Becker's Clinical Quality & Infection Control

7 INFECTION CONTROL & PATIENT SAFETY Inspection report faults Boston Children's for medication errors linked to patient death By Megan Knowles I n 2017, three patients suffered from medication errors at Boston Children's Hospital, including one patient who wait- ed 14 hours for an antibiotic and later died, according to a state and federal inspection report cited by e Boston Globe. Here are eight things to know: 1. e errors took place between January and November 2017 and involved two drugs. e mistakes prompted federal regulators to threaten Boston Children's with termination from the Medicare program. 2. For the patient who died, caregivers or- dered an antibiotic, Zosyn, at noon on a day the patient was receiving treatment in the hospital's intensive care unit. However, the inspection report revealed a nurse did not give the patient the antibiotic until about 2 a.m. the next morning. e patient devel- oped sepsis and died two days later. Aer the antibiotic was prescribed, the patient's nurse mistakenly thought someone had given a verbal order to hold the medicine for further test results. After the patient's death, hospital leaders sent an alert to physicians and nurses in the intensive care unit to remind them all medication orders should be in writing to avoid confusion — except in an emergen- cy. Inspectors said the hospital failed to alert caregivers across the hospital about the rule. 3. Two other Boston Children's patients re- ceived overdoses of the anesthetic Propofol. Aer the first overdose in January 2017, hospital leaders suggested implementing a clearer procedure for measuring doses. Inspectors interviewed one of the hospital's pharmacists, who claimed those recom- mendations "never materialized," according the report. Ten months later, a physician administered an overdose to a different patient using the same potentially confus- ing procedure. at second patient stopped breathing and was resuscitated, but hospital executives said both overdose patients recovered. 4. Aer these incidents, this spring, the hospital implemented improvements for treating sepsis patients quickly and for administering Propofol accurately, avoiding CMS discipline. 5. Jonathan Finkelstein, MD, chief pa- tient safety and quality officer for Boston Children's, did not discuss specific cases, but told e Boston Globe when there is a misstep "we set out the very next day to improve care." 6. In the 46-page report, inspectors said the hospital did not completely analyze the errors and thoroughly correct the conditions that led to the errors. Inspec- tors based report findings on visits to the hospital over five days in November and December 2017. 7. Dr. Finkelstein said the hospital put a new protocol in place that triggers a sepsis evaluation for any patient with a deteri- orating condition. Additionally, Boston Children's sent out a hospital-wide alert that states when medications are handed off to another clinician, only a single, labeled, weight-based dose can be prepared in a single syringe. 8. In a 63-page improvement plan, Boston Children's recognized "the need to focus additional attention in our responses to specific events," including "the potential of a similar event occurring in another area." n Healthgrades honors 458 hospitals for patient safety By Megan Knowles H ealthgrades — an online resource for information on hospitals and phy- sicians — announced the recipients of the Healthgrades 2018 Patient Safety Excellence Award and the Healthgrades 2018 Outstanding Patient Experience Award. Here are five things to know: 1. For 2018, 458 hospitals across the U.S. received the Healthgrades Patient Safety Excellence Award, which puts them in the top 10 percent of all short- term acute care hospitals that report patient safety data. 2. The patient safety award recipients demonstrated excellent performance in safety for Medicare patients as measured by objective outcomes for 13 patient safety indicators defined by the Agency for Healthcare Research and Quality. 3. For 2018, 439 hospitals received the Healthgrades Outstanding Patient Experience Award, which puts them in the top 15 percent of hospitals for patient experience. 4. To determine the patient experience award recipients, Healthgrades ana- lyzed 3,478 hospitals that submitted at least 100 patient experience surveys to CMS, which covered admissions from April 2016 to March 2017. 5. Healthgrades then measured hospital performance by applying a scoring methodology to 10 patient experience measures, using data gathered from a 32-question patient experience survey. Survey questions focused on how patients perceived their hospital care, including cleanliness, noise levels, pain management and providers' responsiveness. n

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