SaferCare Texas

Category: prevention

National Men’s Health Week

National Men’s Health Week is the week in June leading up to Father’s Day. This week is all about bringing awareness to preventable health issues for men and boys.

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SaferCare Texas's Director John Sims speak to his experience with men's health.

When men ignore symptoms and suppress emotions, they risk early death or poor quality of life. Heart disease is the leading cause of death for men, accounting for 25% of all male deaths. On average, men die five years sooner than women, and three out of four men avoid seeking medical attention when unknown symptoms present. Societal pressures to suppress feelings lead to undiagnosed depression and unhealthy coping strategies such as alcoholism, drug abuse, or violent behaviors.

A man lost consciousness at a recent senior event and ultimately lost his pulse, requiring cardio-pulmonary resuscitation(CPR) and evaluation at a hospital. Prior to his cardiac arrest, the man proposed to go home instead. He likely would have died! Another man in his early 50s rationalized his abnormal heart symptoms away. Fortunately, two medically trained family members convinced him present to the nearest emergency room for evaluation. He required quintuple(5) bypass surgery and an 18-day hospital stay. He, too, may have died! SaferCare Texas interviewed this man on their #SpeakUpForSaferCare podcast. Listen here.

Male harm is self-inflicted by avoiding to seek medical attention and concealing their feelings. Much of this harm is preventable. If you are a man or you live with a man, consider the following two steps:

1. Recognize Symptoms

Heart Disease

Chest pain/discomfort

Upper back/neck pain

Heartburn/indigestion

Extreme fatigue

Dizziness

Shortness of breath

Depression

Escapist behavior- spending a lot of time at work

Headaches/digestive problems

Alcohol/drug use

Controlling/abusive behavior

Inappropriate anger

Risky behavior

2. Reduce Your Risk

Heart Disease

Check your blood pressure: Talk with your healthcare provider

Diabetes raises your risk – get tested

Cut out smoking

Check your cholesterol/triglyceride levels: Talk with your healthcare provider

Limit alcohol

Reduce stress

Heart Disease

Set realistic goals/expectations

Emotional support: Seek out support from friends and family

Coping: Manage stress with meditation and mindfulness

Decisions: Avoid making important decisions until depression resolves

Activities: Intentionally engage in activities where you find joy.

Health: Promote better mental health with healthy eating and physical exercise

Men are essential members of society and families. Men’s bodies and emotions are similar to women’s. Recognize and reduce; follow these two steps to maintain longer and healthier lives!

About SaferCare Texas

SaferCare Texas was founded as a response to the national challenge to improve patient safety. We work to eliminate preventable harm through advocacy, education, innovation, and service in Texas and throughout the nation. SaferCare Texas is a department within HSC at Fort Worth.

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Registered Nurse Convicted of Criminally Negligent Homicide: Are future patients in danger?

Background

The Verdict

A former Vanderbilt University Medical Center (VUMC) Registered Nurse(RN) administered a fatal medication in error. The RN had responded to a physician’s order to give Versed/Midazolam for sedation of a patient undergoing a (Positron Emission Tomography)PET scan. The neuro-intensive care RN was designated as a “Help All” nurse, which means she assisted other colleagues but was not assigned patients. The RN, accompanied by a trainee, walked to the radiology suite, where PET scans were performed. There were no computers in this unfamiliar environment, so the RN accessed the automated dispensing cabinet (ADC) to display the patient’s ordered medications using her unique password. She typed “VE” for “Versed/Midazolam,” but the first drug shown was “Vecuronium Bromide,” a paralytic. VUMC leadership had advised staff to bypass overrides to prevent patient care delays, as they were updating their Electronic Medical Record(EMR). The RN administered the dangerous paralytic instead of the ordered sedative, and the patient subsequently died5. 

VUMC has an invaluable reputation as the most prestigious hospital in Tennesee. According to a popular news outlet, a lead investigator on the criminal case found that VUMC had a “heavy burden of responsibility” for the fatal medication error4. Further reports indicate that the error was made possible by systemic failures at VUMC. When a person dies from a medical error or a sentinel event, it must be reported to the county, state, and federal authorities. However, VUMC advised the medical examiner that the patient died of “natural causes” with no mention of Vecuronium Bromide. Instead, VUMC paid the family an undisclosed settlement stipulating their silence, terminated the nurse, reported her to the Tennesse State Nursing Board, and left her to confront criminal charges alone. On March 24, 2022, a Nashville, Tennessee, jury convicted the RN of criminally negligent homicide.

Will Patient Safety Pay the Price?

According to the National Coordinating Council for Medication Error and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a healthcare professional, patient, or consumer6.” This error was preventable, but was it an isolated event, or might it be repeated?

Healthcare systems strive for high reliability; however, humans are unreliable. Healthcare relies on humans who inevitably make errors. Causes of human error may be internal or external7.

Most errors result from faulty systems or processes, not individuals. Strategic design of systems must incorporate human factors to mitigate the risk of harm.

Criminalizing error reporting will profoundly reduce healthcare’s ability to minimize failures, increasing morbidity and mortality. Individuals must be encouraged to report errors within a Just Culture and with Psychological Safety to guide system design. The RN involved is accountable for her actions; however, VUMC share accountability for encouraging unmanaged error precursors, such as overruling the ADC’s “override” alert. The alert was designed to prevent this fatal error! The redesigned process, authorized by leadership, placed the RN, a fallible human, as the last line of defense.

Human Errors

Internal Causes
External Causes

Limited Memory Capacity

Noise

Fatigue

Long Work Schedules

Stress

Inadequate training

Hunger

Poorly designed rules/procedures

Illness

Interruptions

Language Limitations

Distractions

Hazardous attitudes

Language barriers

Internal Cases

Limited Memory Capacity

Fatigue

Stress

Hunger

Illness

Language Limitations

Hazardous attitudes

External Cases

Noise

Long work schedules

Inadequate training

Poorly designed rules/procedures

Interruptions

Distractions

Language barriers

Human Factors
Engineering7

The scientific study of capabilities and limitations of human performance and the application of knowledge to design tools, systems, and processes—to minimize failure and maximize efficiency

Psychological
Safety2

Psychological safety is “a condition in which one feels (a) included, (b) safe to learn, (c) safe to contribute, and (d) safe to challenge the status quo, without fear of being embarrassed, marginalized or punished in some way”

Just
Culture1

Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.

We must accept that we are complex individuals working in a complex healthcare system. Safe and reliable care relies on leadership, a learning system, and a safety culture pre-occupied with failure, yet working together to prioritize patient safety. VUMC took the easiest path, to focus on individual behaviors (blame) instead of a more holistic view of organizational drivers that can drive behaviors (incorporating human factors into system design) This is called a system’s view or Systems Thinking. A shift to systems thinking in the medical industry is lacking, and the victim is not the RN but our patients!

References
  1. Boysen, Philip G 2nd. “Just culture: a foundation for balanced accountability and patient safety.” The Ochsner journal 13,3 (2013): 400-6.
  2. Clark, T. R. (2019). The 4 Stages of Psychological Safety. Available online at: http://adigaskell.org/2019/11/17/the-4-stages-of-psychological-safety/ (April 4, 2022)
  3. Domer, Gregory, et al. Patient Safety: Preventing Patient Harm and Building Capacity for Patient Safety. Bethlehem: IntechOpen, 2021.
  4. Kaiser Health News. “In Nurse’s Trial, witness says hospital bears heavy responsibility for patient death.” news. 2022.
  5. States Response To Request For Discovery. No. 2019-A-76. Criminal Court For Davidson County, Tennesee Division IV. 27 3 2019.
  6. Tariq, Rayhan A., Rishkit Vashisht and Yevgeniya Scherbak. “Medication Dispensing Error And Prevention.” Europe PMC (2018): 1.
  7. Topic 2: What is human factors and why is it important to patient safety? In: Patient Safety Curriculum   Multi-Professional Edition. World Health Organization; 2011. Accessed April 5,2022.

DISPOSE YOUR PERSCRIPTON DRUGS CORRECTLY. YOU COULD SAVE SOMEONE’S LIFE.

Often times, consumers are not always familiar with the process of disposing expired, unwanted, or unused medications. As a result, they will attempt to bring these medications back to the pharmacy or the provider’s clinic for disposal. However, these sites are not able to take back the medication once it leaves the premises due to concerns of contamination. This increases concern of unwanted prescription medications left in the house, which allows for other individuals to have access to it such as family and friends. Based on the National Survey on Drug Use and Health in 2015, it was seen that most abused prescription drugs were acquired by family and friends from home.

Reasons why unused medication may be a danger to your family and friends:

  • Up to 92% of patients with opioid prescriptions do not use their entire prescription1
  • Up to 77% of patients do not store their opioid prescriptions in a locked container1
  • One in four teenagers misuse/abuse a prescription drug at least once in their life2
  • Drug overdose involving any opioid prescriptions have increased to 47,600 deaths in 20173

Accordingly, National Prescription Drug Take Back Day was established by the U.S. Drug Enforcement Administration (DEA) to occur twice a year (usually in April and October) for the safe disposal of prescription drugs including opioids. This is a free public event that offers proper medication disposal services to consumers at various authorized collection sites throughout the nation. Consumers should also know that there are ‘no questions asked’ when dropping off mediations at these sites. This service aids in the reduction of accidental or intentional misuse of unneeded medications as well as entrance into the environment.

The goal of this national event is to “provide a safe, convenient, and responsible means of disposing of prescription drugs, while also educating the general public about the potential for abuse of medications.”

If consumers are not able to attend the national event or there are no DEA-registered collection sites in the area, there are other safe disposal methods of medications:

Permanent collection sites4

    • There are permanent collections sites which may be located in retail pharmacies or law enforcement facilities
    • These sites may have a medication disposal kiosk or drop-off box where you can dispose of the medication at the consumer’s convenience
    • Google Maps
      • Search “drug drop off near me” in Google, you will find drug disposal sites near you
      • Learn more

Proper home disposal4

  • Mix the medicine (do not crush tablets/capsules) with an inedible substance (i.e. dirt, cat litter, or used coffee grounds
  • Place the mixture in a sealed container (i.e. plastic bag)
  • Throw the sealed container in your household trash
  • Remove all personal information on the prescription label of the empty bottle before disposal
  • Follow specific disposal instructions on a drug’s label or the patient information that accompanies the medication—and don’t flush the drugs down the toilet

By using available resources and appropriate methods to dispose of prescription medications, this offers a safer community and environment for everyone.

Additional information can be found at: https://takebackday.dea.gov/and www.fda.gov.

 

References:

1.    Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review. JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831

 

2.    National Study: Teen Misuse and Abuse of Prescription Drugs Up 33 Percent Since 2008, Stimulants Contributing to Sustained Rx Epidemic. https://drugfree.org/newsroom/news-item/national-study-teen-misuse-and-abuse-of-prescription-drugs-up-33-percent-since-2008-stimulants-contributing-to-sustained-rx-epidemic/.

 

3.    Overdose Death Rates | National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.

4.    Research C for DE and. Safe Disposal of Medicines – Disposal of Unused Medicines: What You Should Know.https://www.fda.gov/drugs/resourcesforyou/consumers/
buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm.

Nutrition Literacy and Patient Safety: Could this impact your patients?

As a registered dietitian, I know that the misunderstanding of basic nutrition or medical nutrition therapy can have major consequences for patient outcomes. I have seen the link between nutrition literacy and patient safety many times. Some of the more memorable encounters include:

  1. A newborn infant admitted near death because her mother did not know that crushed chips in soda placed in a bottle was not a nutritionally sound diet for infants. Chips and soda were typical foods for the mother.
  2. Another mother caused her child to fail-to-thrive due to her obsession with a fat-free diet. She was literally starving her child of much needed fat and calories for normal growth and development.
  3. One man living with diabetes, who was post-op toe amputation from complications due to poor blood sugar control, had taken his insulin at 8am but had not yet eaten breakfast. When I went to his home at 10am to check on him, I inquired about a potential low blood sugar reaction and he pulled open a drawer of candy. Instead, he should have eaten within a half hour of taking his insulin to keep his blood sugar stable and to prevent future complications.
  4. A grandmother with morbid obesity was homebound and bedbound with good family support but chronic readmissions. I was checking on her post-discharge from the hospital and was pleased to find a wide variety of fruits and vegetables in her refrigerator. When I inquired from her granddaughter why they were all still in the package, she replied, “The dietitian at the hospital told us we needed to buy more fruits and vegetables…but, we don’t know what to do with them.”
In all of the scenarios described and many more throughout the world, people may not understand basic nutrition principles to thrive, stay healthy and well, or prevent medical complications. 
 

EatRight, LiveRight, FeelRight

This year’s theme for National Nutrition Month® is EatRight, LiveRight, FeelRight! Sounds like an easy concept. However, people are limited in capacity to achieve these aspirations by their level of nutrition literacy. Nutrition literacy requires skills and capabilities empowering people to be food and health literate. These concepts also raise the questions do people have adequate access to nutritious foods and knowledge about food for proper selection or skills for preparation?

Nearly one billion people living in the world today are hungry on a daily basis, and over thirty percent of the world’s population experiences malnutrition in one form or another (World Food Program, 2018). The burden of malnutrition falls most heavily on girls and women who make up nearly two-thirds of this statistic (World Hunger, 2016). Babies born to mothers who are malnourished are at greater risk for low birth weight, which further places the baby at risk for early mortality, under five years of age. In the United States (U.S.), 40 million people are “food insecure” or lack access to healthy foods. This includes more than 12 million children. Malnutrition in children is the biggest contributor to childhood mortality, opening the door to opportunistic infections by inhibiting the effectiveness of the immune system (World Hunger, 2016).

However, good nutrition and access to healthy foods are not only essential for maternal and child health outcomes but for all populations. Good nutrition is important for prevention and management of chronic conditions such as obesity, heart disease, diabetes, and some types of cancer. Additionally, proper nutrition is one aspect of preventing obesity, which is a major health risk globally and in the United States. While the importance of good nutrition is well understood by clinicians, putting nutrition recommendations into practice can be very challenging for many families. For example, some places in the United States, labeled “food deserts,” lack healthy food that is affordable for the families that live there or sometimes lack healthy food entirely (USDA, 2009). Additionally, these neighborhoods frequently have more fast food restaurants and convenience stores that only sell unhealthy food options (USDA, 2009). Those living in low income neighborhoods generally have to travel further to access a supermarket, and 2.3 million households live more than one mile from a supermarket and do not have transportation (USDA, 2009). As a result, disparities exist in achieving the goal to EatRight, LiveRight, FeelRight!

Additionally, nutrition literacy causes health barriers without regard to socioeconomic status. Even the most affluent of households suffer from chronic diseases or complications related to poor nutrition literacy. Previously, public health promotion strategies have focused on nutrition education but have not been successful in changing dietary intake (Vidgen, 2016). Explicitly supporting and building food literacy infrastructure may more effectively address the self-efficacy people need to navigate the current food system and make healthy food decisions (Vidgen, 2016). Promoting National Nutrition Month®, the Academy of Nutrition and Dietetics recommends multi-faceted interventions to address poor food and nutrition literacy. Registered Dietitians receive specific training to help people navigate food and nutrition, complex phenomena made up of multiple factors of environment and lived experience, empowering people to eat healthy and reducing disease risk among populations. The Academy also supports advocacy for nutrition policy to help correct environmental, knowledge/skill and access barriers therefore, create a culture where everyone can EatRight, LiveRight, FeelRight!

If you are struggling with health literacy or have questions about the topic, feel free to contact us or read our resources for more information. 

References

  • US Department of Agriculture. (USDA). (2009). Access to affordable and nutritious food: measuring and understanding food deserts and their consequences. Washington, DC: Report to Congress.
  • Vidgen HA (editor) (2016) Food Literacy: Key Concepts for Health and Education. London: Routledge.
  • World Food Program (2018). Zero Hunger. Retrieved from http://www1.wfp.org/zero-hunger
  • World Hunger (2016). Women and Hunger Facts. Retrieved from https://www.worldhunger.org/women-and-hunger-facts/

Written by Teresa Wagner, DrPH, MS, CPH, RD/LD on March 14, 2019

COMMUNICATION BETWEEN HEALTH CARE PROFESSIONALS IS KEY

A friend recently began experiencing physical symptoms and was hospitalized, tests were run, and a quite serious condition was discovered. He was discharged from the hospital with referrals to several specialists to pursue a course of treatment. Expressing frustration, he and his wife shared with me that they felt as if they were starting over with each new individual practitioner. They failed to recognize any organized communication or coordination between those practitioners. Following their care journey has reminded me of the benefits of an integrated team approach to care over the more traditional parallel practice model of care.

Parallel Practice Care vs. Integrative Care

In a parallel practice model of care, independent healthcare practitioners share a common patient. Each practitioner performs their role, within their scope of practice with the patient.1 Though communication may occur between these practitioners, it is typically rather informal and may not be evident to the patient and patient care givers. These often ad-hoc care teams typically have no assigned leader or case manager to ensure that information is transferred between practitioners and the patient efficiently. This approach to care often fails to integrate the patient and care givers as a part of the care team. Of the 251,454 deaths per year in America attributed to medical error,2 up to eighty percent of those medical errors are associated to communication errors.3

Integrative care consists of an interprofessional team of practitioners providing a seamless continuum of care. Each practitioner, the patient and their care givers contribute knowledge and skills to develop a shared plan of care.4 This patient-centered approach to care recognizes the importance of communication within and across the care team which includes the patient and their care givers. It can range from care teams that meet with the patient to discuss plans of care, or teams coordinated by an assigned team leader or case manager. Integrative teams are typically non-hierarchical, focused on treating the whole person, valuing the contributions that each practitioner, staff member and patient bring to the team.

Supporting an Integrative Healthcare Model

As a practitioner in the field of mental health, I have had the opportunity to practice within both parallel practice and integrative models of care. I personally found the integrative model of care a much more satisfying practice experience. My friend and his wife fortunately have made their way into an integrative care practice. Though struggling to accept and adjust to a serious medical condition, they report renewed hope in being a part of an interprofessional patient-centered practice, where they feel an integral part of the team.

If you have any questions about these types of healthcare models or would like more information, the SaferCare Texas team is here to support you. You can reach us at 817-735-7633 or by email.

References

  1. Boon, H. Verhoef, M. O’Hara, D. Findlay, B. (2004) “From Parallel Practice to Integrative Health Care: A Conceptual Framework.” BMC Health Services Research, 4(1):15.
  2. Makary, M. and Daniel, M. (2016) “Medical Error the Third Leading Cause of Death in the US” British Medical Journal, 353:i2139.
  3. Joint Commission on Accreditation of Healthcare Organizations. (2012) “Joint Commission Perspectives” 32(8).
  4. Boon et. al.

Written by David Farmer, PhD, LPC, LMFT on February 26, 2019