Strong Publishes Study of Stroke Care Safety

Hospital Puts Changes in Place to Boost Safe Care

May 02, 2007

The quality and safety of stroke care in U.S. hospitals can be vastly improved if institutions first understand how patients may be injured as a result of medical mishaps, says a study conducted at Strong Memorial Hospital

The study, which appears in the February 20, 2007 issue of Neurology, the scientific journal of the American Academy of Neurology, looks closely at care provided to 1,440 stroke patients hospitalized at Strong between July 1, 2001 and December 31, 2004.  By analyzing “incidents” reported by staff, the study details the frequency, types, and preventability of various adverse events. 

Associate professor of Neurology and lead author Robert G. Holloway, M.D. hopes that analyzing and sharing Strong’s experience will prompt physicians and hospitals across the country to improve the safety of the care provided in their institutions.  “Learning about what caused these events in our stroke patients is the ONLY way to keep them from happening again,” Holloway said.

 “This study represents the honest self-scrutiny that’s needed if we are to truly understand and reverse the epidemic of hospital errors,” said Donald Berwick, M.D. president and CEO of the Institute for Healthcare Improvement.  Berwick is one of the nation’s leading authorities on health care quality and safety improvement.  “I applaud the University of Rochester Medical Center for having the courage to use its own experience as a national springboard for change,” he said.

Over a three-and-a-half-year period, Holloway studied the experiences of patients who were treated for strokes caused by blood clots or spontaneous bleeds in the brain.  Of the 1,440 patients studied, 12 percent, or 173 patients, experienced an adverse event. A total of 201 events were reported for the 173 patients, although 18 events were considered “near misses,” meaning that the error did not reach the patient. Of the 183 remaining adverse events, 86 were considered to be preventable, 37 were not preventable, and 60 were indeterminate.  Preventable events included transcription/documentation errors, failure to perform a clinical task, communication/handoff errors between physicians and/or staff, and failed independent checks or wrong calculations. 

 “Although few patients who experienced a preventable adverse event were seriously harmed, adverse events do lead to temporary discomfort, longer hospital stays, and in some cases, serious injury or the potential for legal action,” Holloway said.  He says that in the years since the study, Strong has concentrated on reducing medication errors, and preventing complications such as blood clots and falls. 

Strong Memorial chief quality officer Robert Panzer, M.D. says that Strong has implemented a hospital-wide effort to reduce medication errors by implementing safety checks at the points that medications are prescribed, dispensed, and administered.  For example, computerized order entry systems have eliminated the need for handwritten prescriptions and screen medication orders for potential dosing errors, interactions, allergies and more.  Robotic dispensing systems in the hospital’s pharmacy ensure that the right medications are delivered to patient care units. Three years ago, Strong replaced all of its intravenous medication pumps with new smart-pump technology that checks the type and dosage of a drug just before it is administered.    

In addition, Strong has taken steps to prevent patients – particularly those recovering from strokes – from falling.  This includes more consistent use of bed alarms on its inpatient stroke unit that alert staff when a patient who is unstable has gotten out of bed.  Laminated signs hang outside of patient rooms to remind staff to check to make sure that alarms are always active and similar signs remind staff not to leave the patient alone in the bathroom. These aggressive fall-prevention measures have gone a long way to minimize the falls and the injury that can sometimes result from them, Holloway said. 

Strong Memorial Hospital is also leading a multi-hospital initiative to prevent hospitalized patients from developing blood clots (thrombosis), a complication which stroke patients are particularly prone.  The prevention programs includes getting patients up to walk whenever possible, using compression stockings or pads, and requiring the use of blood thinning drugs, such as heparin, at appropriate levels.  Today, 90% of patients at risk for developing thrombosis, are placed on the new protocol.

Curtis Benesch, M.D. director of the Strong Stroke Center, said that this study underscores the importance of the Hospital’s participation in the American Stroke Association’s (ASA) Get With the Guidelines-Stroke initiative.  This initiative represents a focused effort to implement national guidelines in the care of patients with stroke, such as the appropriate use of clot-busting drugs, interventions to prevent deep-vein thrombosis, and pneumonia, counseling for smoking cessation and early treatment to lower blood pressure and cholesterol levels.  “In comparing Strong’s performance on such measures as medical treatment to prevent strokes, screening for swallowing problems, and efforts to prevent potentially deadly blood clots in leg veins, the hospital performs better than other benchmark institutions,” he said. 

Over the last two decades, much attention has been given to improving the quality of stroke care in U.S. hospitals by establishing dedicated stroke centers and units, evidence-based guidelines, and performance measures.  The study’s authors point out that while these steps have been useful, most hospitals have yet to fully understand and address the safety of stroke patients.  This study was partially supported by a grant from MCIC Vermont, Inc., the risk retention group for the University of Rochester Medical Center. 

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