection that will render the test results inaccurate. Acts such as leaving a tourniquet on for more than a minute or not drawing the tubes in the proper order are examples of things that are done all the time and will alter the results the physician receives. The sad thing is, the lab testing the sample can't tell if it was drawn incorrectly and will report out the results and the physician will act on them. Draw a tube that is to be tested for potassium after one that has a potassium-rich additive such as EDTA in it and the test results could make a hypokalemic patient appear to have a normal potassium. Send him off to surgery with a low potassium and he may well code on the table. Draw a tube with a clot activator in it before you draw a tube to be tested for coagulation studies, and you alter the coag test results the physician will use to medicate her patient. I can't emphasize enough the importance of being properly educated in blood sample collection before you actually do it. Obtaining a good blood sample that will accurately reflect a patient's actual physiology isn't as simple as it is made out to be. There is a huge foundation of knowledge that needs to be in place before it can be done properly. Despite the fact that quality blood samples are extremely important to good patient outcomes, the procedure continues to be downplayed to something anyone off the street can do with minimal or no training. Inaccurate lab test results is a silent killer of our patients. Improper technique and no knowledge of arm anatomy contributes to untolled numbers of disabling injuries every year as probing needles hit nerves and arteries. As long as healthcare administration sees blood sample collection as "entry level" and "unskilled" patients will continue to be injured and die. I have the legal cases sitting on my desk to back up this statement.

Catherine Ernst, , RN Center for Phlebotomy Education March 19, 2014 5:57 PM
Corydon IN

Lots of good people working on ways to improve hand hygiene. Thanks for noting that, Jose


Barbara Smith March 16, 2014 11:13 PM

Lack of hand hygiene at the point of care.  Wall-mounts are great for visitors and back up for providers but Body-attached dispensers with electronic monitoring ingrains personal accountability to hand hygiene's best practices - the 5 Moments for Hand Hygiene.  

Performing hand hygiene while entering and exiting a patients room is not enough!  Numerous hand hygiene opportunities arise during a single patient encounter but are disregarded due to lack of accessibility.  

Point of care hand hygiene prevents and reduces infection rates and deaths.

Jose, Point of Care Hand Hygiene March 12, 2014 1:24 PM

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About this Blog

    Occupation: Infection Control Professionals
    Setting: Welch Allyn; St. Luke’s Hospital (Smith)
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