Health care groups endorse standardized 'safe practices'.

Since studies began documenting the rising numbers of medical errors in the United States, hospitals across the nation have implemented myriad but often conflicting patient-safety measures. In response to a widespread cry for standardization, health care purchasers, quality-oversight groups, and government agencies have agreed for the first time to endorse a new set of 30 "safe practices" that hospitals should implement to prevent patient injuries and deaths.

"Hospitals have been complaining about thousands of [different] measures in a thousand ways; this [standardization] is a light at the end of the tunnel," said Dr. Charles Denham of Laguna Beach, California, cochair of the committee that developed the practices, which were announced last October by the Washington, D.C.-based National Quality Forum (NQF), a nonprofit membership organization that sets voluntary health care quality standards.

The new guidelines were developed by the NQF Consensus Standards Maintenance Committee and endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the federal Centers for Medicare and Medicaid Services, the Institute for Healthcare Improvement, and the Agency for Healthcare Research and Quality. They replace guidelines published by NQF in 2003.

Denham said the committee is making final modifications before it formally issues the voluntary guidelines--to incorporate feedback it received during the public comment period that ended in mid-November--but he declined to elaborate on the changes. Currently, the list contains three entirely new guidelines and 23 materially changed practices from the 2003 list; four practices from the original list remain unchanged.

The NQF and the endorsing organizations have agreed that the 2006 practices should be minimum requirements for hospitals to obtain certification through JCAHO. If JCAHO withholds certification from noncompliant hospitals, those facilities will no longer be eligible for important government contracts, including agreements to participate in Medicaid and Medicare programs.

The new practices call for facilities to create and sustain a "culture of safety" built on accountability and disclosure, Denham said. This encompasses "four areas: leadership structures and systems, culture measurement for improvement, teamwork training and projects, and identification and mitigation of risks and hazards," he said.

"This may seem to be second nature and common sense, but it is not so," said Barry Walker, a Birmingham, Alabama, attorney who handles medical error cases. "Research shows that in many instances there is a culture of secrecy instead. Rather than being forthcoming about mistakes, mistakes are clothed in secrecy."

One new measure instructs providers to notify the patient--and family, where appropriate--of any serious, unanticipated outcomes. Another requires hospitals to have adequate non-nursing direct-care staff and to provide sufficient training to staff in their assigned duties.

Hospital employees are "often put to work without an adequate level of training, and facilities assume that their prior education is enough," Walker said, noting that enhanced training and standardized systems could go a long way in reducing medical errors.

"My goal is to litigate fewer of these cases," he added. "Ultimately that's what we as trial lawyers want."

Several of the practices address poor communication among heath care providers and between providers and patients. One requires that providers ask patients or legal surrogates to "teach back" key information about treatments or procedures for which they were asked to give informed consent. Documents seeking informed consent should be written at a fifth-grade reading level and in the primary language of the patient, the practice states. Another measure requires providers to create a "discharge plan" for each patient and give a concise summary report to caregivers at the time of discharge.

Other updated measures include

* ensuring that information is documented and transmitted to patients and their providers in a timely and understandable manner

* verifying spoken orders and critical test reporting by having the person who receives the information record and read back the complete order or test result

* implementing standardized policies and systems to ensure accurate labeling of diagnostic studies and laboratory specimens 

* following the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery for all invasive procedures.

Seven practices specifically address preventable medication errors, which one recent study blamed for at least 1.5 million patient injuries or deaths every year. (See Alba Lucero Villa, Rampant Drug Errors in Hospitals Are Preventable, Study Says, TRIAL 78 (Oct. 2006).) A new measure instructs hospitals to develop, update, and communicate--throughout a patient's stay--an accurate list of medications he or she is taking. Updated measures say facilities should

* implement a computerized system that checks providers' medication orders against a patient care plan

* adopt standardized "do not use" abbreviations, acronyms, symbols, and dose designations for medications or treatments

* implement a computerized prescriber order system and require pharmacists to actively participate in medication-management systems

* standardize methods for labeling and packaging medications

* identify "high alert" medications and establish procedures to minimize their risks

* dispense medications in single-unit doses whenever possible.

"These guidelines definitely go further and state directly what should be done in a more correct way than has been done in the past," Walker said.

Committee cochair Denham runs the nonprofit Texas Medical Institute of Technology, which designs safety surveys for the Leapfrog Group--a Washington, D.C.-based membership organization of health care purchasers. The surveys rate hospital performance according to four quality practices: computer physician order entry; evidence-based hospital referral; intensive care unit staffing by physicians experienced in critical care medicine; and the Leapfrog Safe Practices Score, based on NQF-endorsed "safe practices."

This score will now be recalculated based on the new set of practices, Denham said. The 1,267 hospitals that Leapfrog usually assesses will have until the end of June to submit responses to new surveys.

Once the NQF formally issues the guidelines, it will make the report, Safe Practices for Better Healthcare-2006 Update, available on its Web site, www.qualityforum.org.