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SAFETY: falls and pressure ulcers by type of hospital unit

Development of a hospital quality improvement measure that evaluates patient falls and pressure ulcers was the focus of this study based on 2013 data from the National Database of Nursing Quality Indicators.  Table 2 has interesting unit-level data for different types of hospital patient care units based on statistics supplied by 857 hospitals.  The different types of patient care units compared included: critical care, step-down, medical, surgical, med-surg, rehab and critical access.  The group of hospitals in this study is said to under-represent small hospitals.

Highest and Lowest Rates by Type of Hospital Unit

  • 6.09 total falls / 1000 patient days in rehab units – critical care units had the lowest falls rate (1.13 per 1000)
  • 6.42 percent of patients in critical care units had hospital acquired pressure ulcers – critical access hospitals had the lowest occurrence – at 1.52 percent
  • 17.36 percent of patients in critical care units had restraints – critical access hospitals had the lowest rate at 0).

Source: Boyle, D.K., and others. (2017). A pressure ulcer and fall rate quality composite index for acute care units: A measure development study. International Journal of Nursing Studies. 63, 73-81.  Click here: http://www.journalofnursingstudies.com/article/S0020-7489(16)30146-8/pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Private rooms help reduce hospital acquired infections

The Canadian Standards Association has issued standards aligned with US recommendations in that new hospital construction should have single patient rooms.  In Canada, over half of hospital beds are in wards of four or more per room, and hospitals charge more for semiprivate or private rooms than for wards, a price differential that totals an estimated $200 million or more in Ontario alone.  An interesting observation, coming from Roger Ulrich, an international hospital design expert:

  • “…the operational costs of running a hospital for 30 years are at least 15 times higher than the initial capital costs.”

The arguments in favor of single patient rooms are summarized in this series of brief articles.  Among these are patient safety, patient preference (an estimated 90 percent of patients think that having other patients in the room is a significant source of stress), and the ability to run the hospital at a higher occupancy rate. 

Sources:  Stall, N.  Private rooms: a choice between infection and profit.  CMAJ. Canadian Medical Association Journal;184(1):24-25, Jan. 10, 2012.  Click here for full text: http://www.cmaj.ca/content/184/1/24.full.pdf ; Stall, N.  Private rooms: the fiscal advantage.  CMAJ. Canadian Medical Association Journal;184(1):E47-E48, Jan. 10, 2012.  Click here for full text: http://www.cmaj.ca/content/184/1/E47.full.pdf ; Stall, N.  Private rooms: evidence-based design in hospitals.  CMAJ. Canadian Medical Association Journal;184(2):162-163, Feb. 7, 2012. Click here for full text: http://www.cmaj.ca/content/184/2/162.full.pdf  Canadian Standards Association.  CSA Z8000: Canadian Health Care Facilities: Planning, Design and Construction, 2011.   A copy can be purchased here: http://shop.csa.ca/en/canada/landing-pages/z8000-canadian-health-care-facilities/page/z8000/  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Patient room design: advantages of same-handed concept

Nursing unit design using a standardized “same-handed” design was found to be superior in some respects to a “mirrored” design, in this research conducted at two hospitals.  The findings suggest that the same-handed design concept resulted in patient perceptions of lower noise levels, better quality sleep, and a greater likelihood that nurses approach the bed on the patient’s right side (which has been associated with a lower rate of near falls).  Nurses reported higher satisfaction with the way the work space is organized on the same-handed units as well. 

What I like about this article:  1. That is an actual research study, not just an opinion piece.  2. The first author is the director of research at HOK, a large architectural firm.  3. Although they did not formally study this concept, they also discuss the advantages of “balanced headwalls.” 

Source: Watkins, N., and others.  Same-handed and mirrored unit configurations: is there a difference in patient and nurse outcomesJONA. Journal of Nursing Administration;41(6):273-279, June 2011.  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Best practices in avoiding retained surgical sponges

Despite established practices for counting, cotton sponges are the most common item to be left behind in a patient after intraabdominal surgery.  Several years ago, the Mayo Clinic (Rochester, MN) implemented a data-matrix-coded (fka bar coded) sponge counting system.  In 18 months of continuous use, there have been just under 2 million sponges used in the Mayo Clinic Rochester operating rooms and zero retained-sponge events.  There is a short learning curve to learn to use the new system (about 4 cases), and no increase in overall operative time was found.  There was an average cost increase of just under$12 per case to implement this new system.

Source: Cima, R.R., and others.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 monthsThe Joint Commission Journal on Quality and Patient Safety;37(2):51-58, Feb. 2011.  Posted by the AHA Resource Center, (312) 422-2050, rc@aha.org

Medication-Related Adverse Outcomes in Hospitals and ERs

An overview of the incidence of medication-related adverse outcomes in hospital inpatients and emergency outpatients is provided in a new report from the Agency for Healthcare Research and Quality.  Three types of prescription drug-related adverse outcomes were looked at:

  1. Adverse drug reactions — side effects — where harm was caused by a drug at normal doses
  2. Adverse drug events where harm was caused by use of a drug, such as unintentional overdosing by a patient
  3. Medication errors where there was inappropriate use of a drug, such as a prescribing or dosing error

In 2008 there were 1.9 million inpatient hospital stays [nearly 5% of all stays] and another 838,000 treat-and-release visits to emergency departments involving a drug-related adverse outcome. Over half of inpatient adverse outcomes were with patients aged 65 and older; in the emergency outpatient setting, most adverse outcomes visits [36%] were with patients aged 18-44. The incidence of medication-related adverse outcomes increased by 52% between 2004 and 2008 and is expected to grow further with an aging population, rising comorbidities, and polypharmacy.

Corticosteroids were the leading cause of adverse outcomes for hospital inpatients, while analgesics and antibiotics were most often caused the adverse outcomes for treat-and-release emergency visits.

Cases involving use of illicit drugs and intentional drug overdosing were excluded in the data analysis.

Source: Lucado J, Paez K, and Elixhauser A. Medication-related adverse outcomes in U.S. hospitals and emergency departments, 2008.  Agency for Healthcare Research and Quality, HCUP Statistical Brief #109, April 2011.  http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.pdf

Posted by the AHA Resource Center, (312) 422-2050, rc@aha.org

Wrong site surgery: 1 case/year in typical 300 bed hospital

What is the incidence of wrong site surgery?

[The following is a selection from the health care literature on this topic.  A comprehensive search would yield more citations.]

(Stahel, et al., 2010) reviewed over 27,000 cases of adverse occurrences self-reported by physicians from 2002 to mid-2008 and found 25 instances of wrong-patient and 107 instances of wrong-site procedures.  Causes of the wrong patient errors were communication problems and errors in diagnosis.  Causes of the wrong-site errors were primarily errors in judgment and lack of a surgical time out. 

(Malloy and Hughes, 2008) summarized the literature in a concise chapter about wrong site surgery.  They discuss incidence, as well as techniques for avoiding this type of medical error.

(Clarke, et al., 2007) studied the incidence of wrong site surgery based on over 430,000 surgical operations performed in Pennsylvania from mid-2004 until the end of 2006.  Based on these extensive data from both hospitals and ambulatory surgery centers, the authors estimate that the typical 300-bed hospital is likely to have one wrong-site surgery event per year.  Wrong side surgery was the most commonly occurring type of wrong site surgery.  The majority (56%) of the reported events were near misses, caught before any care was rendered.  A table included in this article itemizes suggested process improvement actions to help prevent this type of medical error.

(Kwaan, et al., 2006) analyzed 20 years of data from a malpractice insurer covering about 30 Massachusetts hospitals and developed an incidence rate.  The authors found 40 instances of wrong-site surgery during the study period, from which they estimated that the incidence for non-spine wrong-site surgery is 1 in 112,994 operations.  They mention that the incidence of retained foreign bodies is 10 times more likely to occur than wrong-site surgery. 

Surgical time outs

Lee (2010) studied the implications of instituting an extended surgical time out prior to anesthesia induction for pediatric patients at Kaiser Permanente Bellflower Medical Center.  The children did not seem to experience distress during the time out.  Although staff found the extended time outs to be helpful in improving communication, this approach did not eliminate wrong-site surgery.  Of greater efficacy were changes in the site marking process, which now may only be done by the surgeon.

(Altpeter, T., et al., 2007) describe the surgical time out practice adopted at The University of Louisville Hospital, which serves as a ‘reflective pause’ or ‘preop briefing.’  Besides focusing on confirming the patient identification and operative site, the hospital added an additional 5 components to the STO process.   

(Backster, et al., 2007) describe the effort at one hospital to expand the surgical time out into a ‘preparatory pause,’ which covers avoidance of perioperative risks.  The authors developed an estimate of the financial benefit of instituting an extended surgical time out of $900 per patient.


Altpeter, T., and others.  Expanded surgical time out: a key to real-time data collection and quality improvement.  Journal of the American College of Surgeons;204(4):527-532, Apr. 2007.  http://www.surgicalpatientsafety.facs.org/research/altpeter.pdf

Backster, A., and others.  Transforming the surgical ‘time out’ into a comprehensive ‘preparatory pause.‘  Journal of Cardiac Surgery;22(5):410-416, Sept./Oct. 2007. 

Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Kwaan, M.R., and others.  Incidence, patterns, and prevention of wrong-site surgeryArchives of Surgery;141(4):353-358, Apr. 2006.

Lee, S.L.  The extended surgical time-out: does it improve quality and prevent wrong-site surgery?  The Permanente Journal;14(1):19-23, Spring 2010.  http://www.thepermanentejournal.org/files/Spring2010/TheExtendedSurgicalTimeOutDoesItImproveQualityandPreventWrongSiteSurgery.pdf

Malloy, D.F., and Hughes, R.G.  Wrong site surgery: a preventable medical error, in: Hughes, R.G. (ed.) Patient Safety and Quality: An Evidence-Based Handbook for Nurses.  Rockville, MD: Agency for Healthcare Research and Quality, Apr. 2008, Chapt. 36.  http://www.ncbi.nlm.nih.gov/books/NBK2678/pdf/ch36.pdf

Seiden, S.C., and Barach, P.  Wrong-side/wrong-site, wrong procedure, and wrong-patient adverse events.  Archives of Surgery;114(9):931-393, Sept. 2006. 

Stahel, P.F., and others.  Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.  Archives of Surgery;145(10):978-984, Oct. 2010.

Nursing unit design: same-handed rooms

The advantages and disadvantages of designing nursing units with same-handed versus mirrored patient rooms are reviewed in the (Pressler & Keil, 2011) point-counterpoint discussion.  Same-handed rooms, in which everything can be found in exactly the same location, are thought to enhance patient safety.  However, mirrored rooms may be less expensive in construction costs because of the ability to more efficiently design plumbing.  Same-handed rooms are not a brand new concept.  (Cahnman, 2006) provides a nice review of the developments in patient room design and discusses the factors that should be considered: acuity level, specialties, nursing care model, supply distribution model, how visible the patient is to be from the corridor, patient safety, and family amenities.  She presents examples of a hospital that opted for same-handed rooms with outboard toilet (St. Joseph’s Hospital, St. Paul, MN), and another that chose same-handed rooms with inboard toilet (The Miriam Hospital, Providence, RI).  The extra cost to build a same-handed room has been estimated to be $3,000 to $5,000 per room, due to increased plumbing costs (Maze, 2009).  Maze also quotes estimates from a large construction company about the popularity of different toilet room locations that the company was installing in new patient towers — 50% inboard toilet rooms, 38% outboard toilet rooms, and 12% nested toilet rooms.  CannonDesign also mentions the added construction cost of about $3500 per room more for same-handed than for mirror-image rooms, and identifies the major design challenge with the same-handed rooms to be the placement of nursing substations.  An example of a new 82-bed hospital built with standardized private rooms is St. Joseph’s Hospital (West Bend, WI), described in the items by Reiling.


Cahnman, S.F.  Key considerations in patient room design, part 1Healthcare Design, Apr. 2006; and, Key considerations in patient room design, part 2: the same-handed room.  Healthcare Design, May 2006.  http://www.sypultconstruction.com/images/Healthcare_Design_May_2006.pdf

CannonDesign.  Same-sided patient rooms on the rise, improve facility safety.  Healthcare Building Ideas, [no date].  http://cannondesign.com/FILES/original/2009/06/29/d37b346fb175436822ab15baa089a4693aea05a2.pdf 

Maze, C.  Inboard, outboard, or nested? Healthcare Design, Mar. 2009.

Pressler, G., and Keil, O.  Same-handed patient rooms: point-counterpointFacilityCare, [2011].

Reiling, J.G., and others.  Enhancing the traditional hospital design process: a focus on patient safety.  Joint Commission Journal on Quality and Safety;30(3):115-124, Mar. 2004.  http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/downloads/01-reiling.pdf

Reiling, J.G. Creating a Culture of Patient Safety Through Innovative Hospital Design, [2005].  http://www.ahrq.gov/downloads/pub/advances/vol2/Reiling.pdf

Reililng, J.G., Hughes, R.G., and Murphy, M.R.  The impact of facility design on patient safety, in: Hughes, R.G. (ed.) Patient Safety and Quality: An Evidence-Based Handbook for Nurses.  Rockville, MD: Agency for Healthcare Research and Quality, 2008, Chapt. 28.