Becker's Clinical Quality & Infection Control

14 PATIENT SAFETY & OUTCOMES Why patient falls are so hard to get ahead of By Erica Carbajal F rom shock-absorbing flooring to wearable technologies, hospitals have tried a litany of interventions to get to zero patient falls. But for years, falls have consistently landed on e Joint Commission's list of most common sentinel events. Oentimes, patient falls take the top spot on the accrediting body's annual list of the 10 most frequently reported sentinel events, which the organization defines as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. In the first six months of 2022, 199 falls were reported, making it the most common sentinel event so far this year. In 2021, they were also the most commonly reported sentinel event, with healthcare organizations reporting 485 patient falls. And these figures only include adverse events that were reported. "Every single hospital across the country focuses on falls because it's such a complex initiative," Kristin Ramsey, MSN, RN, chief nurse executive at Chicago-based Northwestern Medicine Memorial Hospital, told Becker's. She described patient falls as "one of the things that keeps me up at night" because "there's really two victims in a fall because the care provider also is traumatized anytime that a patient is injured underneath their care." promote a safe to speak up culture. e safety culture survey will be readministered this fall and the results benchmarked against last year's results in order to identify improvements and opportunities. Leslie Jurecko, MD. Chief Safety, Quality and Experience Officer at Cleveland Clinic: Our caregivers have safety wins every day when they have a questioning attitude, speak up, stop the line, and lean into our value of empathy. It is truly those small wins in the moment, across our large healthcare system that collectively create a culture of safety and highly reliable clinical care at Cleveland Clinic. At the strategic level, our biggest safety win this year has been leveraging our relationships with other large healthcare systems to solve patient safety issues together. We should never compete on safety, and the collective knowledge of all our teams coming together to improve device safety, inform quality improvement initiatives, and enhance the patient experience enables organizations to scale tested interventions quickly, protecting our patients sooner. Global healthcare has not arrived at being a highly reliable organization, there is still too much preventable harm, but working together will accelerate our journey. Our patients and caregivers deserve this collaborative spirit. Pam Upadya, MD. Vice President and Chief Medical Officer at St. Joseph's Wayne (N.J.) Medical Center and Patient Safety Officer at St. Joseph's Health (Paterson, N.J.): Without exception, our biggest win this year is the continued commitment by our entire team at Joseph's Health to move forward a just culture that ensures balanced accountability across our health system. Utilizing the principles of a high-reliability organization, we have developed a safe environment for both patients and employees. Our people have embraced the concept of working within a just culture that has moved from placing blame to improved outcomes and system design as we celebrate all those who are steadfast in delivering quality care at the bedside. Our success in transitioning our perspectives and behaviors in patient safety reflects our strong organizational values and shared accountability by employees at all levels. Tom Peterson, MD. Vice President and Chief Safety Officer at Trinity Health (Livonia, Mich.): At Trinity Health, one of our core values is safety. is year, we have focused on the implementation of our systemwide safety program with a goal of zero harm for patients, colleagues and residents. One key initiative for patient safety included an initiative at Loyola Medicine, where we achieved an 80 percent reduction in operating room safety events. is initiative will now be implemented at other Trinity Health locations as best practice to reduce safety events and improve patient care. Achieving zero harm may seem ambitious, but we continue to gain momentum by being transparent and putting systems in place that make us exceptionally consistent, reliable and mindful about everything we do. n The risks of 'medium COVID' By Mackenzie Bean A plethora of research suggests that the risk of severe health complications is highest in the weeks — not months — after a COVID-19 infection, yet this crucial period is often lumped into the broader term "long COVID-19," Benjamin Mazer, MD, wrote in an Oct. 11 article for The Atlantic. Dr. Mazer, an assistant professor of pathology at Baltimore- based Johns Hopkins Medicine, said the most serious COVID-19 complications occur in the first 12 weeks after an initial illness. "This period of time is so menacing, in fact, that it really ought to have its own, familiar name: medium COVID," he wrote. Numerous studies suggest these health risks may lessen as time advances. For example, Swedish researchers found the risk of developing a pulmonary embolism was 32 times higher in the first month after detecting COVID-19 and fell to just two times higher after 60 days. Despite these differences, most studies research health outcomes in one large bucket called "long COVID," according to Dr. Mazer. "Medium COVID may be time-limited, but it is far from rare — and not always mild," he wrote. "It can mean a month or two of profound fatigue, crushing headaches, and vexing chest pain. It can lead to life-threatening medical complications. It needs recognition, research, and new treatments. For millions of people, medium COVID is as bad as it gets." n

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