This Week's Discussions: "The Pope & Condoms" & "Incident Reporting"

Topic 1: The Pope on Condom Use

In am writing in response to an article in the Washington Post on either March 27 or 29, 2009. The title of the article was "The Pope May be Right" by Edward C. Green a senior research scientist at the Harvard School of Public Health.

The issue is that condoms, according to the Pope, help to spread sexually transmitted disease, not prevent the.

As an expert OR nurse of 33 years, it is my opinion that the Pope is correct. The academic papers I have read about "surgical glove failure," I believe also corroborates my opinion.

Points to ponder:

• Research shows that over 30 - 60% or more of unopened, "sterile surgical gloves" are defected i.e. unsterile. This means that many "surgical staff," if just wearing "one" pair of gloves, are probably using unsterile gloves.
• If a patient has any kind of infection, that infection can be transmitted to the member of the surgical team. I.e., if a member of the "surgical team" has an infection then IT could be transmitted to the patient.
• Research shows that IF the "surgical staff are "double gloving," both parties benefit BUT this is not a 100% cure all either.
• Length of "surgical time" is a factor in "glove failure."
• Type of case is a factor, e.g. orthopedic cases have high amount of "glove failure" boney surfaces can tear the latex. Most gloves are made from latex, there are some other types BUT most are made from latex.
• If latex gloves have been exposed to "heat" at any time for example in transportation from the factories now often in international sites or IF they sit in a hot warehouse, etc. they will decompose or rip easily or become brittle. How about old condoms or condoms that were sitting in someone's wallet or in the glove compartment of their car?
• Many people are allergic to "latex." Condoms are latex.
• Some condoms come with a lubricant. Lubricants used when donning "surgical gloves" is a no no, though many staff (and some still do it) used to put on some type of cream, petroleum jelly, and etc to "protect" their hands from the "surgical glove."
• Now some nurse chat groups are saying that to cut costs in the operating room, ALL staff have been asked to ONLY use one pair of gloves, i.e. not to "double glove." IF a patient's infection HEP B, HEP C, and etc. is transmitted to one of the surgical staff member what kind of "liability" issue could that be for the hospital?
• Most regular condoms, dental dams, and female condoms don't cover ALL of one's genitals.
  

I think some of my "analogies" might help the Pope to defend HIS opinions.

Topic 2: Pennsylvania Patient Safety Authority 2008 Annual Report

A very very interesting article!!!

My question is, how many "issues" did the hospitals not report? It is my opinion that this "report" is just the tip of the iceberg, a snapshot of what is occurring in the entire USA.

I was told that Pennsylvania got so much data at one point, over 15,000 reports in one month, that since then they were unable to handle the huge quantity of data. They had to outsource the data to ECRI.

Executive Summary: Pennsylvania Patient Safety Authority 2008 Annual Report

For the full report click the link above.  The 4 MB file may take several minutes to load.

The following are some examples from the report:

525 hospitals, birthing centers, ambulatory surgical facilities, abortion facilities and birthing centers were subject to Act 13 of 2002 and Act 30 of 2006 reporting requirements. They submitted 219,874 reports of Serious Events and Incidents to the Authority, an increase of 7,891 reports from 2007.

Approximately 96% of all reports were Incidents, or did not cause harm to the patient; approximately 4% of all reports were Serious Events, which indicates that the patient received some level of harm, ranging from minor, temporary harm to death.

The number of Incident reports averaged 17,602 per month, an increase of 3% from 2007. Serious Event reports averaged 720 per month, representing a 19% increase from 2007. A significant portion of this increase can be traced to healthcare-associated infections reported by law as a Serious Event earlier in the year as a result of Act 52 of 2007.

Reports from hospitals accounted for 98.6% of all reports submitted. However, reports submitted by ambulatory surgical facilities increased from 10.7 reports per facility in 2007 to 11.8 reports per facility in 2008.

When evaluated regionally, the largest numbers of reports come from the southeastern and southwestern counties, which is consistent with the population within Pennsylvania. When report volume is adjusted for patient days, facilities in the north central counties appear to be more aggressively reporting events. Serious Events submitted in the north central region were 7.6%, significantly larger than the statewide average of Serious Events (3.5%). These higher numbers could be due to several factors including: a higher number of actual patient safety events; differences in the ability to identify patient safety events (especially Incidents); and differences in the way facilities report patient safety events based on Mcare law interpretation.

Statewide, the most frequently reported events in hospitals involved Errors related to Procedures/Treatments/Tests (23%) and Medication Errors (22%). However, Errors related to Procedures/Treatments/Test comprise only 8% of reports involving harm or death and Medication errors comprise only 4% of events involving harm and 1% of events contributing to or resulting in death.

Conversely, while Complications related to Procedures/Treatments/Tests comprise only 13% of reports overall in 2008, they comprise 43% of the reports of events involving harm and 59% of all reports of events resulting in or contributing to the patient's death.

Patients over age 65 were especially vulnerable to Serious Events and Incidents, representing more than half (52%) of all reports submitted to the Authority. In 2008, approximately 60% of all Falls and 73% of all reports related to Skin Integrity involved older patients. Falls reports for older patients are down by 4% since mandatory reporting began in 2004. Skin integrity reports remain the same. Skin integrity reports include pressure sores, bruises and other skin-related conditions.

In a recent survey, 218 Patient Safety Officers (PSOs) reported making 607 changes in their facilities in 2008 as a result of specific Pennsylvania Patient Safety Advisory articles. PSOs from hospitals (115) cited 484 changes, while PSOs from ASFs (103) cited 123. Please see the section "The Authority's Annual Survey of Patient Safety Officers" in the complete report for more information about this survey.

Dear Patients,

I feel so sorry for patients who suffer from surgical injuries inflicted on them by the system.

I feel so sorry for the families who had loved ones die during or after surgery because of the system.

After 33 years of working in the OR arena, I know the issues, and I know the solutions.

The solutions don't cost any money.

Each hospital knows their own problems and issues!

Someone in each hospital just needs to have the guts to point out the issues.

And in each hospital there needs to be a champion that has the guts to support that person who points out the issues.

AND

If changes are not producing good results, someone needs to be fired.

As a patient advocate, who also now has post-op "issues," I must say that I have worked like hell over the years to make "good" changes in the healthcare arena. However, today is the time for good Nurses everywhere to rise up together, not through a multitude of organizations, but through their own places of employment. No power plays, no cronyism, no bullying, no in-fighting, no trying to make one’s budget look good just for the CEO. But, by working together to protect our patients, we all win!

My next discussion will be on the "issues." The issues that cost nothing to fix.

Have a wonderful weekend,
Blessings,
Helen M. French RN, BSN