The elderly man in room 5115 at Cedars-Sinai Medical Center in Los Angeles is wearing an orange wristband, and the door to his room is marked with an orange circle labeled FALL.
The symbols signify to patient-care personnel that he's more likely than the average patient to lose his balance and fall. Staff know they have to take special precautions with him.
For example, the dietary aide puts the tray close enough that the patient doesn't have to reach too far and possibly tumble from the bed. The care aide pays special attention when helping the patient move. Every person who comes into contact with the patient knows he or she must take special precautions to ensure the patient has no opportunity to fall.
This risk-assessment program for falls, implemented last year, has led to a marked decline in the number of patient falls at the hospital, says Maggie Stempson, the unit manager of cardio-thoracic service. However, the hospital declined to cite specific numbers of falls before and after the policy change, saying that information was protected under California law covering peer review.
The program is part of 846-bed Cedars-Sinai's quality improvement initiative to deal with "significant adverse events," which include sentinel events as defined by the Joint Commission on Accreditation of Healthcare Organizations, plus near misses.
Since late 1997, the Joint Commission has required hospitals to track serious patient-care accidents, which it calls sentinel events, and to perform a "root-cause analysis" of all the systems failures that contributed to the accidents. Many hospitals have dragged their feet on this approach.
Cedars-Sinai, by contrast, has heartily embraced this error-reduction method. It has established a hospitalwide infrastructure, which operates at every level, to promote error reduction and understanding of what can go wrong.
"I think it's one of the better things the Joint Commission has done," says Neil Romanoff, M.D., Cedars-Sinai's vice president of medical affairs. "Sometimes you need the imperative of the regulatory agency."
Cedars-Sinai underwent its triennial Joint Commission survey in early September. "Those surveyors were overwhelmed by the work we've done on this. Staff people can talk about (hospital initiatives) as well as the board," says Linda Burnes-Bolton, vice president and chief nursing officer.
The Joint Commission doesn't comment on survey results at specific hospitals, but Opal Reinbold, a pre-survey consultant with the San Diego-based Premier hospital alliance and purchasing group, says Cedars-Sinai has really taken the intent of the JCAHO's sentinel-event policy to heart.
"Any time there is anything questionable, they pull a group of people together and do a root-cause analysis and do very aggressive follow-up," Reinbold says. "When I did my rehearsal survey, I asked them how many people have participated in root-cause analysis. Almost everybody raised their hands."
Reinbold says she believes the hospital has obtained such strong buy-in from staff at all levels because of the strong support from executive leadership. Once reported, news of an adverse event goes up the chain of command quickly, ending at the board level.
Any patient fall is reported to the nursing supervisor on duty, who then reports it to quality management. If the fall results in injury, it becomes a significant adverse event, which is reported immediately to the chief nursing officer, the chief medical officer and the vice president for medical affairs, Romanoff.
The hospital's director of quality improvement, Marcie Cochran, then arranges a meeting of all the relevant parties to the event and initiates the root-cause analysis. This meeting must take place within 48 hours of the incident. In one case it began 45 minutes later.
"It's a high-priority meeting," Romanoff says. "We don't wait two weeks because somebody is going to be out of town." The hospital even changed the medical staff rules so physicians know they must respond quickly.
He believes that Joint Commission involvement compresses the timeline.
That doesn't mean that Cedars-Sinai submits its findings to the JCAHO. Although the findings of the root-cause analysis team are protected by California's strong peer-review law, the California Healthcare Association has advised hospitals there not to forward the results of their analyses or the notifications of the sentinel events to the Joint Commission. The state's hospital association fears that once the information is outside the hospitals, it might be discoverable by plaintiffs' attorneys.
This is one of the roadblocks in the Joint Commission's approach to sentinel events. It has asked hospitals to forward notices of their sentinel events and root-cause analyses so that it can compile a database of accidents and uncover patterns behind the events.
"The responses we're getting are generally accepting of the need for increased attention to the need for reduction in medical error," says Richard Croteau, the JCAHO's executive director of strategic initiatives. He sees "agreement in principle" with reporting to a central database where results can be analyzed.
As of September, the JCAHO had received 601 root-cause analyses from hospitals and had published 10 sentinel event alerts based on newly discovered patterns of error. There is still strong concern about the risks of sharing documents with the JCAHO or any other outsiders, Croteau says.
Cedars-Sinai does not contribute to the national knowledge base on medical errors. "We learn a lot. We improve. But that data is not being used outside the institution," Romanoff says.
The JCAHO is working to remove this liability impediment. One of the patient-protection bills now before Congress includes provisions to compel mandatory reporting of errors and near misses. Additionally, it would extend confidentiality to root-cause analysis reports forwarded from outside the hospitals.
"The two have to go together for it to work," Croteau says. "You won't get complete reporting if there is a substantial legal risk involved."
Cedars-Sinai keeps its files closed to outsiders-and even insiders. Cochran files under lock and key all paperwork, documents and notes from adverse-event meetings. She maintains a customized template that includes information about what went wrong and how faulty systems contributed to the error. Once the corrective action plan is devised, she makes sure it's implemented at every level.
A summary of that information goes to the executive staff, including the hospital's chief executive officer, and then to the board. All aspects of the root-cause analysis, the corrective action plan and the implementation can be tracked retroactively.
The key to making the whole thing work, Romanoff adds, is employee education. Everyone on the unit, including aides and transporters, knows how to respond to patient-care errors and how to prevent them.