OPERATING ROOM
facilities, Never Events are “errors in medi- cal care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization.”
Tools for preventing Never Events
The list of Never Events is long and includes errors so awful that one wonders how they could even happen.1
happen too easily, which maybe shouldn’t be so surprising after all when patients are re- ceiving care from multiple healthcare work- ers (HCWs) who are often extremely busy and stressed on several fronts. Sometimes miscommunication is the problem. Distraction can be a contributor. A slip of the finger at the wrong time can result in catastrophe. Following best practices
and having the right tools for the right time and situation can help prevent these and other mistakes. “It is critical for periopera- tive teams and healthcare facilities to remain aware of the tools and resources available to- day to help prevent the risk of Never Events,” urged Richardson.
Getting the basics correct is critical, and patient admissions is the place to start. One of the first things a patient experiences upon admission is having an identification band applied to his or her wrist. “Wristbands are the first barrier to the occurrence of many Never Events,” said Robert Chadwick, Presi- dent, Endur ID Inc., a company that takes patient identification wristbands to another level. “When you review the list of the NQF’s Never Events, you begin to realize that many of these events can be triggered by the simple misidentification of a patient. Healthcare has come to rely on the seemingly simple patient identification wristband for this function.” Chadwick explained that, whereas most wristbands display basic identifying factors, Endur ID saw the need for more security. “To the standard bands we added barcodes, for medication management; photos, which assist in making sure the correct band is af- fixed to the correct patient; color-coded alerts for allergies; [risk of ] falling, and so on. Not only is the staff alerted, but those with these risks can be identified easily without wearing many extra wrist- bands.
The truth is they can
“In addition to providing all the needed information, we developed tough and du- rable products,” continued Chadwick. “If a band was not waterproof or if it fell off the patient, their identity could not be verified. If a bar code did not scan, then barcode-based medication management would fail. With the average cost of a wristband being under 40 cents, the justification for a high-quality wristband is simple when compared with the suffering and cost associated with a Never Event.”
Ansell’s SANDEL line also addresses the potential for medication errors. “The SAND- EL Correct Medication Labeling System helps prevent the risk of costly medication labeling errors and aids in compliance with The Joint Commission’s Na- tional Patient Safety Goals,”3
SANDEL Correct Medication Labeling System
said Rich-
ardson. “A variety of medication label- ing kits are avail- able and contain everything needed to label medication
on the sterile field. Kits include items such as preprinted labels, colored ID flags with matching syringe strips, a specimen zone, permanent markers, and skin markers.” To prevent surgery-related Never
Events, Richardson said “In compliance with The Joint Commission’s Universal Protocol for preventing wrong-site surgery, SANDEL TIME OUT Skin Markers are used to mark the correct surgical site on a patient’s skin prior to a procedure. “SANDEL TIME OUT Beacons serve as a prominent reminder for the surgical team to comply with The Joint Commission’s Uni- versal Protocol. It can be placed over the surgical site, mayo stand, or back table,” explained Rich- ardson. “TIME OUT Beacons are bright orange and highly recognizable. The Count In Prog- ress Beacon is designed to help reduce the risk of retained surgical items in the OR by eliminating distractions during the counting process. It is bright orange and highly recog- nizable, helping notify the surgical team that a count is about to begin.” Richardson also addressed cost.
“With over 4,000 surgical Never Event malpractice claims occurring annually,4
facilities must weigh the Endur ID identification band system
financial impact of a single Never Event versus the minimal cost of a preventative product. [Reducing] Never Events should be one of the
16 June 2016 • HEALTHCARE PURCHASING NEWS •
hpnonline.com
Peace of mind in preventing medical er- ror can sometimes come with a price, but Wilson advised, “The cost to purchase and implement a solution like Alaris EMR in- teroperability can be offset by the financial benefit it provides. In 2006, the cost to treat a medication error was $8,750.5
By prevent- SANDEL TIME OUT Beacon
ing medication errors, the hospital can avoid these associated costs. These tech- nologies can also drive increased revenue.” Wilson highlighted how one 286-bed level-II trauma center in Montana implemented Alaris EMR interoperability to stream- line its processes and save money. “The hospital reduced the num- ber of key strokes needed to program each infusion from 15 to two (86 percent), greatly decreasing the opportunities for error,” said Wilson. “Self-reported safety events related to all infusion-pump programming were reduced from three to one. In the first month, the hospital decreased lost charges for infu- sions from $980,000 to $610,000. This equated to roughly $370,000 in incremental revenue.” Invuity offers surgical instruments with
built-in light sources that enable surgeons to see the surgical cavity more clearly, thus making it less likely that a foreign object is missed before closing the surgical site. “Invu- ity’s minimal access surgical devices provide
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primary goals for all members of the health- care team, not just cost savings.” Wilson explained how BD addresses prevention of medication errors related to infusion pumps, noting that all it takes is one wrong keystroke when programming an infusion pump to cause a Never Event. “Companies like BD are trying to help through innovative products such as Alaris EMR interoperability,” said Wilson. “The wireless two-way connectivity between the infusion pump and the electronic medical record (EMR) pre-populates the pump with the ordered parameters directly from the EMR, eliminating manual key presses and inherent errors. The connection between Alaris and the EMR is bi-directional; there- fore, time-stamped infusion data is sent from the pump back to the EMR. This includes ac- curate start and stop times, which are neces- sary for complete outpatient reimbursement of infusions.”
BD Alaris EMR interoperability
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