Patient Safety, 2005

Veterans Integrated Service Network, Upstate New York

September 2004

Four VA hospitals in the Veterans Integrated Service Network in Upstate New York are using safety practices from AHRQ's Evidence Report No. 43, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. As a result of one of the region's Clinical Consultant meetings, four safety practices were adopted.

Geoffrey W. McCarthy, MD, MBA, now Chief Medical Officer in the Northwest VA network, was Director of Medical-Surgical Care for the New York region. He and Sherry Van Horn, RN, MS, the Chief Clinical Coordinator, led the semiannual Clinical Consultant meetings, which 40 to 70 VA staff members attended. "The first topic every meeting was patient safety," he recalls.

After reviewing the AHRQ safety practices, Dr. McCarthy and Ms. Van Horn chose five relatively low-cost, low-risk practices to bring to the November 2001 meeting. They challenged the group to analyze the following five practices:

Patient safety target	Patient safety practice
Prevent adverse events related to chronic anticoagulation with warfarin (Coumadin™)	Patient self-management using home monitoring devices
Prevent central venous catheter-related blood infections	Use of maximum sterile barriers during catheter insertion
Prevent ventilator-associated pneumonia	Semi-recumbent positioning
Prevent central venous catheter-related blood infections	Patient safety practice
Prevent hospital-acquired urinary tract infections	Use of silver alloy-coated catheters

Meeting attendees—physicians, nurse practitioners, physicians' assistants, and mid- and upper-level hospital administrators—were divided into groups to evaluate each of the five practices. A mix of professions in each group ensured diverse points of view and sound medical opinions. Each group came to the independent conclusion that VA patients could not cope safely with self-management of warfarin (Coumadin).

The four other practices were unanimously adopted and brought back to the four inpatient facilities represented at the meeting. Dr. McCarthy reports, "Within a week, there were 'Elevate HOB' signs up in the ICUs."

While it is difficult to change the behavior supporting current cultural norms, progress is being made. Currently, these VA hospitals have no measuring efforts underway to determine specific changes as a result of the incorporation of the four safety practices. However, a national project, led by Dr. Marta Render of the VA hospital in Cincinnati, will study the ability of ICUs to adopt and institutionalize evidence-based practices, such as those undertaken by the VA group in Upstate New York.

In addition to the AHRQ safety practices adopted, Dr. McCarthy says the hospitals have also begun a rigorous deep venous thrombosis (DVT) protocol to reduce DVT and pulmonary embolization. He explains that one VA hospital volunteered to develop an automatically triggered

menu based on strong evidence that a computer-generated prompt for patient orders reduces medical errors. Walter Rivera, MD, and Michelle Biscossi, RN, MS, were the originators and change agents for this "pop-up" dialogue box for inpatient orders.

The forcing function is now in use in all Upstate New York VA facilities, for both medical and surgical patients. When VA staff members write patient orders, an order menu and reminder screen pops up that asks the patient's age and reminds the user of the DVT risk to that patient. The next mouse click automatically orders the selected prophylaxis. The use of the forcing function has made a dramatic difference in the accuracy of written prescriptions, from a low of just 30 percent to 80 percent written correctly.

Overall, Dr. McCarthy says, the quality of AHRQ's information is "superb—the current basis for what we should be doing for inpatient care."

Impact Case Study Identifier: Multi-Center 05-06 (COE, CQuIPS)
AHRQ Product: Evidence Report
Topic(s): Patient Safety
Scope: New York

Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Summary. July 2001. AHRQ Publication No. 01-E057. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety/summary.htm.

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