Patient Safety a Daily Priority at St. Joseph Hospital in Kokomo

By Lisa Kipps

At 9 o’clock in the morning Monday through Friday at St. Joseph Hospital, you’ll find the leadership team just standing around talking. And that’s a good thing.It’s called the Safety Huddle.

During the huddle, leaders representing every department in the facility go through a seven-point patient safety agenda.

No. 1:  A quick update on key patient safety statistics, including how many days since the last serious safety event, how many days since the last patient fall, and the current patient loyalty score.

No. 2: What’s happened in the past 24 hours related to patient safety or patient experience? 

No. 3: Any follow-ups to issues from the previous day?  The expectation is that issues are to be resolved within 24 hours. 

No. 4: Anything anticipated for today that could become a safety concern?

No. 5: Any good safety catches or great patient experience stories? The stories help St. Joseph identify heroes and assures that what one department learns is shared with all.

No. 6: Any announcements?

No. 7: The final item is a brief prayer, assuring that every member of the team leaves the huddle thinking about his or her reason for being there that day — to care for patients in the best way possible.

April will mark the one-year anniversary of the Safety Huddle. Eighty percent of the time it’s led by the president of St. Joseph Hospital, Kathy Young, MS, FACHE.   Each individual department has their own safety huddles, too. The message at St.Joseph is crystal clear: Patient Safety is the No. 1 priority.  There isn’t a single employee who does not know that.

Meeting in a huddle instills a sense of teamwork.

“The beauty of huddle is it strengthens the sense of team,” said John Rudy, PhD, executive director of diagnostic and treatment services. “When there’s a problem, it’s not ‘there’s a maintenance problem or a housekeeping problem or whatever.’ It’s our problem.”

To read full article please visit
http://www.kokomoperspective.com/news/local_news/st-joseph-s-leadership-team-focuses-on-safety/article_5fdbfd9a-5586-11e0-85e0-001cc4c03286.html

WSJ Interviews Dr. Pronovost about Patient Safety and Limiting Hospital Infections

Laura Landro interviewed Dr. Pronovost in the Wall Street Journal

By Laura Landro

As medical director for Johns Hopkins University's Center for Innovation in Quality Patient Care, Peter Pronovost, 46, has spent most of his career as a champion of innovative but practical solutions to fix system flaws that can lead to deadly mistakes and complications in hospitals. That mission took on new urgency in 2001, after 18-month-old Josie King died at Johns Hopkins following missteps in her care.

Dr. Pronovost's current crusade is preventing deadly bloodstream infections linked to central lines or catheters used in intensive-care units. A pilot project in Michigan showed that participating hospitals reduced rates of hospital acquired infections and death by using a checklist of evidence-based steps to reduce the infections—and by fostering a culture of patient safety and teamwork.

Dr. Pronovost's boyish appearance and enthusiastic manner belie a steely determination to challenge the status quo in medicine. He hasn't shied away from criticizing his peers for resisting safety and quality improvement efforts, a theme of his 2009 book "Safe Patients, Smart Hospitals."


To read rest of article and interview please visit

http://online.wsj.com/article/SB10001424052748704364004576131963185893084.html?mod=wsj_share_twitter

100 Top Hospitals Award Winners Announced- Rankings include Patient Safety

Thomson Reuters has annouced their 100 Top Hospital award winners.Their study evaluates performance in ten areas: mortality; medical complications; patient safety; average patient stay; expenses; profitability; patient satisfaction; adherence to clinical standards of care; post-discharge mortality; and readmission rates for acute myocardial infarction (heart attack), heart failure, and pneumonia. The study has been conducted annually since 1993.

."This year's 100 Top Hospitals award winners have delivered exemplary results, despite volatility from healthcare reform," said Jean Chenoweth, senior vice president at Thomson Reuters.For the 100 Top Hospitals study, Thomson Reuters researched almost three thousand short-term, acute care, non-federal hospitals. The information all comes from public informationinluding - Medicare cost reports, Medicare Provider Analysis and Review (MedPAR) data, and core measures and patient satisfaction data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website.

The study concludes that if all Medicare inpatients received the same level of care as those treated in the award-winning facilities:

* Nearly 116,000 additional patients would survive each year.
* More than 197,000 patient complications would be avoided annually.
* Expense per adjusted discharge would drop by $462.
* The average patient stay would decrease by half a day.

For more information, please visit www.100tophospitals.com

Northside Forsyth Hospital in Georgia Highly Ranked for Patient Safety

As reported in Forthsyth News .com
by Crystal Ledford

Northside Hospital-Forsyth has been named one of the best hospitals in the nation for patient safety.
HealthGrades, an independent organization that ranks medical providers to empower consumers to make informed health decisions, listed Northside-Forsyth, Georgia in the top five percent of hospitals across the nation for patient safety.The survey analyzed 40 million Medicare patient records from 2007-09, looking at 13 safety indicators. 

According to the HealthGrade study, patients treated at hospitals ranking in the top 5 percent have a 46 percent lower risk of experiencing a patient safety incident than those treated in lower performing hospitals.
In addition, the study found patients treated in the top performing hospitals were on average about 52 percent less likely to contract a hospital-acquired infection following surgery.


Northside-Forsyth was one of four hospitals in Georgia named to top 5 percent.The others included Gainesville's Northeast Georgia Medical Center, Piedmont Hospital in Atlanta, and Saint Mary's Hospital in Athens.

Skip Putnam, CEO of Northside-Forsyth, said he and his staff were "very proud and honored" to receive the ranking from HealthGrades."Ensuring patient safety and quality of care is a part of everyone's job at Northside Hospital-Forsyth," Putnam said. "We will continue to provide the safest environment and best possible care for our community."

James McCoy, president of the Cumming-Forsyth County Chamber of Commerce, said the ranking speaks well not only for the hospital, but the entire community."The fact that we have a local hospital recognized for safety on a national level is remarkable," he said. "This is a great accomplishment for the leadership of the hospital and our community.

To read full article please visit Forsyth News

AHRQ Hospital Survey On Patient Safety Culture Shows Improved Patient Safety Scores

Some interesting information pulled from the Executive Summary of the new AHRQ Hospital Survey:

The Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture comparative database. The first annual comparative database report was released in 2007 and included data from 382 U.S. hospitals. The Hospital Survey on Patient Safety Culture 2011 User Comparative Database Report displays results from 1,032 hospitals and 472,397 hospital staff respondents

Areas of Strength for Most Hospitals

Three areas of strength emerged. Results are expressed in terms of percent positive response. Percent positive is the percentage of positive responses (e.g., Agree, Strongly agree) to positively worded items (e.g., "People support one another in this unit") or negative responses (e.g., Disagree) to negatively worded items (e.g., "We have safety problems in this unit").

Teamwork Within Units (average 80 percent positive response)—This composite is defined as the extent to which staff support each other, treat each other with respect, and work together as a team. This composite had the highest average percent positive response.

Supervisor/Manager Expectations & Actions Promoting Patient Safety (average 75 percent positive response)—This composite is defined as the extent to which supervisors/managers consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems. This composite had the second highest average percent positive response.

Patient Safety Grade—On average, most respondents within hospitals (75 percent) gave their work area or unit a grade of either "A-Excellent" (29 percent) or "B-Very Good" (46 percent) on patient safety.

Areas With Potential for Improvement for Most Hospitals

Three areas showed potential for improvement.

Nonpunitive Response to Error (average 44 percent positive response)—This composite is defined as the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file. This composite had the lowest average percent positive response.

Handoffs and Transitions (average 45 percent positive response)—This composite is defined as the extent to which important patient care information is transferred across hospital units and during shift changes. This composite had the second lowest average percent positive response.

Number of Events Reported—On average, most respondents within hospitals (54 percent) reported no events in their hospital over the past 12 months. It is likely that events were underreported. This is an area for improvement for most hospitals because underreporting of events means potential patient safety problems may not be recognized or identified and therefore may not be addressed.

Results by Hospital Characteristics

Bed Size

    * Very small hospitals (6-24 beds) had the highest overall average percent positive response on the patient safety culture composites.

    * Small hospitals (25-49 beds) had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (81 percent positive for 25-49 beds vs. 70 percent for 400 beds or more).

Results by Respondent Characteristics

Work Area/Unit

    * Respondents in Rehabilitation had the highest average percent positive response across the composites (69 percent positive); Emergency had the lowest (57 percent positive).

    * Rehabilitation had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (84 percent); Emergency had the lowest (63 percent).

    * ICU (any type) had the highest percentage of respondents reporting one or more events in the past year (63 percent); Rehabilitation had the lowest (42 percent).

Staff Position

    * Respondents in Administration/Management had the highest average percent positive response across the composites (74 percent positive); Pharmacists had the lowest (60 percent positive).

    * Administration/Management had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good"(86 percent); Pharmacists had the lowest (67 percent).

    * Pharmacists had the highest percentage of respondents reporting one or more events in the past year (72 percent); Unit Assistants/Clerks/Secretaries had the lowest (18 percent).

Trending: Comparing Results Over Time

Results regarding changes over time on the patient safety culture composites, patient safety grade, and number of events reported for the 512 hospitals (of the 1,032 total database hospitals) that administered the survey and submitted data more than once are highlighted.

Trending: Overall Summary Statistics

    * The average percent positive scores on the patient safety culture composites increased slightly by 2 percentage points (ranging from 1 to 3 percentage points).

    * The average percentage of respondents who gave their work area/unit a patient safety grade of "A-Excellent" or "B-Very Good" increased slightly by 3 percentage points.

    * The average number of respondents reporting one or more events increased by only 1 percentage point.

    * The top three patient safety actions implemented by hospitals between the previous and most recent survey administration were:

          o Improved fall prevention program (56 percent).

          o Conducted root cause analysis (52 percent).

          o Implemented SBAR (situation-background-assessment-recommendation) communication (51 percent).

Trending: Bed Size

    * Hospitals with 50-99 beds had the greatest increases in percent positive response over time on 8 of the 12 composites (average increase of 3 percentage points).

    * Very small hospitals (6-24 beds) had the greatest increase in the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (a 4 percentage point increase, from 77 percent to 81 percent).

Trending: Work Area/Unit

    * ICU and Pediatrics had the greatest increases in percent positive response on 5 of the 12 patient safety culture composites (average increases of 4 and 3 percentage points, respectively).

    * Emergency had the greatest increase over time in the average percentage of respondents giving their work area/unit a patient safety grade of "Excellent" or "Very Good" (a 4 percentage point increase, from 60 percent to 64 percent).

    * Lab and Pharmacy had the greatest increases in the average percentage of respondents reporting one or more events in the past year (5 percentage point increases). The largest decrease was in Psychiatry/Mental Health (a 5 percentage point decrease).

Payers and Providers Study: Turning Clincial Data into Actionable Information Key Mandate for Clinical Analytics

Using clinical analytics to meet Stage One MU criteria and lowering clinical costs emerged as the top drivers for providers and payers, respectively, for using and analyzing clinical data. This is according to a new HIMSS Analytics whitepaper  based on a 2011 annual study of payers’ and providers’ use of clinical data.

The HIMSS research is the second annual study conducted by HIMSS Analytics and sponsored by Anvita Health™, comprising a series of focus groups and one-on-one interviews with CMOS and chief medical information officers from the payer and provider communities.

To read the full article please visit

http://psqh.com/news/current-news/773-payers-and-providers-study-turning-clincial-data-into-actionable-information-key-mandate-for-clinical-analytics.html

Bloodstream Infections in ICUs Plummeting, Too Many Remain in Hospitals and Dialysis Clinics

The number of bloodstream infections in intensive care unit patients with central lines decreased by 58 percent in 2009 compared to 2001, according to a new CDC Vital Signs report. During this time span, the decrease in bloodstream infections represented up to 27,000 lives saved and almost $2 billion in excess health care costs. Bloodstream infections in patients with central lines can be deadly, killing as many as one in four patients who gets one.

A central line is a tube usually placed in a large vein of a patient's neck or chest to deliver treatment in an ICU, elsewhere in the hospital, and during dialysis. A bloodstream infection can happen when germs enter the blood through a central line, often because proper procedures were not used while the central line was placed or maintained. In recent years, studies have proven that health care providers can prevent most bloodstream infections in patients with central lines by following CDC infection control recommendations, which include removing central lines as soon as medically appropriate. In hemodialysis patients, central lines should only be used when other options are unavailable.


To read the full article please visit

http://www.psqh.com/news/current-news/770-infections-in-icus-plummeting-too-many-remain-in-hospitals-and-dialysis-clinics.html

Patient Safety Ranked Higher at Top Rated Hospitals

 HealthGrades released a study that found that patients have a 46% lower risk of experiencing a patient safety incident at a top-rated hospital compared to a poorly rated hospital. The annual HealthGrades Patient Safety in American Hospitals study, which analyzed 40 million Medicare patient records, from 2007 to 2009. HealthGrades utilized the patient safety indicators published by the Agency for Healthcare Research and Quality (AHRQ) to identify preventable medical mistakes that occurred during patients' hospitalizations.

Study findings show that, despite encouraging research from the Centers for Disease Control and Prevention showing reductions in hospital acquired bloodstream infections in certain patients, progress is inconsistent. Some hospitals have made rapid progress in reducing infection rates, but hospitals continue to show wide variation in their rates. For example, HealthGrades found that patients treated at those hospitals performing in the top 5% in the nation for patient safety were, on average, 52% less likely to contract a hospital-acquired bloodstream infection or to suffer from post-surgical sepsis than those treated at poor-performing hospitals. Nearly one in six patients who acquired a bloodstream infection while in the hospital died, the study found.

To read the full article please visit Patient Safety & Quality Healthcare website

Patient safety & Quality Healthcare Magazine Publishing a Series of Articles on Rhode Island Patient Safety Improvements

How Rhode Island Is Leading a Revolution in Patient Safety

By Joanne Dooley, RN; Jean Marie Rocha, MPH, RN; Patricia Daughenbaugh, MSN; and Kathy Martin, MBA

This is the first in a series of articles about the statewide implementation of a standardized web-based event-reporting platform to facilitate the reduction of medical errors.


Rhode Island has played a leadership role in numerous revolutions throughou tour  history. The state was the first of the original thirteen colonies to declare independence from Great Britain, igniting the American Revolution. The construction of the first successful textile mill in Pawtucket, Rhode Island, signaled the start of the Industrial Revolution in the United States.

Today, Rhode Island continues that trailblazing tradition by leading efforts in another critical area: patient safety. Thanks to a statewide initiative to standardize the reporting and analysis of both adverse and near-miss medical events, Rhode Island will unite its private acute care hospitals—technologically and culturally—in a common effort to reduce medical errors.

to read the full article please visit www.psqh.com

Research Study Shows More Communication Needed to Improve Patient Safety

Originally published in US News

Nurses often don't speak up about incompetent colleagues or when they see fellow health-care workers making mistakes that could impact patient safety according to a new research study.Hospitals have taken steps to reduce medical errors through measures such as checklists, patient handoff protocols, computerized order entry systems and automated medication-dispensing systems.

The research study, which included 6,500 nurses and nurse managers across the United States, found that too often, nurses don't alert their colleagues when they see a patient safety measure being violated.About 85 percent of nurses said a safety measure had warned them about a problem that might have been missed and could have resulted in patient harm. However, 58 percent of these workers admitted that even though they received the warning, they failed to speak up and solve the problem.

More than 80 percent of nurses said they had concerns about three "undiscussable" issues demonstrated by colleagues: dangerous shortcuts, incompetence and disrespect, the investigators found.

On the issue of shortcuts, more than 50 percent of the study participants said they had witnessed events in which dangerous shortcuts led to near misses or caused harm to patients, but only 17 percent of those nurses discussed their concerns with colleagues.The study also found that more than one-third of participants reported witnessing incompetence that had led to a near miss or actual harm to a patient, but only 11 percent of these witnesses confronted the colleague that they considered incompetent.

The third "undiscussable" issue, disrespect, was cited as the reason why more than half of the study participants could not get others to listen to them or value their professional opinion. Only 16 percent of those who felt ignored actually confronted their disrespectful colleague, the study noted.

The findings show that while patient safety measures can help prevent medical errors, cultures of silence in U.S. hospitals may undermine their effectiveness, the researchers noted.


The American Association of Critical-Care Nurses and the Association of periOperative Registered Nurses partnered with VitalSmarts, a corporate training and organizational performance consulting firm, in an attempt to see how communication barriers can lead to medical errors.

The study, "The Silent Treatment," was to be released March 22.
Because this study was presented at a briefing, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

to read full article please visit-

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/03/22/study-reluctance-to-speak-up-encourages-medical-errors

M2SYS Technology Announces New Patient Identification Product

M2SYS Technology  announced the release of RightPatient™, the healthcare industry's first multi-biometric, instantly deployable patient identification system.The World Health Organization recently recommended healthcare facilities  should consider  biometric automated systems to decrease the potential for inaccurate patient identification. RightPatient™ allows facilities of any size to instantly add healthcare biometrics for patient identification to any EHR/EMR software. Designed to both safeguard patient health and eliminate patient fraud, RightPatient™ ensures 100% accurate patient identification and eases the financial burden precipitated by misidentification. Powered by the Hybrid Biometrics software engine, it is the only biometric patient identification solution that gives users the option to use four different forms of biometric technology - fingerprint, finger vein, palm vein, and iris biometrics - ensuring that patient biometric templates can be reliably and consistently captured, all of the time.

"Inaccurate patient identification is crippling the healthcare industry, jeopardizing quality patient care and costing providers millions of dollars per year," said Mizan Rahman, CEO and CTO of M2SYS. "With RightPatient™, hospitals can immediately implement a scalable healthcare biometrics system that instantly and easily interfaces with any EHR/EMR software. Coupled with our Bio-Hyperpliance™ high-performance one-to-many biometric matching server, the system can instantly scan a database containing millions of patients registered with Fujitsu PalmSecure, Hitachi Finger Vein Authentication Technology, iris, and fingerprint technology."

Read more: http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2011/03/23/prweb8226697.DTL#ixzz1HQLSR5CV

Premier Creates Alliance with Chief Nursing Officers to Improve Quality of Healthcare and Patient Safety

More than 130 chief nursing officers (CNOs) nationwide have joined a network dedicated to improving healthcare quality, patient safety, and efficiency while addressing the expanding role of Chief Nursing Officers to help organizations effectively relate to the consumers of  health care in their communities.  The Premier healthcare alliance, CNO Network, will collaborate and share best practices regarding these issues.

“CNOs today face challenges and expectations that we have not traditionally faced,” said Lanie Ward, RN, MBA, NEA-BC, system vice president of patient care services and chief nursing officer at Summa Health System in Akron, Ohio. “The purpose of this network is to bring together CNOs from across the nation to collaborate and share best practices specific to driving improvements in patient care, as well as operations and efficiencies.”

According to Carolyn C. Scott, RN, M.Ed, MHA, Premier vice president of performance improvement and quality, “We created this network at the request of our member hospital CNOs to share best practices around what is working – and what isn’t – in the administration of patient care. Nursing leadership is critical to ensure hospitals perform optimally, and this group is at the heart of improving patient care through the enhancement of safety and quality.”

Emergency Medicine Patient Safety Foundation Hosting Summit on Patient Safety

The Emergency Medicine Patient Safety Foundation (EMPSF)  announced that they will be hosting a summit on patient safety in emergency care in Las Vegas, NV, on May 5-6, 2011. The meeting, Patient Safety in Emergency Care: Excellence in Outcomes, (Twitter hashtag #empsfmtg1) will bring together key emergency medicine and patient safety stakeholders and thought leaders from across North America. The two day summit will be a forum for sharing insights on solving the patient safety challenges associated with providing emergency care in the pre-hospital and emergency department (ED) settings. Attendees will include leadership from key organizations, emergency medicine providers, nursing, hospital administrators, emergency medical services (EMS), pharmacy, risk management and patient safety officers and researchers.

"We are receiving a tremendous response to the summit," said Dianne Vass, executive director of EMPSF. "It is critical for those whose mission is to provide, deliver and support the continuum of emergency care to have a forum for sharing new insights, best practices and lessons learned with fellow leaders. As the only organization whose sole focus is dedicated to the advancement of patient safety knowledge in emergency medicine, EMPSF is pleased to host this first annual meeting of emergency and patient safety leaders."

According to the National Center for Health Statistics, there were over 116.8 million visits to hospital emergency rooms in the United States in 2007. This is an increase of 23% over 1997.  About 18 million ED patient visits arrived by ambulance and over 14.6 million visits resulted in the patient being admitted to the same hospital. With an aging population and a large uninsured/underinsured population, hospitals expect to see future demand for emergency services continue to grow.

The EMPSF 1st Annual Patient Safety Summit will be held at the Four Seasons Hotel in Las Vegas, NV, on May 5-6, 2011. Those interested in attending, sponsoring and exhibiting are encouraged to contact EMPSF for more information.

About EMPSF

The Emergency Medicine Patient Safety Foundation (EMPSF) is a national, 501(c) (3) not-for-profit organization that was formed in 2003 to identify and respond to the challenges of providing safe, quality health care in the practice of Emergency Medicine. For more information, call (888) 294-4624, visit www.empsf.org, www.twitter.com/empsf and Facebook.

Secretary Sebelius Visits Ohio to Recognize Solutions for Patient Safety

U.S. Secretary of Health and Human Services Kathleen Sebelius visited Nationwide Children's Hospital  to celebrate the achievements of Solutions for Patient Safety, a  collaboration involving Ohio business leaders and health care providers that is working to improve health care quality and eliminate certain avoidable medical errors. "Today, the Department of Health and Human Services released its first-ever National Quality Strategy, a ground-breaking roadmap for improving healthcare quality and patient safety nationwide, built on best practices from around the nation," said Secretary Sebelius. "Over the last two years, I've visited neighborhoods that are improving health by serving healthier school lunches, met with employers who are bringing down health costs with onsite health clinics, and toured hospitals that are showing that it's possible to improve patient outcomes. That's why I came to Columbus: to recognize Solutions for Patient Safety for their success, to learn how they've done it, and to help their best ideas spread."

The Solutions for Patient Safety initiative, launched in January 2009 and funded with a $1.5 million investment from the Cardinal Health Foundation, is a partnership among the Cardinal Health Foundation, the Ohio Business Roundtable, the Central Ohio Hospital Council, the Ohio Hospital Association, the Ohio Children's Hospital Association and 25 hospitals throughout the state. By focusing on reducing infections and adverse drug events, the hospitals collectively achieved nearly $13 million in health care savings, more than 900 fewer patient days spent in the hospital and nearly 3,600 fewer adverse drug events and infections in children.

The state's eight children's hospitals will be building upon the foundation of success realized through Solutions for Patient Safety, in their next effort – eliminating Serious Safety Events (SSEs) in Ohio's children's hospitals and developing a patient harm index. The Cardinal Health Foundation has committed an additional $1 million to support the next phase of this initiative, and Solutions for Patient Safety is also working to engage other businesses and organizations at the state and national level to support the continued expansion of this public-private partnership. 

The 17 central Ohio hospitals have expanded their work from Solutions for Patient Safety by continuing infection-prevention through monitored hand hygiene with student nurse observers, sharing an iPad compliance application developed by the Quality Institute of OHA with other hospitals statewide and rolling their blood-stream infection prevention efforts into a statewide initiative. 

"These efforts to save lives and reduce costs align closely with Governor Kasich's principles for health and economic vitality and the Medicaid modernization strategies that are included in the Executive Budget," said Greg Moody, director of the Governor's Office of Health Transformation. "By eliminating avoidable errors, we not only improve the quality of care, we can reduce costs and save money for individuals, taxpayers and employers. It is a win-win for everyone involved."

"Programs like this promote patient safety, reduce costs, and improve our health care system overall," U.S. Sen. Sherrod Brown (D-OH) said. "Solutions for Patient Safety has developed a national best practice model on data collection, hand sanitation, and cross-hospital collaboration. With this kind of leadership and collaboration, we can drive down health costs and improve patient outcomes."

A medical malpractice reform bill recently introduced in the North Carolina Senate is the latest threat to a citizen's private right of action against negligent health care providers. Senate Bill 23, which seeks to limit damages and would change the standard of medical negligence in claims involving emergency room errors, was introduced in February.

One of the bill's co-sponsors argued that the measure would create huge savings by reducing defensive medicine practices, stating that extra testing and other diagnostic decisions make up a quarter of all health care costs in America, a vast exaggeration. In a 2010 study in the public policy journal Health Affairs, health care experts and other researchers from Harvard University showed that the medical liability system -- inclusive of everything from defensive medicine and malpractice insurance to verdicts and settlements -- amounts to less than two and a half percent of health care expenditures in the U.S.

The executive director of the North Carolina Coalition for Patient Safety commented that the proposed legislation would actually do nothing to combat rising health care costs. Objective analysis seems to agree: the nonpartisan Congressional Budget Office's (CBO) analysis of even broader legislation proposed in the U.S. House (which also threatens the rights of North Carolina medical malpractice victims) showed a proposed cost savings of well below one percent. At the same time, a severe patient safety toll would be imposed: a study cited by the CBO in its analysis predicts that such reforms would result in an increase in the U.S. death rate amounting to 4,000 additional patient deaths a year.

Defending Clients, Defending a System That Protects Patient Safety by Preserving Individual Rights

Hospital negligence and medical malpractice continue to cause avoidable suffering in North Carolina, including wrongful death. Our communities are served by many excellent medical institutions and thousands of skilled and dedicated health care professionals. But when a failure to adhere to accepted standards of medical practice leads to a surgical error, birth injury, cancer misdiagnosis or medication error, injury victims and their families must not be left without full legal recourse.

Victims of medical errors and surviving family members can discuss their concerns with an experienced North Carolina medical malpractice lawyer. An attorney can explain the latest legal developments and help you assess your prospects for recovery.

Article provided by Devore Acton & Stafford, PA

Visit us at www.devact.com

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CDC Awards 2 Million Dollar Grant To Help Prevent Healthcare Associated Infections

The CDC (Centers for Disease Control and Prevention) is awarding a $ 2 million dollar grant to researchers at the Cook County Health & Hospitals System and Rush University Medical Center  to continue a successful program aimed at preventing healthcare-associated infections, antibiotic resistance, and other adverse events associated with healthcare. The Chicago Antimicrobial Resistance and Infection Prevention Epicenter (CARPE), is one of only five CDC Prevention Epicenters in the country.

Rush and Cook County were chosen  because the two institutions have a long standing collaboration and legacy of research innovation in antimicrobial resistance and infection prevention by internationally known infectious disease experts.

The CDC estimates that one out of 20 hospitalized patients will acquire an infection while receiving health care treatment for other conditions. Healthcare-associated infections cause significant death and illness among patients treated in U.S. healthcare institutions and add billions of dollars to healthcare costs. With the emergence of drug-resistant infections and new pathogens in health care settings, new strategies to detect and reduce health care-associated infections become even more critical.

To read the full article please visit:
http://www.infectioncontroltoday.com/news/2011/03/cdc-cook-county-and-rush-collaborate-to-research-and-prevent-hais.aspx

Radiation Patient Safety Addressed in New York Times Letter

“W. Virginia Hospital Overradiated Brain Scan Patients, Records Show” (news article, March 6) again highlights issues of concern regarding radiation safety for patients. The American College of Radiology has always been a leader in developing programs to ensure quality and patient safety.

As chairman of the A.C.R. board of chancellors, I am pleased to report that as an element of its broad registry program, the college has developed a CT dose index registry that facilitates direct reporting of CT radiation dose for each examination to a central database, while preserving legally required patient confidentiality.This registry permits facilities to compare dose levels to national benchmarks, helps standardize the dose reporting process, and may potentially alert a facility when a threshold dose has been exceeded.

The college agrees that a requirement for dose reporting should be an integral component of safe medical practice, and we are working with federal legislators and regulators to create a national policy that would mandate such reporting. 

John A. Patti
Boston, March 9, 2011
The writer is a radiologist at Massachusetts General Hospital.

Standard Register Healthcare Hostng Patient Safety Summit- Quest 2011

Standard Register Healthcare will host its first healthcare summit, Quest 2011. The invitation-only event,  will be held March 23-24 at the Baltimore Hyatt Regency in Baltimore, Maryland,and will focus on “Fostering a Culture of Patient Safety: Compliance vs. Engagement.”  

Dr. Peter J. Pronovost, one of healthcare’s most influential advocates for patient safety, will be the keynote speaker and lead an interactive session in which other thought leaders and innovators in patient safety will share ideas and successes for creating more patient-centric environments and safer care.

“Patient safety is one of the most pressing issues facing the healthcare industry today. The World Health Organization estimates that in developed countries as many as one in 10 patients is harmed while receiving hospital care,” said Brad Cates, president for Standard Register Healthcare. “The goal of Quest 2011 is to facilitate thought leader collaboration and create a path to further advances in patient safety.”

Pronovost is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore. He is best known for having led the Michigan Keystone project which uses checklists and other interventions to measurably reduce catheter-associated bloodstream infections in ICUs . For this work and more, he received a MacArthur Foundation Fellowship and Time Magazine named him as one of the 100 most influential people in the world.

Standard Register Healthcare is hosting Quest 2011 in collaboration with Patient Safety and Quality Healthcare magazine, which is the exclusive media sponsor for the event. For more information on Patient Safety & Quality Healthcare or to subscribe please visit their website- www.psqh.com

Fresenius Medical Care PSO Recognized by Dept of HHS.

Fresenius Medical Care  Patient Safety Organization (PSO.)was recognized by the U.S. Agency for Healthcare Research and Quality. The certification by the United.States Secretary of the Department of Health and Human Services, the first for a dialysis organization, furthers Fresenius Medical Care’s mission of continuously improving patient safety and health care quality. The purpose of a PSO is to establish a framework by which doctors and other health care providers may voluntarily report information to PSOs, on a privileged and confidential basis, to collect and analyze patient safety events. Regulations outline how the PSO may utilize data and act as a resource for health care providers to understand and minimize the risks and hazards in delivering patient care.

A PSO's workforce must have expertise in analyzing patient safety events, such as the identification, analysis, prevention, and reduction or elimination of the risks and hazards associated with the delivery of patient care.

“Each of our more than 1,800 kidney dialysis clinics in the U.S. has a Quality Improvement Committee that investigates the root causes of all patient adverse events, with the objective of continuous improvement in patient safety and quality of care,” said Michael Lazarus, M.D., director of Fresenius Medical Care Patient Safety Organization. “Our companywide Patient Safety Organization performs a more global root cause analysis of aggregate data. We do this to maximize safe conditions in our facilities and to provide the safest dialysis treatments

Pennsylvania Patient Safety Authority Shares Data on Wrong Site Surgery

As reported in Becker's Hospital Review

 Pennsylvania's Patient Safety Authority data showed the share of medical errors attributed to wrong-site blocks  increased from 20 percent of the total in 2004 to 44 percent of the total in 2009. Some anesthesia experts attribute the increase in anesthesia-related wrong site surgery problems to the increased use of nerve blocks. As anesthesiologists use nerve blocks in place of general anesthesia with increasing frequency, they must make sure the correct block site is marked prior to administering the block.

A pilot study conducted by the Joint Commission's Center for Transforming Healthcare at Mount Sinai Medical Center in New York City discovered that Universal Protocol safety checks were not always followed prior to surgery. The hospital created a new process called an "active time-out," in which the surgeon, anesthesiologist and scrub person are each responsible for a series of questions and statements in response to the circulating nurse.


To read the full news item please visit www.beckershospitalreview.com

Pre- Surgery Checklist Could Greatly Improve Patient Safety In South Carolina

Reported by John Monk in the South Carolina State

Atul Gawande, a  leader in patient safety initiatives that have already saved numerous lives, joined with the South Carolina. Hospital Association Wednesday to formally kick off a pioneer medical error-reduction program in sixty one South Carolina hospitals.At least 500 of the 5,000 patients who die each year following surgeries in S.C. hospitals should be saved by 2013 with a savings of $28 million if his pre-surgery checklist is only minimally successful, Gawande said.

“This is not a transformation that will take one year — the politicians won’t be happy with the pace of change, but it will be lasting change,” said Gawande, 45, the Boston surgeon largely responsible for developing a “checklist” procedure that’s attracted widespread attention.

Based on Boeing airplane pilot checklists, it helps ensure surgical teams don’t skip a key procedure in the incredibly complex, fast-paced world of today’s modern operations.Airlines long ago found out that aviation had gotten so complex that pilots needed checklists — not so detailed that it caused undue delays, but one that allowed pilots to pay attention to key areas where the risk was great. “The complexity of flying aircraft began to exceed the capacity of the brains of even their top pilots — it just wasn’t possible to remember it all,” Gawande said. “The checklist enabled them to remember a bundle of things, parts of which could easily slip away.”

When fully implemented — and if South Carolina’s results in preventing unnecessary deaths match results in more limited studies — it’s possible that more than 2,000 S.C. patients a year would survive preventable complications, Gawande said.


To read full article please visit The State website

AORN Releases Learning Module to Prevent Retained Surgical Items

The Association of periOperative Registered Nurses has  released the AORN Retained Surgical Items Confidence-Based Learning Module(CBL).Preventing retained surgical items is a key patient safety focus in the perioperative setting because any surgical item left in a patient, whether it's a sponge, towel, instrument fragment or other surgical item, can lead to complications with the patient's recovery. The prevention of retained surgical items requires the  coordination of every member of the perioperative team.

The development of the CBL was made possible by an educational grant from Medline Industries, Inc. and ClearCount Medical Solutions, Inc. to the AORN Foundation. In addition, the companies will fund free access to the module for the first 500 registrants.

The RSI learning module is designed for directors, managers, educators, staff nurses and other personnel working in traditional operating rooms, ambulatory surgery centers, physicians' offices, cardiac catheterization laboratories, endoscopy suites, radiology departments and other areas where surgery and other invasive procedures are performed.

About ClearCount Medical Solutions
ClearCount Medical Solutions is a medical device company focused on patient safety solutions. ClearCount has assembled an extendable RFID-based platform that provides a comprehensive solution to improve efficiency while preventing medical errors. ClearCount Medical Solutions has been recognized with a Popular Science 2009 Best of What's New Award, and has received additional recognition from TIME and WIRED magazines, the 2009 Wall Street Journal Technology Innovation Award, the International Design Excellence Award (IDEA) and more. ClearCount's SmartSponge and SmartWand-DTX systems are the first RFID enabled systems for counting and detecting surgical sponges, thereby improving patient and OR safety, enhancing productivity, and reducing cost. To learn more, visit www.clearcount.com.

About Medline Industries, Inc.
Medline, the nation's largest privately held manufacturer and distributor of healthcare products, manufactures and distributes more than 100,000 products to hospitals, extended-care facilities, surgery centers, home care dealers and agencies. Headquartered in Mundelein, Ill., Medline has more than 900 dedicated sales representatives nationwide to support its broad product line and cost management services. To learn more, visit www.medline.co

Institute for Healthcare Institute Symposium Next Week

IHI will be presenting their 12th Annual International Summit on Improving Patient Care in the Office Practice & the Community next week in Dallas. Capable office practices in partnership with other community care organizations are the key to transforming our health care system. The theme for this year's symposium is  "building new partnerships".

The Symposium will be held March 20-22, 2011, in Dallas, Texas.This event is designed for health care professionals working in primary care and community settings, including:

• Physicians and physician’s assistants
• Nurses and nurse practitioners
• Primary care clinicians
• Specialists with office-based practices
• Behavioral Health professionals
• Medical directors
• Health care administrators and office practice managers
• Health plan leaders
• Government, association, and coalition leaders
• Health policy makers
• Pharmacists
• Quality improvement leaders and staff
• Senior leaders
• Students, faculty, and residents in health professions
• Community leaders who are working to optimize care while maximizing health care resources

All experience levels are invited to attend - from beginners in improvement work to more experienced veterans in the field.

For more information please visit IHI website

National Patient Safety Foundation Annual Patient Safety Congress in May.

The National Patient Safety Foundation (NPSF) will be holding their 13th Annual Patient Safety Congress in Washington D.C. on May 25- 27th.The NPSF Patient Safety Congress is a great opportunity to learn from and exchange ideas with patient safety experts and practitioners from around the globe.

Created by leaders in the patient safety field to provide real-world tools, resources, and evidence-based solutions for patient safety issues, the NPSF Patient Safety Congress is the only conference with a singular focus on patient safety.This program delivers 30 educational sessions led by industry experts. A full day of in-depth Pre-Congress sessions and a variety of motivational plenary speakers make the Patient Safety Congress the foremost learning and networking event in the field.

Join us this May in our nation’s capital for an exciting program that will help you build the foundation to nurture patient safety in your organization.For more information please visit the conference website-http://npsfcongress.org/

Patient Safety & Quality Healthcare Magazine is pleasd to be a Media Sponsor for this important industry event.

New HealthGrades Report Shows Patient Safety Trends

As reported in US News & World Reports

Certain types of medical errors are forty six percent less likely to occur at top-rated  hospitals than lower-ranked hospitals, according to a new HealthGrades study. Their researchers analyzed 40 million Medicare patient records from 2007 to 2009 and focused on 13 patient safety indicators, such as bed sores, bloodstream infections from catheters, foreign objects left in the body after procedures and excessive bleeding or bruising after surgery.

The patient safety indicators published by the U.S. Agency for Healthcare Research and Quality were used to identify preventable medical errors and which hospitals were in the top 5 percent for avoiding those errors.
Nationwide, hospitals varied widely in their performance, according to the annual HealthGrades Patient Safety in American Hospitals report, but some hospitals have made significant improvements, said study co-author Dr. Rick May, HealthGrades vice president of clinical quality service.

To read full article please visit  
http://health.usnews.com/health-news/managing-your-healthcare/healthcare/articles/2011/03/09/hospital-safety-varies-widely-nationwide-report

For more information on Patient Safety please visit our website www.psqh.com

Safe Patient Handling Program Introduced at HCMC

Hennepin County Medical Center (HCMC) in Minneapolis has selected Ergolet  to introduce a safe patient handling program for patients who need assisted lifting or transfer to bathrooms, beds or wheelchairs. Ergolet,  manufactures overhead lifts, sit-to-stand aids and mobile lifts to assist in patient transfers that are safe and comfortable for the patient, with improved safety for hospital staff.

“HCMC is committed to enhancing patient and staff safety through a Safe Patient Handling program and is excited to partner with Ergolet,” said Kathy Wilde, HCMC Chief Nursing Officer.  “The equipment and education they provide will help us minimize manual lifting and improveboth patient safety and staffsafety.” The program will include ceiling-based lifting units with in-room overhead tracking, plus portable lifts that will assist HCMC staff as they transfer patients.

To read more please visit  Patient Safety & Quality Healthcare

VitalGo Inc. Introduces New Bed for Patient Safety

VitalGo, Inc., a provider of  technology-based solutions for staff and patient safety,  introduced a bed that can raise a patient from a lying position to a fully standing position – with no manual lifting. The Total Lift Bed (TLB) is a solution to the epidemic rise in injuries that caregivers and patients suffer from due to manual lifting patients and transfers to and from bed.

“This new concept changes the way caregivers lift and transfer patients,” says VitalGo CEO Ohad Paz, “It not only minimizes the risk of injury to both caregiver and patient, but it simplifies the transfer process while providing optimal patient comfort.” The TLB can be used in place of regular hospital and nursing home beds at roughly the same cost but with decreased incidence of worker injury and corresponding Workers Compensation cases.

To read the full release please visit Patient Safety and Quality Health Care

Study on RFID Use to Prevent Retained Surgical Sponges

As reported in Patient Safety & Quality Healthcare

RF Surgical Systems, Inc announced the first published data on the use of RFID to identify retained surgical items in all patient types. The prospective study, published in the February 1 edition of American Journal of Surgery, found that the sensitivity and specificity of radio-frequency (RF) technology is one hundred percent in patients of varying body size.

The study, “Sensitivity of Detection of Radiofrequency Surgical Sponges: a Prospective, Cross-Over Study,” included data from 210 subjects at an academic medical center and a U.S. Department of Veterans Affairs medical center. Results found that RF technology is superior to the reported accuracy of intraoperative radiography and has greater sensitivity than manual surgical counting.

To read the full news item please visit Patient Safety & Quality Healthcare

GE Listed as National Patient Safety Organization by HHS, AHRQ

The Secretary of Health and Human Services (HHS) has listed the GE-MERS National Patient Safety Organization (GE PSO) as part of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Organization (PSO) program. GE Healthcare Performance Solutions joins leading healthcare organizations  working to minimize risks in patient care. GE’s PSO provides its members a single common medical event reporting platform, with comprehensive data analytics and advisory support to identify the root causes of risk, and help hospitals make lasting patient safety improvements.

“Over a decade has passed since the Institute of Medicine made an influential call to decrease the number of costly medical errors that kill nearly 100,000 Americans each year; however, event-reporting limitations have often impeded progress toward this goal,” said Jan De Witte, President and CEO, GE Healthcare Performance Solutions. “Our Performance Solutions business has the elements necessary – reporting, analytics and advisory - to help hospitals make measurable and lasting improvements in patient safety.  Performance Solutions has a long term commitment to helping the healthcare industry reduce cost, improve quality and increase access and we will continue to invest in new technology capabilities and programs that improve overall performance.”

To read more please visit Patient Safety & Quality Healthcare

New Award Announced for Leadership n Healthcare Quality

The American Hospital Association  announced the new Dick Davidson Quality Milestone Award to recognize  hospital associations’ leadership in improving healthcare quality. The award will be presented annually to a hospital association that demonstrates leadership and innovation in healthcare quality improvement and contributes to national healthcare improvement efforts. The first award will be given at the 2011 AHA/Health Forum Leadership Summit in July.

“The Dick Davidson Quality Milestone Award will highlight innovative state, regional and metropolitan hospital association efforts that help hospitals improve quality of care,” said AHA President Rich Umbdenstock. “Hospital associations have contributed to nationwide efforts to improve healthcare quality for patients. The AHA is proud to recognize the outstanding work they do and will work to help others learn from their success.”

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