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Patient Safety Monitor Alert

This e-mail newsletter provides healthcare professionals with the latest patient safety news, while offering useful information on creating safer patient care environments and reducing medical errors.

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Patient Safety Monitor Alert

Issue 52, December 30, 2004

• Experts propose solutions for Martin Luther King Jr./Drew Medical Center

  The Los Angeles Times asked two dozen healthcare experts from around the country for solutions to...

• Doctors lack whistle-blower protection

  A judge recently ruled that thousands of federal doctors and medical researchers who receive some...

• State error-reporting laws pave the way for a national effort

  While the federal government has been unsuccessful for several years in passing patient safety...

• IHI launches patient safety campaign to save 100,000 lives

  The Institute for Healthcare Improvement announced on December 14 that it is partnering with the...

Issue 51, December 22, 2004

• JCAHO issues sentinel event alert on PCA pumps

  The JCAHO issued a sentinel event alert on patient controlled analgesia (PCA) by proxy on December...

• Hospital sues state to prevent facilities from offering angioplasties

  Deborah Heart and Lung Center in Browns Mills, NJ, is suing the state to prevent it from allowing...

• Forum emphasizes leadership role of nurses in patient safety

  The nation’s first Chief Nursing Officers Patient Safety Leadership Forum on November 3-4...

• USP report finds that computers contribute to medication errors

  Despite the perception that technology will improve patient safety and reduce medication errors...

Issue 50, December 17, 2004

• FL hospitals cite patient safety risk from LiveStrong wristbands

  Several hospitals in Florida are asking patients to remove their yellow, rubber LiveStrong...

• Massachusetts Nurses Association opposes Magnet Recognition program

  The Massachusetts Nurses Association (MNA) opposes the Magnet recognition program for nursing...

• MA hospital teams with community to form patient safety council

  Staff members and doctors at Nashoba Valley Medical Center (NVMC) in MA met on December 7 with...

Issue 49, December 10, 2004

• Technology company improves patient safety

  Last year BD, a medical technology company based in Franklin, NJ, received positive press when it...

• Americans unsatisfied with medical care

  When it comes to patient safety, hospitals still face an uphill battle, according to a new survey...

• Could movies play a role in doctor-patient relationships?

  At least one doctor is concerned about how his profession is portrayed in films these days, and...

Issue 48, December 1, 2004

• Nursing shortages hurt patient care

  Nursing is one of the five fastest-growing professions in the United States, according to the...

• Medical simulation centers crop up on American soil

  The Israel Center for Medical Simulation at Tel HaShomer is world renowned for training doctors on...

• New hospital design will improve patient safety

  All the bells and whistles are going into the new Banner Estrella Medical Center on the west side...

• Patient identification system could reduce medical errors

  Last week the technology company, BD Diagnostics announced the release of version 6.0 of its BD.idT...

Issue 47, November 23, 2004

• A monthly meeting could improve kidney dialysis treatments

  Here's some good news--patients who are treated by healthcare teams, that meet on a monthly basis...

• Maryland doctors sick of high insurance premiums

  Along with the holiday season, most doctors are faced with paying their medical malpractice...

• Female hospital CEOs polled on patient safety

  According to a recent nationwide poll of 150 female hospital chief executive officers (CEOs), the...

• Conscientious staff are promoted less and harassed more

  Conscientious and pleasant workers are less likely to be promoted in the workplace, according to a...

Issue 45, November 9, 2004

• IOM report authors give healthcare improvements C+

  The nation’s healthcare system rates a C+ at best when it comes to cutting its medical error...

• IOM report authors give healthcare improvements C+

  The nation’s healthcare system rates a C+ at best when it comes to cutting its medical error...

• FDA takes steps to boost drug safety evaluations

  The Food and Drug Administration (FDA) on November 5 announced steps to strengthen the...

• Florida Hospital sues to block error-reporting amendment

  Florida Hospital in Orlando and the Florida Hospital Association filed two lawsuits November 4 to...

Issue 44, November 7, 2004

• World Health Organization launches patient safety alliance

  Patient safety went global October 27 when the World Health Organization (WHO) launched the World...

• Positive thinking lowers heart disease risk

  Patients who describe themselves as highly optimistic have lower rates of cardiovascular death than...

Issue 41, October 18, 2004

• Skin patches can cause overdoses

  Transdermal patch delivery systems are more vulnerable to errors when the frequency of application...

• Beware of these blood transfusion injuries

  FDA warns against blood transfusion-related injuries

Issue 39, September 29, 2004

• Drug shortages are impacting safety

  Drug shortages are having far-ranging, negative effects on patient care and hospital costs...

• How to disagree with a JCAHO surveyor

  How to disagree with a JCAHO surveyor’s finding

Issue 37, September 15, 2004

• Physicians often give harmful drugs to pregnant women

  Physicians are prescribing harmful drugs to pregnant women, AHRQ finds

• Injuries on the rise among nurses

  Nurses are more vulnerable to injuries after systems changes take place

• New JCAHO guidance on 'abbreviations' goal

  JCAHO clarifies questions about 'abbreviations' patient safety goal

Issue 36, September 8, 2004

• FDA tells how to prevent hospital bed hazards

  There are seven hazardous zones in hospital bed systems that can trap patients, according to new...

• "Info prescriptions" encourage patients to educate themselves

  "Info prescriptions" encourage patients to educate themselves

• Physicians override CPOE system warnings 80% of the time, study says

  Physicians override 80% of alerts generated by computerized physician order entry systems (CPOE...

Issue 35, August 31, 2004

• Most physician executives encounter disruptive physicians

  Does your three-year-old throw things, scream, and pout when he doesn't get his way? He has a lot...

• The JCAHO seeks best practices for smoking cessation

  In an effort to develop best practices and educational strategies, the JCAHO is researching ways to...

• Join our free discussion group!

  Find out what all the talk is about, stay in touch with your peers, help each other solve...

• Involve pharmacists in medication reconciliation activities

  Your medication error-rate will drop noticeably if your organization assigns pharmacists in your...

Issue 33, August 13, 2004

• Physician’s group dismisses HealthGrades’ findings as flawed

  The American Medical Association (AMA) is discounting a controversial study by the Colorado-based...

• HealthGrades identifies 88 hospitals as leaders in patient safety

  HealthGrades, Inc., has recognized 88 hospitals as the leaders in patient safety across the U.S...

• Keypad design of IV pumps can cause dosing errors

  The keypad design on some IV pumps can lead to dangerous dosing errors if clinicians mistakenly...

Issue 32, August 13, 2004

• Nearly half of ear, nose, throat specialists experience errors

  Nearly half of ear, nose, and throat specialists say that a medical error occurred in their...

• Elderly patients often receive inappropriate medications

  Physicians commonly prescribe inappropriate medications for elderly patients, according to new...

Issue 31, August 5, 2004

• Study: A physician’s emotional state can contribute to medical errors

  Although the healthcare industry emphasizes the importance of addressing system problems to...

• JCAHO turns focus on worker safety

  The JCAHO has teamed up with the Occupational Safety and Health Administration (OSHA) to educate...

• Clinicians should improve their screening for alcohol abuse

  Healthcare providers miss an important opportunity to improve patient health when they don’t...

Issue 30, July 28, 2004 - VIEW THE FULL ISSUE

• New JCAHO alert warns against infant death and injury during birth

  Provide team training in perinatal areas to improve communication and cooperation among staff to...

• Study: Top performing hospitals don't rest on their laurels

  Lest there be any doubt, new research shows that continuous improvement over time is strongly...

Issue 29, July 21, 2004

• Metal clamp the size of a ballpoint pen is left behind in surgical patient

  A Los Angeles County hospital has tightened its patient safety procedures after a metal clamp the...

• GAO questions JCAHO's ability to ensure patient safety

  JCAHO surveyors fail to identify critical patient safety hazards, such as infection control issues...

Issue 28, July 14, 2004

• Boost patient and staff safety with a better hospital design

  Poor hospital design contributes to patient injuries from falls, poor communication between staff...

• The 2005 National Patient Safety Goals are finalized

  Missing from the new goals are a bar coding requirement and a proposal designed to reduce the risk...

• Anesthesiologists, rather than surgeons, should administer certain anesthetics

  Anesthesiologists are better suited to administer certain anesthetics than surgeons because they...

• Missouri takes action to stop medical errors

  Up to 2,000 patients in Missouri hospitals die each year from preventable medical errors, according...

Issue 27, July 12, 2004

• Medication deaths caused by weak patient safety culture, systemic problems

  The probe resulted in an 83-page report that was released June 29. The report urges the Calgary...

• Wrong-patient medication errors continue to plague hospitals

  The top five reasons for wrong-patient medication errors that are reported to the U.S. Pharmacopeia...

• Long shifts + tired nurses = More errors

  Long hours worked by hospital staff nurses can negatively impact patient safety, according to a new...

Issue 26, June 29, 2004

• A "no-blame culture" would improve safety, care

  Eighty-two percent of physicians have seen a colleague make a mistake or give sub-optimal care, but...

• Closer monitoring needed of patients who have high blood pressure

  Carefully monitor the cholesterol levels of patients who have high blood pressure. A new study...

• Pennsylvania is first state to require mandatory near-miss reporting

  All Pennsylvania-licensed hospitals, ambulatory surgical facilities, and birthing centers are now...

Issue 25, June 23, 2004

• Use of dietary supplements is on the rise among women, former smokers

  Make sure providers obtain a complete list of all vitamins, dietary supplements, and other forms of...

• Physicians feel they lack proper training to care for chronically ill patients

  Physicians do not feel prepared to care for the more than 125 million Americans who suffer from...

• June 23 is "National Time-Out Day"

  The Association of periOperative Registered Nurses (AORN) is sponsoring a National Time-Out Day...

Issue 24, June 17, 2004

• Elderly patients with chronic illnesses are higher suicide risk

  Healthcare professionals should be alert to the possible threat of suicide among elderly patients...

• Physicians, nurses, more likely to blame other nurses for medical errors

  Physicians do not see themselves as sharing an equal responsibility in patient safety, and instead...

• Canada lags behind U.S. in patient safety

  Hospital patients in Canada are safer than they are in Australia or the United Kingdom, but not as...

Issue 23, June 10, 2004

• Birth trauma is the most common pediatric adverse event

  Birth trauma involving long bone and skull fractures is the most common pediatric adverse event...

• Boston patients wait more than a month to get an appointment with specialists

  New patients in Boston wait up to 37 days to see a specialist for non-urgent matters while similar...

• Patients want clinicians to be more honest, positive, clear

  Healthcare workers should make more of an effort to be honest, clear, and accurate. They should...

Issue 22, June 1, 2004 - VIEW THE FULL ISSUE

• Patients with chronic conditions are likely to stop taking their medications

  Patients with such chronic conditions as asthma and heart disease rapidly stop taking their...

• Surgeon General: Smoking causes leukemia, cataracts, pneumonia, other illnesses

  Smoking causes diseases in nearly every organ of the body, according to a report from the U.S...

• Anesthesiologist assistants: A cure for staff shortages?

  Hire "anesthesiologist assistants" to help alleviate the shortage of professionals who are...

Issue 21, May 25, 2004

• Providers must do more to protect patients against overdoses of acetaminophen

  Pay closer attention to how much acetaminophen your patients ingest to prevent them from exceeding...

• Patients stop taking beta-blockers once they leave the hospital

  Less than half of heart attack survivors continue taking beta-blockers during the first year after...

• Think twice before allowing patients to use their own equipment in the hospital

  Hospitals should think twice before allowing patients to use their own medical equipment while...

Issue 20, May 20, 2004 - VIEW THE FULL ISSUE

• Standardized abbreviations are the toughest patient safety goal to comply with

  Hospitals are finding it most difficult to comply with a JCAHO requirement that calls for hospitals...

• Patient suicide, post-op complications are top sentinel events

  Poor communication, training, and patient assessment continue to be the leading causes of sentinel...

• Researchers: Computer prescribing systems can harm patient safety

  Computer prescribing systems used by general practices in the United Kingdom are endangering...

Issue 19, May 12, 2004

• Patients receive inadequate care, even in world-class cities

  Patients suffer thousands of preventable complications and deaths each year due to quality deficits...

• Surgery can reduce the risk of stroke in some patients

  Immediate surgery is the best option for some patients with severe narrowing of the carotid artery...

• New legislation would establish minimum staffing levels

  An Illinois congresswoman introduced national legislation May 6 that would establish minimum...

Issue 18, May 7, 2004

• Patient outcomes are worse in hospitals with low nurse staffing levels

  Hospitals that have low nurse staffing levels, nurses who spend less time with patients, or fewer...

• New guidance on where to locate alcohol-based hand rub dispensers

  Alcohol-based hand rubs are now permitted in patient rooms and suites, and in hospital corridors...

• Think inside the "box" to better understand pharmaceutical ads

  Pharmaceutical ads marketed directly to consumers may minimize the risks and exaggerate the...

Issue 17, April 28, 2004

• Check drug interactions with the Adverse Drug Interactions Program

  Physicians need to make sure new prescriptions that they give patients won’t interact with...

Issue 16, April 21, 2004

• Bar-coding technology can reduce lab test errors

  A developer of portable technology solutions for hospitals created a wireless, hand-held bar-coding...

• Woman finds surgical scissors inside of her 18 months after surgery

  A Sydney (Australia) woman is suing a local hospital after discovering that surgeons left a pair of...

• Poor math skills can cause fatal errors

  England’s National Patient Safety Agency (NPSA) found that doctors and nurses with poor math...

Issue 15, April 14, 2004

• Investigators find numerous problems at Marin (CA) General Hospital

  The California state Department of Health Services (DHS) surveyed Marin General Hospital (MGH) on...

• Anesthesia debate heats up in Florida

  Florida anesthesiologists and nurse anesthetists are butting heads about whether to allow...

• Entrepreneur creates talking prescription bottles

  Entrepreneur Jerry Mahoney was fed up with trying to read the small-print instructions on...

Issue 14, April 7, 2004

• Hospitals still resist computerized patient records

  Numerous healthcare advocacy groups strongly urge hospitals and physicians to adopt electronic...

• New medication safety group organized

  The National Consumers League (NCL), a consumer advocacy group, has joined forces with more than 60...

• Medical errors are more likely in outpatient settings

  A recent study of malpractice claims indicates that medical errors occur more often in outpatient...

Issue 13, March 31, 2004

• New drug may slow progression of Type I diabetes

  The results of an 18-month clinical trial indicate that a new drug helps improve a diabetic's...

• Transitioning from different healthcare settings can lead to problems

  Healthcare organizations need to address how they deliver care across different settings to really...

• New law in New Jersey requires physicians to report medical errors

  The New Jersey Senate passed a bill March 29 requiring doctors and hospitals to report medical...

Issue 11, March 17, 2004

• Intimidating coworkers are endangering patient safety

  Patient safety is at risk because nurses and pharmacists work in intimidating environments where...

• How to create a "culture of safety"

  What does it mean to create a "culture of safety?" Certainly, it requires more than being careful...

• Boston surgeon has smelled of alcohol at more than one hospital's OR

  A Massachusetts surgeon recently accused of showing up drunk to perform surgery did the same thing...

• Woman who refused Caesarean section charged with taking drugs while pregnant

  A Utah woman charged with killing her unborn fetus by refusing an emergency Caesarean section to...

• Many hospitals still allow staff to smoke on site

  The majority of readers who responded to our recent online survey report that their hospitals do...

Issue 10, March 9, 2004

• Surgeon loses privileges after appearing drunk before surgery

  A Massachusetts physician with a history of drunken driving lost his medical staff privileges this...

• New book highlights patient safety strategies

  The U.S. Pharmacopeia (USP) has published a new book that highlights different strategies that...

• Couch potatoes may one day tie smokers as most endangered

  Better preventive measures are necessary to stop the large majority of deaths in the U.S, according...

Issue 9, March 4, 2004

• New tool measures children's health perceptions

  Researchers at the Johns Hopkins Bloomberg School of Public Health found that children as young as...

• Final FDA bar code reg to help hospitals improve patient safety

  Hospitals will soon be able to scan bar codes on patients' wristbands and medications to ensure...

• Systematic failures allowed nurse to kill undetected

  Charles Cullen, the night shift nurse who says he has killed at least 40 people during his 16-year...

• Join our free talk group

  Share ideas and get helpful advice from your colleagues. Subscribe to our FREE talk group, Patient...

• Online survey results: Half of hospitals don’t use smart pumps

  Medication administration errors are difficult to detect. And although some IV pumps are designed...

Issue 8, February 25, 2004

• Patient units are as noisy as jackhammers

  If you think your care units allow patients to get a good night's sleep, try spending the night in...

• Panel advises against certain routine heart tests for low-risk adults

  Low-risk adults who show no signs of heart disease should not be subjected to treadmill exercise...

• Develop patient safety plans to transport patients

  Hospitals should develop a patient safety plan before transporting critically ill patients within...

• Women don't tell all about their medications

  Healthcare providers should spend extra time questioning women about their medication usage...

Issue 7, February 18, 2004

• Specialists develop first-ever guidelines to treat sepsis

  Critical care specialists from 11 major medical societies have developed groundbreaking clinical...

• Medication safety group revises its list of high-risk medications

  The Institute for Safe Medication Practices (ISMP) has updated its list of high-alert medications...

• Survey: Lack of specialty physicians is the real cause of ED overcrowding

  Hospital emergency departments (ED) that divert ambulances to other hospitals say that a lack of...

• Four-drug cocktail can reduce death risk of heart patients

  Heart attack and unstable angina patients who were prescribed all four medications had a 90% lower...

Issue 6, February 11, 2004

• Elderly patients receive "inappropriate" medications during ambulatory visits

  About 8% of elderly patients receive "inappropriate" medications during outpatient visits...

• Teaching hospitals have lower death rates for certain surgical procedures

  Death rates for some complex gastrointestinal surgical procedures are lower at teaching hospitals...

• Hospital uses harmonicas as respiratory therapy tool

  Patients who participate in a 10-week pulmonary rehabilitation program at Advocate Christ Medical...

Issue 5, January 4, 2004

• 1. FDA launches campaign aimed at safe use of over-the-counter pain products 2.

  1. FDA launches campaign aimed at safe use of over-the-counter pain products 2. Bush...

Issue 4, January 28, 2004

• 1. Physicians: Monitor drinkers who take narcotic pain relievers 2. FDA warns

  1. Physicians: Monitor drinkers who take narcotic pain relievers 2. FDA warns against unnecessary...

Issue 3, January 21, 2004

• 1. Electric beds may pose a fire risk 2. Six things you didn't know about drug

  Electric beds may pose a fire risk Six things you didn't know about drug names True quality...

Issue 2, January 14, 2004

• 1. General surgeons should not perform abdominal aortic aneurysm surgeries, spec

  1. General surgeons should not perform abdominal aortic aneurysm surgeries, specialists say 2. New...