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1. COMMUNICATION BREAKDOWN CITED AS FACTOR IN CHILD'S DEATH 2. HEALTH CARE QUALITY DIFFERS NOTICEABLY BY STATE 3. PAY PER VIEW: CASE STUDY: HEAD OFF ERRORS, ELIMINATE COLOR- CODED ADAPTERS ON OXYGEN FLOWMETERS

Patient Safety Monitor Alert, September 24, 2003

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1. COMMUNICATION DEFICIENCIES CITED AS FACTOR IN CHILD'S DEATH

The federal government and the state Department of Public Health (DPH) are investigating patient care irregularities that led to three preventable deaths at Boston's Children's Hospital.

The "serious deficiencies" found by the DPH included residents who were hesitant to call in more experienced doctors; nurses who failed to monitor patients properly; and physicians who were confused over who was in charge. The hospital has not contested the findings and is already working to correct the deficiencies.

The cases involved a five-year-old boy who died in May after suffering a grand mal seizure; a patient who died of a perforated ulcer after both of his non- functioning kidneys had been removed in anticipation of a kidney transplant; and a patient with cerebral palsy who died of a heart attack five days after admission.

Editor's note: Join communication experts Friday, September 26th, at 1 p.m. (EST), to learn how you can identify and correct communication deficiencies.

Click here to register for the audioconference, "Health care Communication in High-Risk Areas: Proven Techniques for Ensuring Patient Safety."

2. HEALTH CARE QUALITY DIFFERS NOTICEABLY BY STATE

The quality of care that patients receive depends on which state they receive it in, according to the sixth annual HealthGrades Hospital Quality in America Study, released September 22. Better-performing hospitals tend to be concentrated in northern and less populous states, while poorer-performing hospitals are concentrated in southern states.

States that exhibited the highest hospital quality, including Florida, Colorado, Ohio, Pennsylvania, and Michigan, ranked among the best consistently across the procedures and diagnoses studied. States with poorer performances at their hospitals, including Arkansas, Alabama, Oklahoma, Tennessee, and Mississippi, were ranked among the worst consistently across all procedures and diagnoses studied.

Healthgrades, headquartered in Lakewood, CO, is a health care quality ratings, information, and advisory services company that rates each of the nation's nearly 5,000 hospitals in 26 procedures and diagnoses. Click here to view results from the study.

3. PAY PER VIEW: CASE STUDY: HEAD OFF ERRORS, ELIMINATE COLOR- CODED ADAPTERS ON OXYGEN FLOWMETERS

Most medical professionals associate the color green with oxygen, particularly when it comes to flowmeter adapters. In many facilities, the regular room air meter has a yellow adapter and the medical oxygen has a green adapter. The two meters are usually located side-by-side.

The different colored adapters should help staff easily identify the meters connected to patients. But the adapters are universal and can easily fit on either device. This can potentially lead to errors, as staff at Alfred I. DuPont Hospital for Children in Wilmington, DE, recently discovered.

Click here to find out how a nurse inadvertently hooked a young girl up to the regular room air meter, and how staff has fixed the problem to improve patient safety. The cost is just $10. Briefings on Patient Safety subscribers received this article as part of their September 2003 issue of the newsletter.

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