Safety tips from Minnesota hospitals
Ten-year review shows the state's hospitals are safer than ever
Ten years after becoming the first state requiring its hospitals and ASCs to publicly submit annual reports about adverse events affecting patient safety, Minnesota's hospitals are getting mixed reviews on the latest report cards.
On one hand, a 10-year program evaluation by the Minnesota Department of Health shows the number of reported adverse events is at its lowest since the program was started a decade ago, indicating that patients in Minnesota's hospitals are safer than ever.
On the other hand, there's still work to be done to prevent medical errors and patient deaths that, by modern medical standards, should be preventable.
Several Minnesota medical centers came under fire last year following a rise in the number of preventable deaths and serious disabilities among patients, including suicides. The uptick in such events triggered state interventions that required staff retraining and increased scrutiny on how facilities were keeping patients safe. The Adverse Health Events in Minnesota report, released by the Minnesota Department of Health in January 2013, detailed the number of patient deaths and injuries that occurred in state hospitals and surgery centers during a one-year period ending in October 2012. At least 26 states have followed Minnesota's lead by tracking and reporting adverse events-things that are not supposed to happen in hospitals, such as patient suicides, disappearances, and medical errors (e.g., leaving items in patients during surgery).
According to a report outlined in the Pioneer Press, the state's 2013 annual report found that patient deaths increased from five to 14 from the previous year, while events involving serious injury grew from 84 to 89. Four of those deaths in 2012 were suicides, triggering a state response to help lower suicide attempts.
"We're obviously very disappointed that people are harmed in our organizations, and we're working very hard to lower the amount of harm," said Lawrence Massa, president of the Minnesota Hospital Association, in a published report at the time.
By comparison, during the 12-month period ending October 2013, the report tracked only three "patient protection" incidents, which included two suicides or attempted suicides by patients.
After the 2012 annual report came out, the Minnesota Department of Health stepped in and required training for staff at the state's hospitals during the spring of 2013. The training, which was conducted by the nonprofit Suicide Awareness Voices of Education, taught suicide awareness and prevention and is credited with at least part of the decrease in patient suicides.
"Since the adverse health event reporting system was created in Minnesota 10 years ago, there have been 24 suicides," says Sarah Ford, MPA, communications manager for the Minnesota Hospital Association. "Because suicide is an adverse health event, we take suicide prevention seriously-as we do with any of the other adverse events."
Safety in the design
In addition to retraining staff in the handling of patients who may be at high risk of harming themselves or others, many hospitals in Minnesota are rethinking their facility's physical environment, going so far as to completely redesign their behavioral health units to make them safer.
Patient suicide has long been a concern in hospitals, and in 1998, The Joint Commission issued a Sentinel Event Alert claiming that suicide is one of the top five most frequently reported events in hospitals-most of them in non-behavioral health units. In 2010, the commission issued a follow-up, bringing attention to the need to screen potential suicidal patients in the general hospital population and offering risk reduction strategies.
"While psychiatric settings are designed to be safe for suicidal individuals and have staff with specialized training, typically, medical/surgical units and emergency departments are not designed or assessed for suicide risk and do not have staff with specialized training to deal with suicidal individuals," the report said. "Compared to the psychiatric hospital and unit, the general hospital setting also presents more access to items that can be used to attempt suicide-items that are either already in or may be brought into the facility-and more opportunities for the patient to be alone to attempt or re-attempt suicide."
Not surprisingly, hospitals have taken notice and worked to revamp their own policies as well as their physical environment.
"It's a challenge to make it look warm and inviting and safe, but you don't want to make it look like a prison, but patients find things to hurt themselves," says Chris Walker, MSN, RN, MHA, director of inpatient mental health units and behavioral access nurses at St. Cloud (Minn.) Hospital. "Some patients have visitors that will sneak in pills and drugs, and some will find something like a paper clip on the floor to try to injure themselves."
St. Cloud conducted an environmental risk assessment in 2009 and worked with attorneys and its insurance provider to completely revamp policies and procedures in the 20-bed mental health unit. In addition to forming an Aggression Incident Prevention Committee, staff members worked together to come up with a checklist designed to use whenever a new patient is admitted to a room-hangers are removed from closets, only vital cords are allowed in the room, furniture is removed, and the patient's clothing and belongings are taken elsewhere. A behavioral ICU was formed with two to four beds that can be isolated from the rest of the unit if needed.
"A grandmother who is there for depression shouldn't have to come to a mental health unit and be afraid of the violent 19-year-old," Walker says.
Physically, the unit has changed as well. Rooms have higher ceilings to prevent hangings, and televisions and artwork are enclosed in shatterproof glass cases. Staff check the room every 15 minutes, and twice a day the room is swept top to bottom looking for anything that could be harmful. Training has come to the forefront-all staff have attended a three-hour de-escalation class and carry a personal infrared transmitter that, in the event of an emergency, can alert others to the staff member's location instantly with the press of a button.
"We have become much more transparent about the problem," Walker says. "Statewide, many places are encouraging that we try to learn from each other. Another facility may be doing something that we can learn from them."
Hospitals looking to make their facilities safer for their patients can take a lesson from their colleagues in Minnesota, but safety experts everywhere have already begun looking at ways to improve security, from training to almost-invisible "soft changes" in the environment. Behavioral health units aren't the only places you'll see these changes-regular ER medical units are being beefed up as behavioral health issues become integrated into the general population. "Mental health is part of every single person, no matter who you are," says Walker. "You could come in for pancreatitis, and your mental health can be affected."
Here are some ways a facility can improve the safety of both staff and patients:
Lower surfaces. Although it can be pricey and difficult for older hospitals to renovate current spaces, newer construction is focusing on design elements that provide fewer opportunities for patients to harm themselves. "You want to design it in such a way that it makes it difficult to jump off higher areas," says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, N.C. Smith has served on a task force for construction and renovation for the International Association for Hospital Safety and Security, which focuses on recommendations ranging from avoiding high parking decks to rooftop play areas (a hospital in North Carolina tried it).
"The people that create these spaces create what's called an attractive nuisance," he says. "Just by the nature [of] how it's designed, it has safety issues or people could easily commit suicide."
Search everyone. Especially in a busy emergency room environment, it can be difficult to assess who will be a violence or a suicide risk, so many hospitals have developed procedures for screening patients as they are admitted. Clothes are removed; sharps, belts, and jewelry are inventoried; and purses and other belongings are placed somewhere safe. In the meantime, a nurse or other staff member asks some basic questions to ascertain each patient's baseline mental status. Finally, a patient may be given a color-coded set of scrubs to dress in. "Does this mean you strip search everyone? Maybe not, but in some places a purple gown can ID someone as high risk," Smith says.
Make a list, check it twice. Many physicians and hospitals swear by checklists to minimize mistakes in the surgical suite; now, some hospitals are adapting checklists to other areas, such as the behavioral care unit.
St. Cloud Hospital debuted a checklist in February that gives staff a list of things to do when preparing a room for a new patient arrival. Tasks on the checklist include things like moving extra garbage cans into the bathroom, removing excess furniture and cords, taking down decorative crucifixes, and folding a room's computer up into a wall when it's not being used.