HCPro.com - Quality/Patient Safety - DO NOT USE Top Stories

CMS publishes infection rate data online

Wed, 08 Feb 2012 16:17:00 GMT

The Centers for Medicare & Medicaid Services (CMS) has published central line-associated bloodstream infection rates among patients in intensive care units on its Hospital Compare website. Beginning next year CMS will publish the rates of infections acquired during or after surgery and catheter-associated urinary tract infections.

Using the Hospital Compare site, consumers are able to compare hospitals against national benchmarks and state averages for process of care measures, outcomes, and patient satisfaction rates. The site is updated quarterly and will ultimately contain data for a full year.

Click here to visit Hospital Compare.

Source: National Journal

Minorities receive less pain treatment, University of Pennsylvania study finds

Wed, 08 Feb 2012 16:11:00 GMT

A study by the University of Pennsylvania School of Nursing revealed that minority and low-income patients are less likely to receive guideline-recommended pain treatment in healthcare settings.

Minority and low-income patients are also more likely to experience restricted access to healthcare due to geographical constraints, and pharmacies in predominantly minority-populated zip code areas are less likely to supply sufficient pain medications, according to the report, Advancing a National Agenda to Eliminate Disparities in Pain Care: Directions for Health Policy, Education, Practice, and Research.

Federally-funded healthcare programs must collect data to track healthcare disparities in accordance with the Patient Protection and Affordable Care Act, but the authors of the University of Pennsylvania study proposed public-private partnerships to promote standardized race and ethnicity reporting regardless of the source of funding. The authors also emphasized a need for providers to examine their weak points in pain care, recommending targeted education in pain disparities in medical education, certification, and accreditation programs.

Source: Penn Nursing Science

HHS health IT challenge aims for better transitions

Wed, 01 Feb 2012 18:06:00 GMT

The Department of Health & Human Services (HHS) launched a Discharge Follow-Up Appointment challenge intended to improve care transitions during hospital discharges. The challenge is part of the Investing in Innovation (i2) Initiative, a program created by the Office of the National Coordinator for Health Information Technology to stimulate innovations in health IT.

The goal of the Discharge Follow-Up Appointment challenge is to encourage software developers to create technological processes and tools that will improve upon the manual system many hospitals rely on for scheduling follow-up appointments and post-discharge testing. According to HHS, scheduling such appointments prior to patient discharge makes care transitions safer and more effective.

Effective discharge and follow-ups may also help prevent patient readmissions within 30 days. Hospitals with the highest rates of readmission within 30 days can lose up to 3% of reimbursements from the Centers for Medicare & Medicaid Services, effective October 2012.

Source: US Department of Health & Human Services

Diagnostic errors survey examines frequency and cause

Wed, 25 Jan 2012 19:44:00 GMT

A survey conducted by QuantiaMD revealed that diagnostic errors occur with relative frequency. Of the 6,400 survey participants, consisting of physicians, nurse practitioners, and physician assistants, 47% indicated that missed, late, or wrong diagnoses occur at their practices on a monthly basis. A majority of respondents believed that errors were sometimes preventable, while 8% believed such errors were always preventable.

The survey found that atypical patient presentation, failure to consider other diagnoses, and inadequate patient history were the top contributors to diagnostic errors. "Zero tolerance" toward physician mistakes and over-testing to avoid malpractice were also cited as factors in diagnostic error.

Source: QuantiaMD

Half of preventative health services missed at annual check-ups

Wed, 25 Jan 2012 19:38:00 GMT

Researchers at Virginia Commonwealth University found that 46% of guideline-recommended preventative services were missed during annual physician visits. According to a new study that pulled data from audio recordings of 484 health examinations, physicians were most likely to recommend screenings for breast cancer, colorectal cancer, and hypertension; they were least likely to offer advice or recommendations for influenza immunization, aspirin use, or vision screening.

Researchers also found that younger patients received fewer preventative services, and patients with higher body mass indexes were more likely to receive a greater number of services. Despite prompts in patients' electronic medical records, physicians tended to deliver fewer preventative services in visits where electronic medical records were accessed.

Source: Medical News Today

Latest issue of Patient Safety Monitor Journal now available

Wed, 18 Jan 2012 17:55:00 GMT

The January issue of Patient Safety Monitor Journal (formerly Briefings on Patient Safety) has been posted to the Patient Safety Monitor website. In this month's issue, learn about current efforts to go above and beyond traditional error reporting:

As the fourth leading cause of death in the United States, medical errors just don't seem to be going away. Many healthcare professionals agree that reporting such errors is the only way to learn from them and prevent them in the future. But although most medical centers have systems in place for staff to report errors, oftentimes these systems can be difficult, cumbersome, and seemingly void of any real, noticeable results. Inertia and a sense of "why bother?" sets in, further concealing the flawed systems and their lack of a streamlined way to ensure that the causes of identified errors are fixed or improved.

Finding a way to revamp the system of medical reporting might seem just as cumbersome (if not more so) than dealing with what is already in place, but a team of patient safety advocates at the VA Pittsburgh Healthcare System (VAPHS), a three-division, integrated healthcare system that serves the veteran population throughout the tristate area of Pennsylvania, Ohio, and West Virginia, decided to establish an alternative method of reporting errors called the Patient Safety Triage Committee (PSTC). Using available technology and anonymous reporting, the PSTC was able to create open dialogue with frontline staff in an effort to increase reporting of safety issues, create opportunities for improvement, and solicit innovative ideas to enhance patient safety throughout the medical center.

Read the entire story at the Patient Safety Monitor website.

CMS innovation advisors aim to improve quality of care

Wed, 18 Jan 2012 17:48:00 GMT

The Centers for Medicare & Medicaid Services has tapped 73 healthcare professionals for its innovation advisors program. Funded with $6 million from the healthcare reform act, the program is designed to help drive improvements to patient care and help reduce healthcare costs. A second group of 120 advisors will be selected in June 2012.

The program, which is managed by the CMS Innovation Center, includes six months of orientation as well as in-person national and regional meetings, virtual training sessions, and seminars and presentations by healthcare experts. Each advisor will receive a stipend of about $20,000 to help cover the cost of transportation, lodging, and other expenses.

This first group of advisors includes clinicians, allied health professionals, health administrators, physicians and nurses from 27 states. Each one is required to develop a systems improvement project that will be scalable to other areas.

To read the rest of this free article, click here.

Source: HealthLeaders Media

Using death rates to evaluate hospital quality faulted, study finds

Wed, 11 Jan 2012 18:25:00 GMT

A new study has researchers at Yale School of Medicine questioning whether death rates in hospitals accurately reflect hospital quality.

Researchers looked at mortality rates of heart attack, pneumonia, and heart failure patients during the initial hospitalization and mortality rates of patients within 30 days. They discovered that the two approaches yielded different results for many hospitals. The study concluded that looking only at death rates of patients during initial hospitalizations favored hospitals that sent patients home quickly. Researchers suggested patient assessment take place over a standard time period to best assess hospital quality.

Source: Medical News Today

Investigation by HHS finds many unreported errors

Wed, 11 Jan 2012 18:17:00 GMT

According to a report from the inspector general of the Department of Health and Human Services (HHS), 85% of adverse events are not recognized or reported by hospital staff members, and hospitals seldom update their practices to prevent the same mistakes from occurring repeatedly. A recent New York Times article notes that the major issue in error reporting does not seem to be that employees are afraid to report errors, but rather that many hospital employees are not aware of what constitutes an adverse event or deserves reporting.

During a thorough review of 293 cases in which patients were harmed, federal investigators discovered 40 cases were reported to hospital managers, and five of the cases resulted in policy changes. The Centers for Mediare & Medicaid Services, incollaboration with the Agency for Healthcare Quality and Research (AHRQ) plan to create a list of events to report and will encourage hospitals to provide employees with explicit information regarding error reporting.

Source: New York Times

December issue of journal stresses patient safety in point-of-care testing

Wed, 04 Jan 2012 20:47:00 GMT

Medical News Today reports that the December issue of Point of Care : The Journal of Near-Patient Testing & Technology focuses on topics in patient safety and the safe use of point-of-care testing (POCT) technologies.

The issue includes case reports, research studies, and editorials on emerging POCT technologies and standards and the potential pitfalls of POCT use and the potential for error associated with the implementation of new POCT technologies. Several articles stress a need for a more methodical approach to operator training, system alerts, patient identification, and quality control.

Source: Medical News Today

Napping could be crucial in minimizing fatigue-related medical errors

Wed, 04 Jan 2012 20:42:00 GMT

An ongoing study is testing whether short, onsite naps, rather than further restrictions on work hours, may hold the key to preventing fatigue-related medical errors. The study's method, which requires residents to completely hand off responsibility during their assigned nap time, indicates a simple reduction in work hours may not be the answer to error prevention.

The updated national restrictions on the number of hours medical residents can work, implemented in 2003, reduced the work week from 100 hours to 80 hours total, and bars residents from working more than 30 hours continuously. Although studies have shown that sleep-deprived workers make more mistakes and perform worse than well-rested workers, there are no studies that clearly demonstrate a correlation between the restrictions on work hours and a decrease in mistakes

Source: TIME

Study finds teamwork and communication lead to decrease in surgery complications

Wed, 28 Dec 2011 19:54:00 GMT

Veteran Health Administration (VHA) facilities that implemented a medical team training program saw decreases in surgery-related complications, according to a report in Reuters Health. The study gathered data from more than 120,000 surgeries at 74 facilities between 2006 and 2008. Of the hospitals studied, 42 introduced a program in which surgeons discuss both the patient and procedure with the aid of a checklist prior to surgery and then follow up with a debriefing session after surgery. Patient involvement was also part of the process.

Researchers reported a drop in surgery-related blood clots, skin surface infections, and deep wound infections among the facilities implementing the program. Douglas Paull, MD, one of the researchers conducting the study, noted that staff and patients alike embraced the team-focused approach and that the program led to better outcomes and boosted morale.

Source: Reuters

Healthcare employee injury rate higher than construction, mining, and manufacturing

Thu, 08 Dec 2011 20:38:00 GMT

The U.S. Department of Labor Department statistics shows the healthcare industry has one of the highest rates of injury and illness among employees at 5.2 cases for every 100 workers.

Mining rates are at 2.3 per 100 cases, construction 4, and manufacturing, 4.4. The rate specifically for hospitals falls squarely at 7. Many of the injuries are back sprains, falls, and needle stick injuries.

Source: Pittsburgh-Post Gazette

CMS releases quality information to consumer groups

Wed, 07 Dec 2011 19:13:00 GMT

The Centers for Medicare & Medicaid Services (CMS), under the Affordable Care Act, announced the final rule for more transparency on quality data.

The rule gives qualified organizations, like employers and consumer groups, access to data that can help them identify high quality healthcare providers or create online tools to help consumers make educated health care choices. Information that could identify specific patients, however, will not be publicly released and strong penalties will be in place for any misuse of data.

Data will be based on Medicare claims. This final rule creates a framework for providers to receive a single, actionable performance report covering all or most of their practice, rather than receiving Medicare data in piecemeal, as before.

The rule also gives healthcare providers more time with the reports to review and appeal data before they become public.

Source: CMS press release.

Paper new culprit in germ transmission

Wed, 30 Nov 2011 21:03:00 GMT

Researchers in Germany found that bacteria survived on paper for at least 72 hours and could still be cultivated a week later, proving that bacteria can transfer from paper to hand and back again.

Paper cannot be disinfected with chemicals, so researchers suggested hand washing. The study was published n the American Journal of Nursing, with a comment from the Editor-in-Chief Maureen Shawn Kennedy, MA, RN, that urged infection control professionals to encourage hand washing and called the tactic of asking patients to ask clinicians to wash their hands " just another work-around in a dysfunctional system." The onus, she said, should not be placed on the patient for policing clinician behavior.

Source: American Journal of Nursing

Family of patient settles with MGH over alarm sentinel event

Wed, 30 Nov 2011 20:31:00 GMT

The family of a patient who died after nurses failed to respond to alarms on his cardiac monitor has settled with Massachusetts General Hospital for $850,000.

The attorney representing the family, Andrew Meyer, told the Boston Globe that "much to Mass General's credit, they recognized the error and tried to do right by the family."

State and federal investigators found that 10 nurses on duty did not recall hearing the beeps of the patient's alarm. Alarm fatigue, plus the fact that one of the alarm's volume had been turned off, contributed to the death.

Source: The Boston Globe.

Kaiser sues nurses’ union over strike

Wed, 23 Nov 2011 19:56:00 GMT

Kaiser Permanente's Northern California hospital unit and medical group filed a lawsuit against the California Nurses Association (CNA).

Kaiser is stating that the strike that occurred on September 22 to 23, 2011 was a breach of contract. CNA stated that the short strike was in sympathy with the National Union of Health Care Workers, which walked out at a number of Kaiser and Sutter Health facilities.

The largest nurses’ strike in state history, as many as 22,700 nurses took part in this protest.

The strike was brought further into the limelight after a patient at Alta Bates Summit Medical Center died after she received an incorrect dose of medication administered by a replacement nurse. At the time, regular staff nurses employed by Sutter Health System were locked out following a one-day strike by 23,000 nurses across the state.

Source: San Francisco Business Times

Poverty, community problems at heart of readmissions, researchers say

Wed, 16 Nov 2011 20:56:00 GMT

A new study found that by Memphis-based Qsource showed that the patients with the most repeat readmissions live in the same ZIP codes in the Nashville area—an area in which hospitals are likely to lose 1% Medicare reimbursement due to high readmissions levels compared to the rest of Tennessee.

The ZIP codes indicate low-income areas where people do not have access to transportation to the hospital and lack funds for medicine. Qsource CEO Dawn FitzGerald told The Tennessean that the results show readmissions are a community—not just hospital—problem, indicating hospitals should not be penalized.

Researchers note that the Medicare formula does not factor in race, income, education, or access to care.

Source: The Tennessean

AHRQ awards $34 million to expand fight against HAIs

Wed, 09 Nov 2011 19:58:00 GMT

The U.S. Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) announced that it has awarded $34 million in fiscal year 2011 for grants and contracts to hospitals, academic medical institutions, and healthcare research organizations to expand the fight against healthcare-associated infections (HAI).

These projects and others funded by the agency help to attain the goals of HHS' Partnership for Patients initiative, a nationwide public-private partnership that aims to make care safer for patients and reduce unnecessary return visits to the hospital while making care less costly.

These awards include projects to develop, test and spread the use of new modules of the Comprehensive Unit-based Safety Program (CUSP), a proven method to prevent and reduce HAIs. Since 2008, AHRQ has been promoting the nationwide adoption of CUSP to reduce central line-associated blood stream infections (CLABSIs). The new modules target three additional infections that are also areas of focus for the Partnership for Patients:

Catheter-associated urinary tract infections, the most common HAI, which can occur in patients with urinary catheters.
Surgical site infections, a complication of surgery that can occur at the incision site or deeper within the body.
Ventilator-associated pneumonia, which can occur in patients who require mechanically assisted breathing and, as a result, have a higher risk of developing health care-associated pneumonia. This new module will be pilot tested in two states with funding from the HHS Office of Healthcare Quality.

Read the entire AHRQ press release.