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Jacob Lopez

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Executive Summary ChecklistPerson and family engagement -- often referred to as "patient" and family engagement or "PFE" -- is an underutilized resource and strategy for achieving the goal of zero harm. An effective program to optimally implement and sustain PFE should include the following actionable steps: * Assess strengths and gaps in your organization's PFE efforts by using this checklist:  Have you...o Elicited feedback from your senior leadership team, staff, patients and families about PFE efforts?o Inventoried policies, processes, position descriptions and training programs to determine whether PFE is included?o Discussed findings and conclusions with leadership, staff and patients to create awareness and lay the groundwork for improvement efforts?
* Deploy a system to implement PFE and monitor progress on improving PFE using this checklist. Did you...o Develop an infrastructure that brings the patient and family voice systemically into your patient safety improvement work, such as: Appointing persons who identify as patients or patient advocates to your governing body, Establishing patient and family advisory bodies that contribute to organizational safety initiatives, Including patient advocate input into improvement committees or root cause analysis teams, and/or Establishing a functional area within your organization whose role and accountability is to engage patients and families?o Select measures that will allow you to see whether processes and patient safety outcomes are changing?o Ensure systems are in place so that needed data can be collected and shared?o Compile results in a format that is easy to understand and monitor?o Share results with staff, senior leadership, board, community and public?[Adapted from Healthcare Research & Educational Trust, A Leadership Resource for Patient and Family Engagement Strategies \cite{trust}.] The Performance GapDespite widespread recognition of patient safety as a public health issue since at least 1999, preventable patient harm still occurs.  Estimates suggest that the problem may be getting worse not better, although arguably the larger and more alarming estimates now are a product of more effective measurement.  For example, deaths due to medical error in United States hospitals were estimated at 180,000 annually by the landmark Harvard Medical Practice Study in 1984 \cite{Leape_1995}.  New research in 2016 suggest that U.S. hospital deaths attributed to medical error are 250,000, making it the 3rd largest cause of preventable death .  Existing research or public health data still lacks the ability to reliably estimate preventable harm due to missed, wrong or miscommunicated diagnoses.   And data on harm due to medical error in non-acute care settings are still just guesses.Whatever the estimates the challenge before us is huge and touches millions of people worldwide.The promising news is that collaborative efforts among healthcare provider organizations, thought leaders and policymaking bodies, payors positioned to incentivize achievement of expected outcomes, innovators and researchers, educators, nonprofit/non-governmental advocacy groups, product makers and activated people who use healthcare can make a difference.  Through focused attention and aligned efforts in the United States driven by the Centers for Medicare and Medicaid Services (CMS), measureable patient harm was reduced by 21% between 2010 and 2015, resulting in 125,000 few deaths, 3 million fewer injuries and $28 billion in saved costs.    At the local level, collaboration between the public health sector, hospitals and outcomes improvement experts reduced hospital readmissions by 7,000 in Minnesota between 2011 and 2013, enabling patients in Minnesota to spend 28,120 nights sleeping in their own beds instead of the hospital, and helping reduce healthcare costs by more than $55 million.  PFE is an underused "natural resource" for improving the safety of care.  Users of healthcare and their family members play substantial roles in managing care and often see and learn things that care providers and researchers miss.  If their observations, insights and lessons learned are overlooked in safety improvement, the organization loses important opportunities to prevent harm.  In a 2013 editorial, then Health Affairs Editor Susan Dentzer recognized the value of PFE in characterizing it as the "blockbuster drug" of the 21st Century, observing:Even in an age of hype, calling something "the blockbuster drug of the century" grabs our attention. In this case, the "drug" is actually a concept--patient activation and engagement--that should have formed the heart of health care all along. Ample evidence has accumulated demonstrating that patients who are actively engaged partners in managing their own chronic healthcare conditions achieve measurably better outcomes.   Moreover, persons who use care or manage its use for loved ones are typically highly motivated to partner with their professional and organizational care providers to improve safety.  Their experiences bring an urgency to the patient safety movement that propels action by generating empathy -- they engage our hearts as well as our minds and hands.  In 2006 the World Health Organization captured this urgent offer to partner in the London Declaration of its Patients for Patient Safety group, a core component of its Global Patient Safety Programme :

Jacob Lopez

and 15 more

Executive Summary Checklist International rates of cesarean section are currently increasing ranging from an average of 40.5% in Latin America/Caribbean area to 7.3% in Africa (Betran 2016).  In the United States one-third of patients give birth surgically (Martin, 2017) and international experts have identified this high cesarean rate as a significant maternal health safety issue (Council on Patient Safety in Women’s Health Care 2016). It is well established that cesarean birth has short-term complications, including blood loss, infection, and venous thrombosis with the small but real risk of maternal mortality (Bauserman 2015).  These risks,  however, are compounded by the long-term effects in subsequent pregnancies including subsequent uterine scar rupture,  abnormal placentation, increased risk of hemorrhage, and hysterectomy (Bauserman 2015, Marshall 2011, Rageth 1999, Galyean 2009) where there is an exponential increase in such complications with the number of prior cesareans (Clark 1985).  While appropriate intervention with cesarean section can save the lives of women and newborns, overuse can be viewed as a significant maternal safety issue and a contributing factor to the rising maternal mortality rate.  The increasing number of patients with pregnancies complicated by morbidly adherent placentation (MAP) is directly related to the number of prior cesarean sections (Clark 1985) and can lead to markedly increased risk of severe maternal morbidity and mortality (Liu 2007).  Indeed, the "epidemic of MAP" can be considered a mainly iatrogenic problem which is an understandable complication in unavoidable cesarean birth but a tragedy if the first cesarean birth was avoidable.  Therefore, reducing preventable cesarean birth as a cause of maternal morbidity and mortality and overall reduction of cesarean birth rates becomes an important strategy to improve women's health (Council on Patient Safety in Women’s Health Care 2016).Up to 90% of patients having a primary cesarean section in their first pregnancy will continue to have cesarean births in subsequent pregnancies.  Conversely, more than 90% of vaginal deliveries lead to subsequent vaginal deliveries (CMQCC Toolkit 2016). Therefore, a spotlight on preventing this initial procedure has been the primary focus of current recommendations (American College of Obstetricians and Gynecologists/The Society for Maternal-Fetal Medicine 2014) and reducing the lifetime risk of maternal morbidity and mortality.  To address the problem the National Partnership for Maternal Safety within the Council on Patient Safety in Women’s Health Care convened a panel of experts in 2016 to define a bundle of actions to achieve a reduction in first time cesarean sections (Council on Patient Safety in Women’s Health Care 2016) and subsequently the California Maternal Quality Care Collaborative (CMQCC) developed a corresponding toolkit (CMQCC Toolkit 2016).  The common sense approaches recommended in the bundle and toolkit can be used to lower first-time cesarean births leading to reduced costs, maternal morbidity, and eventually maternal mortality. Readiness 1.       Build a health care provider and maternity unit culture that values vaginal birth and understands the risks for current and future pregnancies of cesarean birth (Chaillet 2007, Spong 2012).2.       Optimize patient and family engagement in education, informed consent, and shared decision making about normal healthy labor and birth (Declercq 2017).3.       Develop healthcare provider expertise in approaches to labor that maximize the likelihood of vaginal birth in areas such as assessment of labor, methods to promote labor progress, labor support, and both pharmacologic and non-pharmacologic pain management and shared decision-making. (Chaillet 2007, Bisognano 2014, Hodnett 2013) Recognition and Prevention1.       Implement standardized admission criteria, triage management, education, and support for women presenting in spontaneous labor (Spong 2012, Safe Prevention of primary cesarean delivery ACOG/SMFM 2014, ACOG 2017) 2.       Offer standardized techniques of pain management and comfort measures that promote labor progress and prevent dysfunctional labor (Hodnett 2013)3.       Use standardized methods in the assessment of the fetal heart rate status including interpretation, documentation using NICHD terminology and encourage methods that promote freedom of movement (Macones 2008)4.       Adopt protocols for timely identification of specific problems, such as herpes and breech presentation, for patients who can benefit from proactive intervention before labor to reduce the risk for cesarean birth (Hollier 2008, Hofmeyr 2015) Response 1.       Have available an in-house maternity care health care provider or alternative coverage that guarantees timely and effective responses to labor problems (Rosenstein 2015, Iriye 2013, Nijagal 2015)2.       Uphold standardized induction scheduling to ensure proper selection and preparation of women undergoing induction (ACOG 2009)3.       All providers follow standardized evidence-based labor algorithms, policies and techniques which allow for prompt recognition and treatment of dystocia (Spong 2012, Zhang 2010)4.       Adopt policies that outline standard responses to abnormal fetal heart rate patterns and uterine activity (Clark 2013)5.       Make available special expertise and techniques to lessen the need for cesarean birth, such as breech version, instrumented birth and twin birth protocols (Hollier 2008, Barrett 2013) Reporting/Systems Learning1.       Track and report labor and cesarean measures in sufficient detail to: 1) compare to similar institutions, 2) conduct case review and system analysis to drive care improvement, and 3) assess individual health care provider performance (Challitt 2007, CMQCC 2016)2.       Track appropriate metrics and balancing measures that assess maternal and newborn outcomes resulting from changes in labor management strategies to ensure safety

Jacob Lopez

and 13 more

Executive Summary ChecklistSuccessful implementation of NG tube safe practices includes a commitment from hospital governance and senior administrative leadership to Identify and maintain awareness of performance gaps within their organization.Institutional procedures guiding NGT insertion and placement verification should be evidence-based and should provide guidance to staff on when a patient is considered high risk for misplacementAll NGTs should be radio-opaque throughout their length with external centimeter length markings to be used to detect post-insertion tube movement.All staff who place NGTs should be specifically trained in this procedureAccurate measurement prior to insertion should utilize the NEMU (Nose→Earlobe→Mid-Umbilicus)pH of gastric aspirate should be used to confirm NG placement prior to initial use with pH in desired range of 1.0 to 5.0.  If unable to obtain a gastric aspirate within the required pH range, confirm NG placement with a radiograph.All staff who read radiographs should be specifically trained in reading the radiograph using the following four criteria:  Does the tube path follow the esophagus/avoid contours of the bronchi?Does the tube clearly bisect the carina or the bronchi?Does the tube cross the diaphragm in the midline?Is the tip clearly visible below the left hemi-diaphragm?Confirmation of NG tube should be documented in the EMR and method of confirmation (ph or radiograph).  Tubes should be secured to the patient after confirmation in such a way that the centimeter mark is visible at the nare.  This mark should be documented in the medical record and used as a point of reference for other caregivers to gauge movement of the tube.Observe for signs of respiratory distress or gagging/vomiting and remove tube if these signs are present as NG tube may have been dislodged into the airway or lungs.A mandatory reporting system should be developed to track nasogastric feeding tube misplacements as a percentage of all tubes placed. The Performance GapNasogastric tubes (NGTs) are a commonly used intervention in clinical practice for decompression or for administration of enteral nutrition, fluids and medications.  In a neonatal and pediatric one day prevalence study of 63 institutions, 24% of hospitalized infants and children required an orgastric (OG), nasogastric (NG), or transpyloric tube \cite{Lyman_2015}.  Of those patients, 61% were located in a neonatal intensive care unit (NICU). A National Patient Safety Alert (NPSA) issued by the National Health Service (NHS) documented over 3 million NG or OG tubes were used from 2011-2016 in the United Kingdom (UK) \cite{parker2016}. These tubes are inserted using blind placement technique, so called because the person doing the procedure cannot discern where the tube is going in the body as it is being advanced.  As a consequence, complications can occur if the NG or OG is misplaced into the esophagus, duodenum or pulmonary tree.  Serious patient harm and deaths have occurred when tube misplacement is not detected prior to use.Studies of adult patients report NGT misplacement with serious harm to patients in 1.3 to 3.2% of tubes placed\cite{Gilbertson2011,Bourgault2009}. A study of neonates documented an incidence of 59% NGT misplacements with the majority of tubes being in the esophagus\cite{October2009}.  The Pennsylvania Patient Safety Authority documented 44 NGT misplacements into the lung from 2011-2013\cite{Powers2013}. Of these events, 24 were classified as serious patient harm.  Case reports in the literature describe such injuries as pneumothorax, enteral formula administration into the lung, esophageal perforation, and even death \cite{Gilbertson_2011,Bourgault_2009}. Failure to detect misplaced NGTs are attributed to: use of non-evidence based methods to confirm initial placement (auscultation or aspiration), failure to recognize when an NGT has changed position, failure to properly read an abdominal radiograph, failure to accurately interpret an electromagnetic device screen \cite{October_2009,Powers_2013}.