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Breaking Health Care’s First Commandment

Posted By Administration, Friday, June 26, 2015
Updated: Friday, June 26, 2015

Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol.

by Nanne Finis, RN, MS


The often-quoted phrase “First, Do No Harm” is not really in the modern Hippocratic Oath. But a recent study of medical errors in U.S. hospitals suggests that perhaps it should be widely adopted as the first commandment of health care.


That study estimates the true number of deaths due to preventable errors may be four times more than the 98,000 per year quoted by the Institute of Medicine in its report To Err Is Human.


A culture of safety?

Given the mission of health care institutions, the general public might be surprised to hear the rising chorus of health professionals calling for a “culture of safety” to be adopted in our nation’s hospitals. Yet a 2012 IOM study reported that one-third of all hospital patients experience some form of hospital acquired conditions (HACs), ranging from minor injuries to death.


Infection, for example, was historically considered an acceptable risk of providing care, but recent changes in reimbursement regulations mandated reductions in medical errors and penalized re-admissions and infection-related length of stay. Now a whole range of technologies is available to contain the spread of infection, from robots that blast germ-killing ultraviolet light to remote monitors that keep track of hand hygiene compliance by health care workers.


But problems persist. The Joint Commission, which accredits more than 75% of U.S. hospitals, found infection prevention and control deficiencies in about half of the hospitals it surveyed in the first half of 2014. Although one in 25 hospital patients will acquire an infection during treatment, more than a third of U.S. hospitals that responded to a recent survey reported they do not have a certified infection prevention specialist on staff.


While progress is being made, it’s clear that more needs to be done. Although handwashing is regularly touted as the best way to fight infection, handwashing studies of hospital staff repeatedly place compliance in the 30% to 40% range. Health care providers need more tools to protect workers and the general population.


Readmissions and communication breakdowns are other areas of concern. A record 2,610 hospitals are under CMS penalties for readmissions. Last year, nearly 18% of Medicare patients were readmitted within 30 days. That’s two million patients at a cost of $17 billion.


The Ebola scare in a Dallas hospital last fall raised a number of new questions about communications breakdowns, preparedness, and the priority given to patient safety in U.S. hospitals. Two nurses infected with Ebola while treating a Liberian national were successfully treated for the disease, but the outcome could have been far worse. The death of “Patient Zero” in Dallas could have happened at almost any hospital in the world. And it could happen again, as long as the potential for breakdowns in communication exists.


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The Infection Multiplier Effect

A hospital that my organization worked with reported to us that one infected hospital patient was found to have come in contact with 216 people in a single day. This was during the course of a normal day of treatment. Even if a small percentage of that group was infected, imagine how quickly things could spiral out of control, especially with a virulent strain of infection.


With that kind of potential for exposure, it’s vital that hospitals have the means to identify within minutes all of the hospital personnel who may have come in contact with a contagious patient. The same goes for medical devices and transport equipment.


Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol. Most hospitals still use manual processes to distribute warnings about infected patients, including physically posting isolation status at the entrance to patient rooms. This can lead to inadvertent infection exposure among hospital employees who enter the room before the warning has been posted.

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Leaders must lead

Saying that “safety comes first” isn’t enough. What drives continuous success are accountability, transparency, and regular communication. While it is laboriously time-consuming to monitor protocols and track infectious patients, health care IT is bringing real-time operational visibility to patient safety and care delivery.

  1. Check to see how well your departments talk to each other. Manual processes, like posting isolation status at the entrance to patient rooms, are too slow for the pace of today’s hospital environment. This outdated process could lead to inadvertently infected hospital employees because they haven’t been alerted to the presence of infection in a patient or patient room.

  2. Make sure there is a single source for infection information so employees don’t have to seek out details in patient records. Make someone in the organization the point person for mobilizing key stakeholders from nursing, emergency medical services, emergency medicine, critical care, infection prevention and control, and give that person the responsibility of working with external government health departments and emergency management.

  3. If your infection control processes have been in place for years and if infection rates have been trending up, find out whether hospital leadership has explored the benefits of implementing infection-tracking technology.

  4. Finally, find out if technologies currently in place have been optimized to support infection prevention. Some systems come with embedded features that only need to be activated. Among these are Real Time Location Systems (RTLS), patient flow systems, and capacity management platforms

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What’s available now?

Current technologies can also chart the path of anyone or anything (like medical devices) that came in contact with an infected patient. Some allow infection warnings to stay with the patient as long as the condition lasts and wherever the patient travels within the hospital, providing a second line of defense against the spread of infection. Isolation status can be instantly distributed to care team members, environmental services staff and transport employees via page, mobile and desktop computer alerts. Hand washing monitoring systems can provide real-time reports on compliance, including name, time, and location enterprise-wide.


Prepare, prepare, prepare

"If an Ebola patient walks into a hospital that has a high rate of infection,” says Leah Binder, president and CEO of The Leapfrog Group, “they are going to be woefully unprepared.”


Technology is no silver bullet. Without discipline, infection control is problematic no matter what plans are in place. Getting serious about safety is the first of many steps that will need to be taken to ensure the safety of patients, hospital employees, and the public at large, given the current state of infection control.


Does your organization do an effective job of communicating about infection control and risk? Comment on this post below. (To comment, please log in. If you are not already registered on our site, please register here.)

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Nanne Finis, RN, MS, is vice president of consulting services at TeleTracking Technologies, Inc. Contact her at

Tags:  communication  infection  readmissions 

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