www.uhc.edu University HealthSystem Consortium
Safety E-News February 2007
IN THIS ISSUE:
Hot Topics
New Assessment Tool Available on Marketplace for Disaster Preparation
FDA Issues Public Health Notification for Respiratory Gas Humidifier (CE30031)
BD Recalls Integra Insulin Syringes (MS50631)
World Death Toll of Avian Flu Pandemic Could Reach 62 Million, Harvard Study Shows
HHS Increases Stockpile of Vaccine, Antivirals and Respiratory Protection
Patient Safety
FDA Issues Advisory on Gadolinium Contrast Agents for MRI
Congress Passes Medical Error Bill, Increases Pressure for Hospital Drug Bar Coding
Free Pediatrics Safety Program Available
JCAHO Rebrands Itself, Adopts Shorter Name
National Patient Safety Awareness Week March 4-10
Environmental Safety
New Report Recommends Fast Action to Deal with Mercury Contamination
CMS Proposes Automated Sprinklers in All Long-Term Facilities
Deadline for H2E Annual Awards is Feb. 14
Medication Safety
ISMP Teleconference Covers Physician Compliance to Patient Safety Initiatives
Employee Safety
Flu Prevention Presentation Available on Marketplace
NPSF 2005 Congress -- Call for Posters, Early Registration
Health Care Workers Honored for Preventing Sharps Injuries
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Hot Topics

New Assessment Tool Available on Marketplace for Disaster Preparation

To assist members in their preparation for disasters, Novation has released a new supply needs assessment tool.

This tool allows health care facilities to calculate the amount of supplies and pharmaceuticals to have on hand in the event of a disaster. Having the quantity of products estimated based on usage per patient is one of the biggest benefits when considering a supply list for disaster preparedness.

The tool calculates supplies needed based on bed count and/or surge capacity to care for patients for one week.

In addition, Novation's disaster-preparedness resource guide provides resources to prepare members to treat patients and protect health care workers if a man-made disaster, natural disaster or mass casualty situation occurs.

For more information, contact Christine Miller, Novation senior clinical manager, at (972) 581-5644 or cmiller@novationco.com.

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FDA Issues Public Health Notification for Respiratory Gas Humidifier (CE30031)

On Feb. 1, the U.S. Food and Drug Administration notified health care professionals of the reintroduction of the Vapotherm® 2000i respiratory gas humidifier system, available through contract CE30031 from Mediq PRN Equipment Rental.

This system was recalled in 2005 because of possible contamination with bacteria. The FDA noted that premature neonates, immunocompromised patients and those with underlying respiratory illness (such as cystic fibrosis) or malignancy may be at particularly high risk for infection if exposed to breathing gases from a contaminated Vapotherm device.

The FDA has issued recommendations for the steps to take before using the reintroduced device. The device's operating instruction manual is available by contacting Vapotherm at (866) 827-6843 or info@vtherm.com.

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BD Recalls Integra Insulin Syringes (MS50631)

Becton, Dickinson and Co. has recalled one lot of its BD Integra 1 mL insulin syringes. These syringes are available on Novation contract MS50631.

The affected lot number is 6073436. The reorder number is 305282. BD is conducting the recall because it has received reports that the needle may come loose from the syringe.

Members should determine whether they have any of the affected products, and if so, to return them to BD. Additional information and instructions are available in BD's letter to customers.

For more information, contact Pat Baxter, Novation product manager, at (972) 581-5446 or pbaxter@novationco.com; or Kevin Curley, BD director, corporate national accounts/sales, at
(972) 471-4231 or kevin_curley@bd.com.

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World Death Toll of Avian Flu Pandemic Could Reach 62 Million, Harvard Study Shows

An avian flu pandemic could kill up to 62 million people, with developing countries bearing the brunt of the deaths, according to a new forecast.

The new assessment, reported in The Lancet medical journal, was conducted by researchers from Harvard University. Researchers based the prediction on data from the 1918-20 influenza pandemic, which caused more deaths than World War I.

Since 2003, when researchers began tracking instances of the H5N1 strain of avian flu, 270 confirmed cases and 164 deaths have been reported, mostly in China and southeast Asia. These cases generally have occurred as a result of direct contact between humans and birds carrying the virus.

Researchers used death registration data to calculate excess mortality during the 1918-20 "Spanish flu" pandemic in 27 countries. Extrapolating the results to the worldwide population of 2004, they found that
62 million people could have died had a similar pandemic occurred that year. As in 1918, people with high incomes were less likely to die than the poor, with 96 percent of deaths occurring in developing countries.

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HHS Increases Stockpile of Vaccine, Antivirals and Respiratory Protection

U.S. Department of Health and Human Services Secretary Mike Leavitt has provided an update on current federal activities related to funding, monitoring and surveillance, research, vaccines, antivirals, state and local preparedness and communications.

This update is the third in a series of recent reports on pandemic planning. It includes reports on these key topics:
  • vaccine -- The U.S. government has stockpiled enough vaccine to inoculate about 3 million Americans against bird flu and expects to stockpile another 5 million treatment courses in 2007.

  • antiviral drugs -- Two antiviral drugs are effective against H5N1 virus in lab testing: Tamiflu®, manufactured by Roche Laboratories; and Relenza®, manufactured by GlaxoSmithKline. The government's goal was to have 26 million courses of antivirals in the national stockpile by the end of 2006 and 50 million courses by the end of 2008. The federal stockpile, in addition to the subsidized state purchases of an additional 31 million courses, will ensure that there are enough antivirals for 25 percent of the population.

  • personal protective equipment -- Personal protective equipment has been increased as well, with 73.1 million N-95 respirators already purchased for the national stockpile, with another 31.8 million on order, and 37.4 million surgical masks stored, with another 14.1 million on order. Face shields, gloves and gowns are included in the stockpile.

  • ventilators -- While studies are being conducted to determine the most appropriate types of ventilators to stockpile for a response to a pandemic flu, HHS has allocated $25 million for ventilator purchases, which are projected for 2007-2008.
The Pandemic Planning Update III report notes that every state has at least drafted a pandemic plan. Many states have conducted pandemic flu exercises, and the National Governors Association, with HHS funding, will assist states with additional issues such as public health preparedness, continuity of government and maintaining the central functions of society during a pandemic.

And in early 2007, a team of pandemic flu experts will undergo an exercise that will test how the media and the experts will respond should an actual pandemic occur. This exercise will help them work through the challenges of getting and reporting timely and accurate information during a pandemic.

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Patient Safety

FDA Issues Advisory on Gadolinium Contrast Agents for MRI

The U.S. Food and Drug Administration is evaluating important safety information about gadolinium-containing contrast agents after discovery of a possible link between such agents and a new disease known as nephrogenic systemic fibrosis or nephrogenic fibrosing dermopathy.

NSF/NSD "may occur in patients with moderate to end-stage kidney disease after they have had a magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) scan with a gadolinium-based contrast agent," the FDA stated in a public health advisory issued Dec. 22, 2006. Additional information is posted on Marketplace@Novation®.

The FDA urges health care providers and patients to report adverse event information to the FDA online, by phone at (800) FDA-1088 or by fax at (800) FDA-0178.

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Congress Passes Medical Error Bill, Increases Pressure for Hospital Drug Bar Coding

A medical errors bill that Congress included in the tax cut/Medicare package it passed just prior to adjourning in December 2006 could increase pressure on hospitals to put bar code technology in place. The bill calls for the Department of Health and Human Services to develop new quality standards, which HHS says could include bar coding of individual dosages. The bill also states that hospitals not meeting the standards risk losing Medicare funding.

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Free Pediatrics Safety Program Available

A health care communication system called Emmi is offering its latest program on patient safety for pediatrics free to health organizations to post on their Web sites. The program was created in response to demand in health care for a program geared toward parents to raise safety awareness. It offers practical and effective ways parents can help their children stay safe in the hospital. A program for all patients is also available.

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JCAHO Rebrands Itself, Adopts Shorter Name

The Joint Commission on Accreditation of Healthcare Organizations has introduced a new brand and logo, as well as a new tagline: "Helping Health Care Organizations Help Patients."

The rebranding also includes a shorter official name -- The Joint Commission -- and a new Web site address, www.jointcommission.orgThe new brand is intended to reflect the commission's continuing efforts to improve the value of accreditation and its utility as a mechanism for improving the quality and safety of patient care.


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National Patient Safety Awareness Week March 4-10

Patient Safety Awareness Week, March 4-10, is a national education and awareness-building campaign for improving patient safety at the local level.

Hospitals and health care organizations nationwide are encouraged to plan events to promote patient safety within their own organizations. The National Patient Safety Foundation has suggested activities for health care facilities, as well as for patients and their families.

Educational activities are centered on educating patients on how to become involved in their own health care, as well as working with hospitals to build partnerships with their patient community.

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Environmental Safety

New Report Recommends Fast Action to Deal with Mercury Contamination

"Halting the Child Brain-Drain," a new report by Health and Environment Alliance and Health Care Without Harm pulls together the latest understanding of the health effects of low levels of mercury exposure and recommends fast action to deal with mercury contamination.

The report mentions a small-scale study conducted in 21 countries that found that one in six women may have mercury levels above what is widely considered safe. The findings are worrisome because scientific reports have shown conclusively that low-level exposure to mercury in the womb can cause brain damage in children.

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CMS Proposes Automated Sprinklers in All Long-Term Facilities

A new proposed rule from the Centers for Medicare and Medicaid Services would require all long-term care facilities to install automatic sprinkler systems throughout their facilities in order to receive Medicare or Medicaid payments.

Since 2000, only newly built long-term care facilities and those undergoing renovations have been required to install the systems.

After more than 30 resident deaths from fires in long-term care facilities in 2005, CMS required the placement of battery-operated smoke alarms in patient rooms and in public areas. The proposed regulation would expand on this requirement to include the requirement that all long-term care facilities install and maintain approved, supervised automatic sprinkler systems.

CMS is asking for public and industry recommendations on an appropriate implementation timeframe, permitting older facilities time to retrofit.

Novation has contracts with two companies for batteries: Duracell for general batteries (BP50100) and Unipower for medical device batteries (BP50110). For more information, contact Brent Molloy, Novation product manager, at (972) 581-5208 or bmolloy@novationco.com.

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Deadline for H2E Annual Awards is Feb. 14

The Hospitals for a Healthy Environment®s annual awards recognize organizations for achievement in addressing environmental issues and for accomplishments that can significantly boost management support for environmental initiatives.

H2E®s awards application deadline is Feb. 14. The H2E Awards Ceremony and Pharmaceutical Disposal workshop is scheduled for May 14-15 in Minneapolis.

The H2E Awards Web site gives descriptions, criteria and application forms for each of the awards categories. Award winners can expect media coverage, internal recognition and the confirmation of environmental awareness and engagement within their organizations.

H2E has recognized Novation with its Champions for Change award every year since 2004 for its environmental achievements and commitments in the health care sector. Novation actively promotes environmental safety through contracting programs, educational resource guides, safety products databases and Safety E-News.

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Medication Safety

ISMP Teleconference Covers Physician Compliance to Patient Safety Initiatives

The Institute for Safe Medication Practices is hosting the teleconference, "Gaining Physician Compliance to your Patient Safety Initiatives," on Feb. 22 from 1:30 to 3 p.m. EST.

Russell Jenkins, ISMP medical director and trustee, will discuss how to win, not just enforce, physician compliance to organizational safety goals; the traits necessary for physician safety champions; clinical credibility; communication skills; and how champions can break down the barriers to physician engagement. To register, visit the ISMP Web site.

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Employee Safety

Flu Prevention Presentation Available on Marketplace

A PowerPoint® presentation, "Preventing Flu in the Workplace," available on the Employee Safety area of Marketplace@Novation, can be used to create an educational program for employees. The presentation reviews respiratory etiquette, hand hygiene basics and prevention techniques specific to the workplace.

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NPSF 2005 Congress -- Call for Posters, Early Registration

The National Patient Safety Foundation will host its ninth annual Patient Safety Congress on May 3-4 at the Marriott Wardman Park Hotel in Washington, D.C. The theme is "Learning from the Past, Creating the Future," and sessions will focus on effective implementation of programs that result in cultural change and sustained improvement.

Pre-conference activities on May 2 will include "Pre-Congress: Leadership Day" and "Patient Safety 101."

Early bird registration is now available with $100 discounts for registration by March 15. More information, including hotel accommodations and sponsorship opportunities, is available on the NPSF Web site.

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Health Care Workers Honored for Preventing Sharps Injuries

In conjunction with World AIDS Day and International Sharps Injury Prevention Awareness Month, the International Sharps Injury Prevention Society has announced the winners of the 2006 Sharps Injury Prevention Award. Other information in the latest issue of the ISIPS newsletter includes recent health care facility OSHA violations and real needlestick and blood exposure stories.

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Disclaimer: This document has been compiled based on information gathered from many primary and secondary sources, which UHC and Novation believe to be accurate to the best of their knowledge. It is intended as general information only and is provided as an accommodation to the members, however, and not as an authoritative basis for specific clinical decisions. Use of this data is at your sole risk. This information is presented "AS IS" and without any warranty or guarantee, expressed or implied, as to completeness or accuracy, or otherwise. As always, clinical decisions on behalf of any individual patient should be made by the attending physician.