Unintended Patient Safety Consequences of Nonclinical Decisions: 2 Cases

Tags: emergency department | hospital quality | MedAchieve | Michael Cassatly | patient safety

The majority of efforts to prevent hospital-acquired infections and to improve hospital quality are focused on clinical decisions — such as implementing best practices to treat a patient with a certain disease. However, decisions in nonclinical areas can also affect HAIs and quality. Michael G. Cassatly, DMD, president of the business coaching company MedAchieve and diplomate of the American Board of Oral & Maxillofacial Surgery, provides two examples of how a decision unrelated to clinical care can have unintended consequences for patient care.

Example 1: Changing ED signs
Dr. Cassatly describes a case in which a hospital changed its signs instructing patients where to go for different departments. The new sign was multilayered, making it difficult to identify where to go to reach a certain area. A family seeking the hospital's emergency department for a family member who had a heart attack could not determine where the ED was based on the signs and got lost, which delayed the patient's treatment and ultimately lead to his death. When under stress and in a rush, which many patients seeking the ED are, a simple factor such as hospital signs can make a big difference in patient outcomes.


Example 2: Nurse staffing
Dr. Cassatly says cutting staff to reduce costs can also lead to unintended consequences. If the hospital approaches reduced reimbursement from only a financial standpoint, it may make a decision that significantly affects clinical care. For example, if staffing cuts are made in every department, some departments may not have enough staff to clean patients' rooms as fast or see patients as quickly. Delayed cleaning may result in an infection, and delayed nursing care may negatively impact patient outcome; both potential effects would lead to poor quality of care.

To avoid these unintended consequences, Dr. Cassatly suggests hospitals consider how each area of the hospital is connected to other areas. Taking this approach, called a systems analysis, can help hospitals make decisions that benefit patient care. "In the current transformation to a value-based payment system where quality is financially rewarded or penalized, systems analysis may make the difference in your institution's viability," Dr. Cassatly says.

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