Heparin errors and patient harm have been in the news quite a bit the last few years. So what are hospital regulators doing about it?
Let's look at the time line here:
Really? It took until NOW to get some guidelines and recommendations out to hospitals?
“The Joint Commission issued a safety alert saying hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children's units.
The alert said 28 deaths are among 32 reports of drug errors involving blood thinners that it received between 1997 and last year.
“We know that there are many more (deaths) and … that's the reason for issuing this alert,” said Dr. Mark Chassin, president of the Oakbrook Terrace, Ill.-based commission.”
Here's more on the guidelines from the official Joint Commission site.
If an alert like this really makes such a difference, how many people were harmed in the 10 months since the well-known Quaid case? So either this was a really slow response, or the Joint Commission and it's pronouncements just don't matter too much. My local paper posed questions about the value of accreditation, considering that many hospitals with horrible patient conditions (the now-closed King/Drew Medical Center and JPS Hospital) were all accredited.
Christine Cahill, a government inspector, walked in to the operating room of a Los Angeles county hospital and found a technician cleaning a surgical instrument. He told her that he had just washed it, but she noticed no water in the sink, so she questioned how he had cleaned it, and he said he had used a cleaner that was in a bottle on the shelf.
“Give me a Q-Tip,” she said. She shoved it into the hollow bore of the instrument.
“Out came this crud,” she recalled. It was dried-up fragments of bone and blood.
At one out of every three hospitals Cahill surveyed for the federal government in California from 2004-06, she said she found egregious deficiencies that put patients' lives at risk. Yet these same hospitals, within a year before her review, had received passing grades from the Joint Commission, America's top healthcare evaluator.
It gave its most prestigious honor – its trademark Gold Seal of Approval – to Martin Luther King Jr./Drew Medical Center, where Cahill found the filthy surgical instrument.
And the commission also awarded that top honor, symbolizing that a hospital has met the most rigorous standards for patient care and safety, to John Peter Smith Hospital in Fort Worth in spring 2006 – the year before an independent consultant documented pervasive problems that put patients at risk.
The Joint Commission says they are using Lean…. let's hope they can reduce the cycle time for getting “alerts” and new recommendations out into the hospital world. It seems like they also need to take a step back and think about the “value” they are providing for hospitals or patients.
Coming over from the manufacturing world, this all reminds me of the “ISO-9000” industry that has built up over the past few decades. Having ISO-9000 certification is often a “check the box” activity where the piece of paper on the wall (or the flag flying in front of the factory) means NOTHING about the quality of product that's being shipped.
What do you think? Am I (and others) being too harsh on the Joint Commission?
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