Preventing Serious Reportable Events: Hospital safeguards

Today's meeting of the Massachusetts Coalition for the Prevention of Medical Errors identified several very welcome ripple effects from the hospitals' mandated reporting of Serious Reportable Events (SREs). SREs are errors that should never happen, ranging from wrong-patient surgery, or a surgical sponge being left in the patient's body, to arguably less preventable events like falls, or pressure ulcers (open sores caused over time by the pressure of a person's own body on a single area, which sometimes predate the patient's hospital admission). Massachusetts law requires hospitals to formally report SREs to the state's Department of Public Health, and forbids hospitals from receiving payment for SREs.

When hospitals have examined what went wrong in particular SREs, they sometimes have identified, and put into place, changes in practice that can prevent similar SREs from recurring:

For some patients, hospital staff deliberately leave their chest wounds uncovered, following surgery. Because it is important that such wounds be exposed to air to promote healing, nurses are told not to turn those patients to lie on their backs. However, if the patient remains on his back for an extended time, that raises the possibility that a pressure ulcer will develop. One hospital with a pressure ulcer SRE realized that if they placed such patients on an alternate-pressure mattress (imagine Magic Fingers underneath the person's body), the mattress itself would provide enough movement to prevent pressure ulcers from forming. The hospital now ensures that these patients go to rooms that have such specialized beds. They've upgraded the level of standard practice to prevent SREs.

In another Boston-area hospital, a patient in a doctor's office fell off the examining table, causing a severe injury. This SRE spurred the hospital to study and then improve their protection of patients in outpatient offices, e.g., by having frail elderly patients wait in exam rooms in chairs with arms, instead of sitting on raised exam tables while they wait.

One hospital with a computerized physician order entry system now allows nurses to enter orders for a consultation by a Certified Nurse Specialist, to ascertain and lower the risk for the development of pressure ulcers.

Staff at a smaller hospital studied patient falls, and learned that often, patients in their seventies would eat dinner, and then within an hour or so, would fall when they got up to go to the bathroom. The hospital now has nurses ask about that in their hourly rounds.

Another hospital now uses a special stacking device to hold surgical sponges after use, making it easier to separately view and count them, to ensure none have been "retained" in the patient's body.

Bravo to these hospitals for raising their standard of care, developing systematic safeguards. Kudos, too, for their willingness to discuss them.

Read about another way to reduce retained foreign objects in surgery.