Becker's Clinical Quality & Infection Control

11 INFECTION CONTROL & PATIENT SAFETY Healthcare workers clap back, but comply, when hand hygiene monitored By Anuja Vaidya D espite healthcare workers' negative attitudes toward an electronic hand hygiene monitoring system, hand hygiene compliance improved with its implementation, according to a study pub- lished in the American Journal of Infection Control. Researchers studied the effects of installing an electronic hand hygiene monitoring system in two units at Boston-based Tufts Medical Center. They collected electronic data over eight months and also conducted human observations before, during and after implementation of the system. They gave staff surveys before and after installation. The study shows that while survey responses re- vealed negative attitudes about the system before and after installation, hand hygiene compliance, as observed by researchers, increased by an average of 1.3 percentage points per month. n Another patient dies at Oregon mental health facility By Mackenzie Bean A patient died July 29 at Unity Center for Behavioral Health less than a year after state and federal officials cleared the Portland, Ore.-based facility of a different patient death inves- tigation, according to The Oregonian. A spokesperson for Legacy Health, which owns Unity Center, confirmed the death July 31. The hospital no- tified appropriate regulators of the incident July 30. Legacy Health's spokesperson did not share details of the incident but said, "No additional steps need to be taken connected to this patient, given the specific medical cause of death." Two other patient deaths have occurred at Unity since the center opened in January 2017. One patient died in May 2018 due to medical negli- gence, while a second died by suicide in July 2018, according to CMS inspection reports cited by The Oregonian. In November, CMS and the Oregon Health Author- ity concluded Unity Center had resolved all care deficiencies. n Connecticut hospital fined $150K over cancer misdiagnoses By Mackenzie Bean C MS fined Yale New Haven Health's Bridgeport (Conn.) Hospital $150,000 aer the facility mixed up eight patients' test spec- imens, leading to several cancer misdiagnoses, reported e Middletown Press. State health inspectors identified the medical errors during an unan- nounced inspection in July 2018. In one situation, a 41-year-old woman chose to have a hysterectomy aer incorrect pathology results led her to believe she had cancer. In another case, physicians told a 66-year-old patient his lab results were normal when a malignancy existed, accord- ing to a state inspection report cited by e Middletown Press. CMS prohibited Bridgeport Hospital from performing cytology testing and stopped reimbursing the facility for the testing, effective Nov. 29, 2018. e hospital now outsources all cytology testing to Yale New Ha- ven (Conn.) Hospital. Bridgeport Hospital must secure CMS' approval before resuming any in-house cytology testing. "Even in the best organizations, medical errors occur. When they do, our obligation is to acknowledge them, learn from them and ensure that we minimize any chance that they ever occur again," Dana Marnane, direc- tor of communications for Yale New Haven Health, told e Middletown Press. "We took the results of the investigation very seriously and made changes to significantly improve our lab processes. We offered our heart- felt apologies and have pledged to do better in the future." n MedStar Health researchers to assess patient safety trends with machine learning By Mackenzie Bean M edStar Health Research Institute in Hyattsville, Md., is tapping machine learning to help guide patient safety efforts in Pennsylvania. Through a contract with the state's Patient Safety Authority, MedStar researchers will use algorithms to analyze data on nearly 4 million patient safety events collected in a state data- base. They will look at all acute care events and nursing home infections recorded in the database on a quarterly basis. Researchers will use this information to identify new improve- ments or processes hospitals can implement for safer, more effective care. Pennsylvania is the only state that requires healthcare facilities to report events that could potentially harm patients, along with actual adverse events. PSA uses this information to iden- tify and address patient safety issues that may not be visible at an individual facility level. n

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