Becker's Clinical Quality & Infection Control

6 INFECTION CONTROL & PATIENT SAFETY Viewpoint: Why state-mandated nurse ratios could harm patient safety By Megan Knowles N ew York state's proposal to implement mandated nurse-to-patient staffing ratios aims to protect pa- tients from harm, but these rigid rules may take the state backward on patient safety progress, Bea Grause, RN, president of the Healthcare Association of New York State, argued in the Times Union. e Safe Staffing for Quality Care Act aims to mandate nurse-to-patient ratios in New York healthcare facilities, according to the New York State Nurses Association. A bipartisan coalition is supporting it in the New York State Assembly and Senate. e bill aims to protect patients through several measures, such as establishing nurse-to-patient ratios by hospital unit where no nurse is responsible for more patients than the specific ratio and requiring hospitals to create a staffing plan that adjusts staffing according to patient acuity and changing care needs. Here are four insights from the op-ed: 1. e state's current approach of developing trained teams poised to deliver evidence-based care has been widely em- braced across hospitals statewide and nationwide, Ms. Grause noted. "is approach works and supports a culture that helps high-risk industries like hospitals reliably achieve safe outcomes," she wrote. "As a former emergency room nurse, I understand that nurses are important team members, but so are nurses' aides, technicians, respiratory therapists, and of course, physicians." Altering this approach in favor of a one- size-fits-all set of mandated nurse-to-patient staffing ratios could wind up harming patients, Ms. Grause wrote. 2. Ms. Grause said hospitals in New York are nonprofit entities that have limited resources. "If hospitals must hire to fulfill this nurse-only state mandate, then it likely means fewer resources to employ other critical team members," she wrote. "Should government really decide how many nurses should be on duty in a hospital? Would care improve with more nurses and fewer physicians and other members of the care team? e answer emphatically is no." 3. "New York's hospitals and health systems are contin- uously innovating to deliver the highest quality care and improve patient outcomes, using broadly accepted, evi- dence-based approaches," Ms. Grause wrote. "Rigid ratios are neither broadly accepted [nor] evidence-based." 4. Ms. Grause argued trained hospital caregivers should be the people who determine patient needs — not government officials. "Government-mandated nurse ratios will under- mine the years of progress we have made on patient safety." n 13 statistics on never events By Megan Knowles T he Joint Commission implemented a sentinel event policy in 1996 to help hospitals improve patient safety and learn from adverse events, including unexpected deaths and serious physiological or psychological harm to patients. The organization defines a sentinel event as a patient safety event that results in any of the following outcomes: death, permanent harm, severe temporary harm or intervention required to sustain life. The Joint Commission requires hospitals to conduct a root- cause analysis after a sentinel event occurs. The nonprofit organization also considers the National Quality Forum's "never events" to be sentinel events, according to the Agency for Healthcare Research and Quality. NQF classifies the following circumstances as never events: sur- gical events, product or device events, patient protection events, care management events, environmental events, radiologic events and criminal events. Frequency of never events Although most never events are rare, these safety incidents can have significant effects on patients and hospitals. Here are three statistics on the frequency of never events, compiled by the Agency for Healthcare Research and Quality: 1. More than 4,000 surgical never events occur each year in the U.S., according to a 2013 study. 2. The average hospital may experience a wrong-site surgery case once every 5 to 10 years, according to a 2006 study. 3. The majority — 71 percent — of never events reported to The Joint Commission between 1995 and 2015 were fatal. Most common never events In March 2018, The Joint Commission updated its sentinel event statistics for 2017. The organization reviewed 805 reports of senti- nel events reported during the 2016-17 calendar year. Here are the 10 most frequently reported sentinel events for 2017, according to The Joint Commission: 1. Unintended retention of a foreign body — 116 reported 2. Fall — 114 3. Wrong-patient, wrong-site, wrong-procedure — 95 4. Suicide — 89 5. Delay in treatment — 66 6. Other unanticipated event, such as asphyxiation, burn, choking on food, drowning or being found unresponsive — 60 7. Criminal event — 37 8. Medication error — 32 9. Operative/postoperative complication — 19 10. Self-inflicted injury — 18 n

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