Wednesday, June 18, 2008

CA Hospital Infection Legislation

There are two good hospital infection bills that are moving in the CA legislature.

In a great effort, these bills were passed by the Senate and are currently in the Assembly Health Committee.

SB158, sponsored by Sen. Dean Florez and SB 1058 sponsored by Sen. Elaine Alquist.

The Committee has scheduled a hearing on June 24 for both bills. I have been asked to speak at the hearing for SB158 and share my Survivor Story in the hopes that it will touch a legislator’s heart to vote “Yes” and help save lives.

Prior to this hearing we are asking people with personal infection stories to visit legislators in Sacramento and ask them to support these bills. We don’t want these bills to die in this committee after getting this far!

There are two things you can do to help these bills pass:

If you live in the area, travel to Sacramento for the hearing. We would like to have as many members of the public there as possible, especially Survivors and family members of victims of Hospital acquired infections.

Another thing you can do is determine if your assembly member serves on the Health Committee and contact him or her.

We support these bills because they include:
  • Public reporting of hospital acquired infection rates
  • Screening for MRSA or other effective prevention techniques
  • State oversight on hospital cleaning practices and policies
  • State agency oversight on infection issues

Links to the bills:

SB158 (Florez):

SB1058 (Alquist):

Thanks for your support

Committee Members

Mervyn M. Dymally - Chair
(916) 319-2052

Alan Nakanishi - Vice Chair
(916) 319-2010

Patty Berg
(916) 319-2001

Wilmer Amina Carter
(916) 319-2062

Hector De La Torre
(916) 319-2050

Kevin de Leon
(916) 319-2045

Bill Emmerson
(916) 319-2063

Ted Gaines
(916) 319-2004

Loni Hancock
(916) 319-2014

Mary Hayashi
(916) 319-2018

Edward P. Hernandez
(916) 319-2057

Bob Huff
(916) 319-2060

Dave Jones
(916) 319-2009

Sally J. Lieber
(916) 319-2022

Fiona Ma
(916) 319-2012

Mary Salas
(916) 319-2079

Audra Strickland
(916) 319-2037

Thursday, June 12, 2008

Time Out for Patient Safety encourages you to take the opportunity to recognize National Time Out Day on June 18th to remind every member of the surgical team how critical it is to take time out for patient safety.

Please visit our website: for more information on how to prevent medical errors.

Wednesday, June 11, 2008

No Double Dipping on Wipes & Clothes

Antibacterial wipes can spread superbugs
Cloths used in hospitals may transfer bacteria to other surfaces, study finds

updated 1:13 p.m. PT, Tues., June. 3, 2008

LONDON - Disinfectant wipes routinely used in hospitals may actually spread drug-resistant bacteria rather than kill the dangerous infections, British researchers said on Tuesday.

While the wipes killed some bacteria, a study of two hospitals showed they did not get them all and could transfer the so-called superbugs to other surfaces, Gareth Williams, a microbiologist at Cardiff University, said.

The findings presented at the American Society of Microbiology's General Meeting in Boston focused on bacteria that included methicillin-resistant Staphylococcus aureus, or MRSA.

"What we have found is there is a high risk," Williams, who led the study, said by telephone. "We need to give guidance to the staff on how to use the wipes because we found there is a possibility of cross transfer."

MRSA infections can range from boils to more severe infections of the bloodstream, lungs and surgical sites. Most cases are associated with hospitals, nursing homes or other health care facilities.

The superbug can cause life-threatening and disfiguring infections and can often only be treated with expensive, intravenous antibiotics.

Experts have been saying for years that poor hospital practices spread dangerous bacteria, and yet many studies have shown that health care workers, including doctors and nurses, often fail to even wash their hands as directed.

The findings from a study of intensive care units at two Welsh hospitals suggest that even cleaning with antimicrobial wipes may not be enough depending on how staff use them.

The researchers found that many health care workers cleaned multiple surfaces near patients, such as bed rails, monitors and tables with a single wipe and risked sweeping the infections around rather than cleaning them up.

"We found that the most effective way to prevent the risk of MRSA spread in hospital wards is to ensure the wipe is used only once on one surface," Williams said.

Copyright 2008 Reuters.

Wednesday, June 4, 2008

How do you say "There's been a mistake."

From Academic Medicine

The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients
Original Post 05/29/2008
Andrew A. White, MD; Thomas H. Gallagher, MD; Melissa J. Krauss, MPH; Jane Garbutt, MB, ChB; Amy D. Waterman, PhD; W. Claiborne Dunagan, MD; Victoria J. Fraser, MD; Wendy Levinson, MD; Eric B. Larson, MD, MPH
Author Information

Abstract and Introduction


Purpose: To measure trainees' attitudes and experiences regarding medical error and error disclosure.

Method: In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers.

Results: The response rate was 78% (889/1,138).

Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889).

Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure.

Conclusions: Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.


The rise of the patient-safety movement and the publication of the Institute of Medicine report To Err is Human[1] have drawn the attention of both the public and physicians to the problem of medical errors. Physicians are increasingly expected to recognize, prevent, and properly disclose medical errors. In particular, ethical standards and guidelines that have emerged from accrediting organizations[2] and professional bodies[3] reflect a movement toward greater transparency in communicating with patients about errors. Although a few schools provide formal instruction in disclosure, these skills are largely taught via the hidden curriculum and role modeling.[4,5] There is little known regarding trainees' attitudes about and experiences with medical errors or their experience in disclosing errors to patients.

Despite the fact that patients uniformly endorse the disclosure of harmful errors,[6,7] such disclosure currently seems to be uncommon.[8,9] Emerging research is shedding new light on the disconnect between expectations that errors will be disclosed to patients and current clinical practice. Recent survey data from practicing physicians highlight their support for the general concept of disclosure and the difficulty they experience actually disclosing errors to patients.[10,11] Although less is known about trainees' attitudes and experiences regarding medical errors and their disclosure, the available literature suggests that most trainees have been personally involved with errors[9,12,13] and that discussing these events with patients presents substantial challenges for residents.[14,15] In one study, 76% of housestaff reported that they had made a serious medical error that they had not disclosed to the patient or a family member.[12]

Academic health centers can enhance transparency in health care by preparing new physicians for the challenges of recognizing and disclosing errors. Like all accredited organizations, they are also required by Joint Commission regulations to ensure patients are informed about unanticipated outcomes in their care.[2] Improving disclosure and meeting these regulatory goals require understanding how trainees perceive, experience, and disclose errors. Therefore, we undertook a multicenter cross-sectional survey of trainees to explore their attitudes and experiences regarding medical error and error disclosure.