CNBC Interviews CEO about Patient Safety

Patient Safety Interview presented on www.cnbc.com

Over the last twenty years, Americans have witnessed unprecedented advances in the care of patients. Improved diagnostic procedures, quantum leaps in medical technology, enhanced treatments and a public with the concept of preventative medical care all mean that healthcare – especially in the hospital – has changed to meet the health care needs of today’s patients.

And while the advances in hospitalized care are largely positive, the increased touch points between patients and healthcare providers have increased the risk of errors and of preventable hospital infections. New research published in Health Affairs revealed that about one-in-three patients encounter an adverse event during a hospital stay.This demonstrates that much more needs to be done to improve patient safety.


Which is why we support the Obama Administration’s new focus on patient safety and reducing preventable errors. The new Partnership for Patients will work with doctors, hospitals, insurers and employers to support patient safety improvements and reductions in preventable hospital readmissions.

While hospitals have made important strides to reduce healthcare associated infections, there is still much work to be done to eliminate them completely.

Every American should receive safe, high quality healthcare. That’s the goal driving the work between the Blue Cross and Blue Shield companies, the Society of Hospital Medicine, the American Hospital Association and their partners in healthcare across the country to promote programs that improve the way care is delivered in the hospital.

Many hospitals, hospitalists and insurers have already begun the journey toward improved patient safety and reduced hospital readmissions. And their experience will pave the way for millions of Americans to receive safer care. A new report from the Agency for Healthcare Research and Quality shows a 35 percent reduction in central line-associated bloodstream infections in hospitals participating in AHA’s Comprehensive Unit-Based Safety Program.

Creating financial incentives to reward quality instead of quantity of healthcare delivered is a major way to drive better and safer patient quality care. The Blue Cross and Blue Shield system has taken the lead in experimenting with many different payment systems meant to reward higher quality and has partnered with hospitals and other providers to directly support important safety improvement activities.

Working closely with hospitals and partners on the widespread adoption of life-saving health information technology like electronic medical records, and adopting “e-prescriptions” to flag and prevent potentially life-threatening drug interactions on a real-time basis, is also bearing real results.

Making sure that patients continue to get the care they need after they leave the hospital is critical to reducing readmissions. This means ensuring that patients understand the instructions on taking and monitoring their medications.

To read the full interview please visit:

http://www.cnbc.com/id/42768103

Scott P. Serota, is President and Chief Executive Officer, Blue Cross and Blue Shield Association, Jeff Wiese, MD, SFHM, President of Society of Hospital Medicine and Rich Umbdenstock, President American Hospital Association.

WSJ Report on Medication Errors and New Efforts to Improve Labeling

Reported in the Wall Street Journal
By Laura Landro

A new push is under way to make prescription drug information clearer and stem the rise in emergency room visits and hospitalizations resulting from patients incorrectly taking their medicine. The Food and Drug Administration is planning to test single-page consumer information sheets that would replace the multi-page package inserts and medication guides widely used in retail pharmacies. And the U.S. Pharmacopeial Convention, which sets quality standards enforced by the FDA for the quality, strength and purity of medicines, is developing a new national standard for prescription labels, which can vary widely from pharmacy to pharmacy and befuddle consumers. The standards, if adopted, would require clear instructions on dose and timing and state in simple terms the purpose of the drug—such as "for high blood pressure"—unless the patient prefers that it not appear.

Improving Patient Safety By Reducing Medication Errors

• Nearly 1.9 million people were treated in hospitals for illnesses and injuries from taking medicines, a 52% increase from 2004 to 2008.
• Another 838,000 people were treated and released from emergency rooms due to harm from medications in 2008.
• Almost 36% of treat-and-release emergency room visits were patients ages 18 to 44, and 18% were elderly.

Doctors and pharmacists are also being encouraged to counsel patients more effectively about their medications. About 100 industry and nonprofit groups are participating in a national awareness campaign about the importance of taking medication as directed, to be launched in May by the National Consumers League. The campaign includes a website for health professionals and a separate website where consumers can download tools such as work sheets to manage their medications. The group says more than a third of medication-related hospital admissions are linked to poor medication adherence.

Medication mishaps often happen in the hospital, due to clinician error and unexpected allergies or reactions. According to the Agency for Healthcare Research and Quality, the number of people treated in U.S. hospitals for illnesses and injuries from taking medications jumped 52% to 1.9 million between 2004 and 2008, the latest year available, including patients admitted from the emergency room. More than half of the increase was due to corticosteroids, blood thinners, and sedatives and hypnotics.

Another 838,000 patients were also treated and released from the ER with problems related to those and other medications, including painkillers, antibiotics, cardiovascular drugs, insulin and other hormones used to treat common diseases such as asthma, arthritis and ulcerative colitis. FDA officials say inadvertent errors made by patients who misunderstand information are causing significant harm. One reason cited is low literacy skills. A study in 2006 showed that of 70% of patients with low literacy who could correctly state the instructions "take two tablets by mouth twice daily," only 34% could then demonstrate the number to be taken daily.

Michael Wolf, an associate professor at Northwestern University's Feinberg School of Medicine who serves on an FDA risk-communication advisory panel, says in recent studies, more than half of adults misunderstood one or more common prescription warnings and precautions. In one study Dr. Wolf and colleagues found that patients better understood simple, explicit language on warning labels—like "use only on your skin" instead of "for external use only"—and those with lower literacy skills also benefited from picture icons, such as a sun with a black bar across with words, "limit your time in the sun."

To read the full article please visit  http://online.wsj.com/article/SB10001424052748703521304576279123606877448.html?mod=ITP_personaljournal_0

Hospital Aquired Infections at Houston Hospitals Reported In New Study

As reported by Yang Wang/ Houston Chronicle

The most common patient safety issue among older patients in the Houston area is systemic vascular infections, a problem often caused by unsanitary or improper procedures during their hospital stay, a new study of Medicare claims shows. Among forty six hospitals within a fifty mile radius of the city of Houston, 50% reported vascular infections in Medicare patients through catheters. A total of 472 "hospital-acquired conditions" were reported from the 234,200 Medicare discharges from October 2008 through June 2010. That's two incidents per 1,000 Medicare discharges in Houston.

Allowing the public to see information about mishaps and errors that occur during a patient's hospital stay has been a contentious issue for hospital personnel, who believe the public could misread it. To date, there's no universal ranking system for the public to determine the safety of the nation's hospitals.The reports released this month by the Centers for Medicare and Medicaid Services is the first to look strictly at how many times bedsores, surgical errors and falls and trauma, for example, occur among Medicare patients. 

To read the full article please visit:  http://www.chron.com/disp/story.mpl/metropolitan/7535533.html

For more reporting on hospital acquired infections please visit Patient Safety & Quality Healthcare

CDC Increases Focus on Patient Safety

Patient Safety Increases Organization focus on Patient Safety

As reported in Medical news Today

HHS Services Secretary Kathleen Sebelius announced the Partnership for Patients: Better Care, Lower Costs, aimed at improving patient safety in America's health care facilities through the prevention of health care-acquired conditions. CDC is one of several federal agencies participating in the initiative. Medical advances have brought lifesaving care to patients in need, but many of these advances come with a risk of health care-acquired conditions, including infections, falls, pressure ulcers (or bed sores), and blood clots (known as deep vein thrombosis).

"Americans expect and deserve safe health care," said CDC director Thomas R. Frieden, M.D., M.P.H. who has made patient safety a top priority at CDC. "CDC has an established track record of improving the quality of health care delivery. This new initiative will help protect patients and ensure that they live healthier, longer, and more productive lives while reducing healthcare costs."


In hospitals and other health care facilities, falls are among the most frequently reported incidents for inpatients. Pressure ulcers, which can occur in health care settings or at home, affect more than 2.5 million people annually. In total, health care-acquired conditions can have devastating emotional, financial, and medical consequences.

Public health officials and clinicians know how to prevent many health care-acquired conditions. However, the problem has been in getting proven protective measures adopted and used consistently in all health care facilities. CDC works with federal, state and local public health and healthcare partners to prevent these conditions.

-- CDC conducts rapid field investigations to address emerging health care safety issues.

-- CDC conducts cutting-edge infection prevention research, turning that knowledge into evidence-based guidelines that health care providers can use.

-- Several published studies have shown that health care-associated infections (HAIs) can be decreased as much as 70 percent when existing CDC prevention recommendations are put into place.

-- CDC has funded 51 locally based HAI coordinators and has supported 30 state-based HAI prevention networks to drive progress toward goals in the HHS Action Plan to Eliminate Healthcare-associated Infections.

-- CDC is working with patient and professional organizations to raise awareness and promote the implementation of current clinical guidelines for the prevention of deep vein thrombosis. CDC has been actively working to prevent deep vein thrombosis by collecting statewide registry data and tracking the quality of hospitalized stroke patients for the past decade through the Paul Coverdell National Acute Stroke Registry.

-- CDC has developed a fall risk assessment tool for practitioners that can be used in clinical settings, because the most effective single approach for fall prevention is an individualized risk factor assessment by a physician or health care provider coupled with referral and treatment.

Tracking progress toward prevention is key to achieving success in improving patient safety. CDC provides the nation's health care facilities with a free system to track infections, monitor prevention progress, and collaborate with peers. The system, called the National Healthcare Safety Network (NHSN), is used in over 4500 U.S. hospitals and is part of the Centers for Medicare and Medicaid Services pay-for-reporting program. CDC is enhancing NHSN to track the occurrence of deep vein thrombosis and the implementation and impact of prevention measures in participating hospitals. CDC also is beginning work with the acute care community to provide guidance for tracking and preventing pressure ulcers in high-risk injured patients.

Together, public and private partners can expand upon the successes seen in individual healthcare facilities and employ these best practices nationwide to protect all Americans and ensure safe healthcare.

Source: U.S. Department of Health and Human Services

Florida Hospitals Reducing Infections Through Hand Hygenie Rules

Hand Hygiene Important Factor in Patient Safety in Florida Hospitals

As reported in News- Press.com by Frank Gluck

Signs posted in hospital break rooms at  Lee Memorial Health System hospitals keep tabs on how often staffers are caught skipping hand washing — usually not often. Once taboo in hospital and health care settings, nurses and support staff are encouraged to call out doctors doing anything that might spread germs. Even casual patient contact with doctors’ neckties and iconic white coats are suspect.

These and a long list of hygiene rules, started in earnest seven years ago and taking place at hospitals nationally, may be behind sharp drops in one of the most common hospital infections, a pair of new studies show. Central-line associated bloodstream infections, which kill up to a quarter of patients who contract them, have plummeted 40 percent at Lee Memorial’s hospitals over the past few years, system records show. Central lines are catheters usually guided near the heart by way of large veins, typically in the neck, chest or arm. They are used to monitor blood circulation, or to provide medication and fluids into the body. 

“It really does take a cultural shift. You really have to work as a team,” said Dr. Marilyn Kole, the system’s medical director for clinical services. “And when you have units that are at zero (infections) — some units have been at zero for several years — it’s devastating for everyone when it doesn’t.” 

Some individual hospital units have not had central-line infections for years. Less than a decade ago, roughly half of patients in a given intensive care unit would get infections.

The Agency for Healthcare Research and Quality reported this month that Florida hospitals have cut central line-related infections by 37 percent since 2009.

To read full article please visit

http://www.news-press.com/article/20110421/HEALTH/110420043/Increased-vigilance-helps-Southwest-Florida-hospitals-lower-infections?odyssey=tab|topnews|text|Home

CDC issues guidance on preventing bloodstream infections

 Hospital Acquired Infections Still A Major Patient Safety Problem

 As reported in American Medical News
By Kevin B. O'Reilly



Recently health officials  updated their recommendations on preventing catheter-related bloodstream infections in light of successful efforts that have helped reduce  the national rate of central-line infections in intensive care units by fifty eight percent between 2001 and 2009. The new guidelines were released in April by the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee 

Among the recommended infection-prevention measures, the new guidance calls for:

• Educating health professionals about when to use catheters, how to insert them and what infection-control measures to take when doing so.
• Designating trained, competent professionals to insert and maintain peripheral and central vascular catheters.
• Avoiding the femoral vein for central venous access in adult patients.
• Using a fistula instead of a central venous catheter in dialysis patients with chronic renal failure.
• Promptly removing any intravascular catheter that is no longer essential.
• Cleaning patients' skin with a chlorhexidine preparation with alcohol before inserting a central venous catheter.

 To read the full article please visit: http://www.ama-assn.org/amednews/2011/04/18/prsb0419.htm?utm_source=twitterfeed&utm_medium=twitter


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

Patient Mobilization Best Practices Improve Patient Safety

Best practices improve health outcomes and ensure patient safety for patients and staff alike.


By Barbara Peterson, RN, BSN, MPH, and Betty Bogue, RN, BSN

Research supports the critical need for mobilizing  hospitalized patients. The adage “If you don’t use it, you will lose it” sums up the weakness and loss of functional status seen with prolonged hospital bed rest. In a hospital , patients often depend on their caregivers for mobilization. The physical demands of mobilization on healthcare caregivers often places risk on both the patient and the caregiver. This article will explore how an effective safe handling practice will improve patient safety, health outcomes, increase healthcare organizations’ profitability, and ensure caregivers’ safety.

In-Patient Early Mobilization Programs 
 
Human mobility serves a greater physiological purpose than just transferring one’s self from one point to the next. Mobility helps us perform activities of daily living, express emotions, and gratify basic needs, as well as sustain our health and enhance our body’s ability to heal and repair. With bed rest or a dramatic reduction of mobility, the body systems most affected are metabolic (fluid and electrolyte imbalance), respiratory (hypostatic pneumonia), cardiovascular (orthostatic hypotension, thrombus), musculoskeletal (atrophy and contractures), urinary elimination (infection and dehydration), integumentary (pressure ulcers) and psychosocial (depression).

To read rest of article please visit Patient Safety & Quality Healthcare

Complimentary Patient Safety & Quality Healthcare Email Newsletter

The April issue of the Patient Safety & Quality Healthcare email newletter is now available. There is no charge to subscribe to the PSQH e-News Alert. You do have to register to receive the first issue- but each month you will automatically receive patient safety news, trends and new product information delivered right to you inbox.

To receive your free subscription please visit

-http://www.psqh.com/online-articles/792-psqh-enews-alert.html

NY Times- New Study on Hospital Acquired Infections at Veterans Hospitals

By Kevin Sacks

An aggressive four-year effort to reduce the spread of deadly bacterial infections at veterans’ is showing impressive results and may have broad implications at medical centers across the country, according to the first comprehensive assessment of the program.

The study of 153 Veterans Affairs hospitals nationwide found a 62 percent drop in the rate of infections caused by methicillin-resistant Staphylococcus aureus, or MRSA, in intensive care units over a 32-month period. There was a 45 percent drop in MRSA prevalence in other hospital wards, like surgical and rehabilitation units.

The Veterans Affairs strategy employs a “bundle” of measures that include screening all patients with nasal swabs, isolating those who test positive for MRSA, requiring that staff treating those patients wear gloves and gowns and take other contact precautions and encouraging rigorous hand washing. The results may not be easily replicated in the private sector, but they are likely to step up pressure by further undercutting the notion, prevalent at many hospitals not long ago, that infections are an unavoidable cost of doing business.

To read full article please visit  http://www.nytimes.com/2011/04/14/health/14infections.html?_r=1

For more information on how hospitals are reducing HAI please read more content at Patient Safety & Quality Healthcare

VHA Joins Partnership for Patients to Help Improve Patient Safety

VHA Inc. announced that it is one of the founding private-sector partners to join the HHS new Partnership for Patients initiative. VHA pledged to continue building on work already underway in many VHA member hospitals to achieve safe, high quality care that will improve patient safety.

VHA Increases Efforts To Address Patient Safety

"VHA is taking on patient safety from every vantage point -- from partnering at high levels with HHS and other national organizations, to piloting hands-on, hospital-based programs to help achieve zero hospital errors," said Michael Regier,

VHA's commitment to the Partnership includes its pledge to:

    * Support clinicians and staff working for and with VHA in order to make care safer, improve communication, and increase coordination by implementing proven systems and processes; and
    * Learn from and share with others VHA's experiences with making care safer and more coordinated.

The launch of the HHS initiative coincided with the announcement of a new regional VHA program, Target Zero, that is an intense, on-the-ground effort to achieve zero defects in patient care. Target Zero, co-sponsored with Healthcare Performance Improvement LLC, is focused in four states in the VHA Central region, with 12 hospitals participating in Indiana, Kentucky, Michigan and Ohio. The two-year project will include interactive meetings, educational seminars and individual coaching calls. As part of the effort, VHA will collect outcomes data, organize the education efforts and disseminate best practices across the participating hospitals.

"VHA is excited to see such a significant public-private collaboration at the national level that builds on the enormous amount of creative energy that hospitals are already directing toward patient safety," Regier said. "We look forward to helping the Partnership for Patients achieve its goals. Nothing in health care is more important than delivering safe, high-quality care."

About VHA
VHA Inc., based in Irving, Texas, is a national network of not-for-profit health care organizations that work together to drive maximum savings in the supply chain arena, set new levels of clinical performance and identify and implement best practices to improve operational efficiency and clinical outcomes. In 2009, VHA delivered record savings and value of $1.47 billion to members.

Maureen Dowd Discusses Patient Safety In NY Times Column

Giving Doctors Orders

By Maureen Dowd

When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.
Michael died in that I.C.U. A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.

A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.

The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.
A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.

Please read her full column at http://www.nytimes.com/2011/04/13/opinion/13dowd.html

HHS Announces New Patient Safety Program

From the Healthcare.gov website

Health care providers in America work incredibly hard to deliver the best care possible to their patients.  Unfortunately, an alarming number of patients are harmed by medical mistakes in the health care system and far too many die prematurely as a result.



The Obama Administration has launched the Partnership for Patients: Better Care, Lower Costs, a new public-private partnership that will help improve the quality, patient safety, and affordability of health care for all Americans.  The Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly.

The two goals of this new partnership are to:

• Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
• Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.  Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.   

Achieving these goals will save lives and prevent injuries to millions of Americans, and has the potential to save up to $35 billion dollars across the health care system, including up to $10 billion in Medicare savings, over the next three years.  Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.  This will help put our nation on the path toward a more sustainable health care system.

Building on Local and National Work to Improve Patient Safety

In 1999, the landmark Institute of Medicine study, “To Err is Human,” estimated that as many as 98,000 Americans die every year from preventable medical errors. Despite many successful efforts, this statistic has not improved much in the following decade.  And many more patients get injured or sicker from preventable adverse events after being admitted to a hospital.  After more than a decade of work to understand and address these problems, promising examples of better practices exist, but patients too often are still injured in the course of receiving care.  There is much more work to be done to prevent unnecessary harm to patients.

• At any given time, about one in every 20 patients has an infection related to their hospital care.
• On average, one in seven Medicare beneficiaries is harmed in the course of their care, costing the government an estimated $4.4 billion every year.
• Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – that’s approximately 2.6 million seniors at a cost of over $26 billion every year.

For more information on the new program please visit http://www.healthcare.gov/center/programs/partnership/index.htmlhttp://www.healthcare.gov/center/programs/partnership/index.html

California Hospital Fast Tracks Technology to Reap Patient Safety Benefits

 Careful planning allows a public hospital in California to reap patient safety and financial benefits from technology on the fast track

 

By Kermit Randa, MHA, FACHE, CPHIMS

 It takes a significant time to bring in new information technology systems at most hospitals.The wheels can move slowly as hospitals attempt to get new technology approved, purchased—and finally implemented. As such, these providers have a difficult time moving to the front of the IT adoption line, even though the patient safety and efficiency advantages would certainly be welcomed by the patient communities that they serve. Many times, public hospitals have even more barriers to overcome to gain access to leading edge technology to benefit their community.

Leaders at Santa Clara Valley Medical Center in San Jose, Calif., however, decided to turn this seeming disadvantage into a distinct advantage as they brought in a new electronic anesthesiology information management system, an advanced technology that has become an important part of their healthcare organization’s enterprise-wide electronic health record (EHR).

Certainly, as a public hospital with limited funding for new technology, Santa Clara leaders acknowledged the importance of taking a very deliberative, measured approach to investing in information technology. After all, with a mission that includes acting as a patient safety net for community members with no medical coverage or ability to pay, the hospital could not afford to go down the wrong path.

To read full article please visit Patient Safety & Quality Healthcare

Reducing Alarm Hazards: Selection and Implementation of Alarm Notification Systems

Patient Safety Alarm Fatigue Threatens Patient Safety

By Tim Gee and Bridget A. Moorman CCE

 Few threats to patient safety have existed as long as alarm fatigue . In December 2010, the ECRI Institute listed “Alarm Hazards” as the second highest technology hazard of 2011. Alarm hazards include inappropriate alarm modification, alarm desensitization or  fatigue, non-restoration of alarm settings to the normal or standard value after being modified for a specific situation, and improper relaying of alarm signals to appropriate personnel (ECRI Institute, 2010).

Additionally, with the evolution of stand-alone devices to proprietary end-to-end systems, there is a proliferation of overlapping and duplicate systems. This ends up in clinicians sometimes carrying a “bandolier” of communication devices. Most alarms and other messaging are simply broadcast throughout the unit via distributed speakers and message panels.

To read the full article please visit the Patient Safety & Quality Healthcare website- www.psqh.com       

http://www.psqh.com/marchapril-2011/799-reducing-alarm-hazards.html

Hospital Invests In Patient Safety Technology

Missouri Hospital Continues Investment in Patient Safety

OSI  announced that its Healthcare division, Spacelabs Healthcare, has received a $1.5 million order from a Missouri hospital, nationally recognized for its patient safety. Spacelabs Healthcare will provide Ultraview SL patient monitors, Ultraview telemetry, and Tru-Link supplies and accessories. Also, Spacelabs’ ICS G2 software applications will provide connectivity throughout the hospital.

“We are pleased to provide Spacelabs patient monitoring and connectivity solutions in support of the hospital’s ongoing commitment to patient safety.”

OSI Systems CEO, Deepak Chopra

About OSI Systems, Inc.
 
OSI Systems, Inc. is a vertically integrated designer and manufacturer of specialized electronic systems and components for critical applications in the homeland security, healthcare, defense and aerospace industries. We combine more than 30 years of electronics engineering and manufacturing experience with offices and production facilities in more than a dozen countries to implement a strategy of expansion into selective end product markets. For more information on OSI Systems Inc. or any of its subsidiary companies, visit www.osi-systems.com. News Filter: OSIS-G

For additional information on patient monitoring, patient identification and patient safety please visit www.psqh.com th official website of Patient Safety & Quality Healthcare

Health Affairs Reports New Study That Majority of Medical Errors Not Reported

The April issue of Health Affairs features a number of articles addressing patient safety and the quality of healthcare. One of the articles presents the results of a new study that reports that medical errors and adverse events are significantly under-reported at hospitals. They report that these events occur in one-third of hospital admissions which would be as much as ten times more than some previous estimates have indicated, The April issue is funded by the Robert Wood Johnson Foundation.

As reported in Health Affairs- by Chris Fleming



...The patient safety study, conducted by David Classen of the University of Utah and coauthors at the Institute for Healthcare Improvement, compared three methods for detecting adverse events in hospitalized patients, including the Institute’s own Global Trigger Tool. The study drew on comparable samples of patients from three leading hospitals that had undertaken quality and safety improvement efforts.

Among the 795 patient records reviewed, voluntary reporting detected four events, the Agency for Healthcare Research and Quality (AHRQ) Indicators detected 35, and the Global Trigger Tool detected 354 events, ten times more than the AHRQ method.  In other words, the AHRQ indicators and voluntary reporting missed more than 90 percent of adverse events identified by the Global Trigger Tool.  If anything, the researchers say, their findings are conservative, because they rely on medical record review, which would not detect as many adverse events as direct, real-time observation would.

The researchers say that reliance on voluntary hospital reporting or the AHRQ indicators could lead to seriously flawed perceptions of patient safety in the United States.  They also note that the Global Trigger Tool detected a much higher rate of adverse events for hospitalized patients than previous studies have shown.  Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review, the researchers suggest that it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.

To read the full reporting please visit 

http://healthaffairs.org/blog/2011/04/07/new-health-affairs-hospital-errors-ten-times-more-common-than-thought/

Loyola University One of Top Ranked Hospitals for Patient Safety

Loyola University Medical Center ranked among the top six percent of major teaching hospitals in patient safety, according to new hospital rankings from Thomson Reuters.Thomson Reuters ranks hospitals on patient safety and other benchmarks in its new 2011 hospital benchmarks report.In the patient safety benchmark, Loyola University Medical Center was in the 94th percentile among 179 major teaching hospitals.

Unlike many other hospitals, physicians who practice at Loyola University Hospital are employees of the health system, not of an independent physician practice group. "Our integrated structure makes it much easier to adopt patient safety practices using the latest evidence-based guidelines," said Dr. Robert A. Cherry, Loyola University Health System chief medical officer and vice president of clinical effectiveness. "Physicians, nurses and administrators all work together to provide the best quality care for our patients."

"Patient Safety has become an increasingly important measure of hospital quality," the Thomson Reuters report said. Patient safety measures reflect "both clinical quality and the effectiveness of systems within the hospital."Thomson Reuters used data from the federal Agency for Healthcare Research and Quality to rank hospitals in eight patient safety indicators: postoperative sepsis (infection); reopening of surgical wounds; postoperative respiratory failure; postoperative physiologic and metabolic derangements; postoperative hemorrhage or hematoma; selected infections due to medical care; death among patients with serious, treatable conditions; and iatrogenic pneumothorax (respiratory complication caused by a medical procedure).

For more information on patient safety programs at hospitals please visit www.psqh.com

AAMC Launches Best Practices for Better Care to Promote Patient Safety Education

The AAMC (Association of American Medical Colleges) has announced a new multi-year effort, Best Practices for Better Care, that harnesses the unique missions of academic medicine—medical education, patient care, and research—and applies them to the challenges of improving quality and safety in health care.

More than 200 medical schools, teaching hospitals, and health systems have committed to implement the campaign’s five initial components:

• Teach the next generation of doctors about the importance of quality and patient safety through formal curricula

• Ensure safer surgery through use of surgical checklists

• Reduce infections from central lines using proven protocols

• Reduce hospital readmissions for high-risk patients

• Research, evaluate, and share new and improved practices.

“America’s medical schools and teaching hospitals are committed to leading the changes that will improve our nation’s health. Best Practices for Better Care is a unique collaboration in which medical schools, teaching hospitals, and their physicians and scientists will work together to advance the quality and safety of patient care,” said AAMC President and CEO Darrell G. Kirch, M.D.

Through the effort, participating institutions, which collectively represent 12 percent of hospital admissions nationwide, will improve care today by broadly implementing proven practices pioneered by teaching hospitals to ensure safer surgeries, reduce infections, and cut hospital readmissions. The campaign also will improve care in the future by schooling medical students and residents in these best practices, with quality and patient safety emphasized in medical education from day one.

For more information about Best Practices for Better Care and a list of participating institutions, visit www.aamc.org/bestpractices.

Patient Safety & Quality Healthcare will publish the 2011 Education & Training Directory in the May/June issue. For more information please visit www.psqh.com

Savannah Hospital Purchases Patient Lift to Improve Patient Safety

As reported on www2.savnews.com
By Tina Tyus-Shaw


Saint Joseph’s/ Candler Health System is raising the bar on patient safety.New patient safety lifts were just purchased and installed.  Those in charge of the program say this is a critical step to keep nurses and patients safe.“We’ve had a large number of work injuries here at St. Joe’s/Candler and statistically across the nation nurses are continuously hurting themselves,” says Diane Hinley.Health Professionals believe the $900,000 investment will prevent injuries and save the health system millions of dollars each year.

for full coverage please visit:
http://www2.wsav.com/news/2011/apPatient Safety r/04/safety-upgrade-new-patient-ceiling-lifts-sjchs-ar-1670833/

To learn more about Patient Safety Programs at US Hospitals please visit www.psqh.com

ImageXpres Announces New Patient Bedside Safety Checklist

ImageXpres Corporation announced the availability of a new addition to their line of Surg-i-Scan™ (Surgical) Safety Checklist products, its Patient Bedside Safety Checklist. The new  checklist board is designed to improve the daily care of patients who are recovering following surgery, or while undergoing diagnostic test procedures. John S. Zankowski, ImageXpres President, CEO, states, "We are getting excellent feedback from hospital staff(s) now using our Surg-i-Scan Safety Checklist system in operating rooms. We are very pleased with the way OR teams have embraced our Surgical Safety Boards, with their unique slider mechanism that ensures positive safety protocol adherence during the perioperative process. Now we are expanding the universe for patient safety checklists by developing, manufacturing and promoting a Patient Bedside Checklist, which promises to deliver the same kind of error reduction and improved patient safety results in the ICU, diagnostic testing, and medical/surgical rooms." There are millions of in-patient rooms where our safety checklist products can be installed, and begin assisting nurses and other caregivers in their daily efforts to deliver improved patient care. 

 For more information please visit- www.imagexpres.com.

WSJ Reports That IBM Developed New Drug That Could Reduce MRSA

As reported in today's Wall Street Journal

International Business Machines Corp.  said they developed a tiny drug, called a nanoparticle, that in test-tube experiments showed promise as a weapon against dangerous superbugs that have become resistant to antibiotics.Their researchers, in collaboration with scientists at the Institute of Bioengineering and Nanotechnology, Singapore, said their nanoparticle can target and destroy antibiotic-resistant bacteria—such as the potentially lethal Methicillin-resistant Staphylococcus aureus, or MRSA—without affecting healthy cells. 

to read the full coverage please visit www.wsjonline.com.

Hospira Enhanced TheraDoc System Can Help Improve Patient Safety

Hospira announced the launch of its enhanced TheraDoc™ clinical surveillance system, used by hospitals to  improve patient safety and prevent adverse events such as healthcare-associated infections. The enhanced TheraDoc system includes new features and functionalities designed to improve user satisfaction, reporting capabilities and work efficiency.Patient safety issues such as HAIs, adverse drug events and antimicrobial resistant infections have been linked to increased morbidity and mortality, and also can have an large financial impact.

The TheraDoc platform enhancements are designed to help hospitals meet and improve upon evolving quality metrics and national patient safety goals. The new platform also helps clinicians more easily identify antimicrobial resistant pathogens and drug-bug mismatches. Improvements to the TheraDoc Infection Control Assistant™module facilitate seamless electronic reporting of HAIs to the National Healthcare Safety Network (NHSN) and provide a new infection control dashboard for enhanced reporting, data comparison and benchmarking.

"The enhanced TheraDoc platform has added even more valuable tools available to our infection prevention team at Kootenai Health," said Lee Rieken R.N., C.I.C., infection prevention unit supervisor, Kootenai Health in Idaho. "The TheraDoc team continues to reach out to its customers and listen to their needs. As increasing demands are placed on the infection preventionist, the tools afforded them are increasing as well. I appreciate the dashboard within the new TheraDoc platform, because it is quite intuitive to use and helps us benchmark against NHSN."Stanley Pestotnik, M.S., R.Ph., general manager, TheraDoc, Hospira, said, "The enhanced TheraDoc system reflects Hospira's commitment to delivering innovative patient safety surveillance and clinical-decision support solutions."


The TheraDoc clinical surveillance platform is being demonstrated at Society for Healthcare Epidemiology of America (SHEA) booth #107 through April 4. For more information about TheraDoc, visit http://www.theradoc.com or call (801) 415-4400.

About Hospira
Hospira, Inc., is a global specialty pharmaceutical and medication delivery company dedicated to Advancing Wellness™.  As the world leader in specialty generic injectable pharmaceuticals, Hospira offers one of the broadest portfolios of generic acute-care and oncology injectables, as well as integrated infusion therapy and medication management solutions. Through its products, Hospira helps improve the safety, cost, and productivity of patient care. The company is headquartered in Lake Forest, Ill., and has approximately 14,000 employees.  Learn more at http://www.hospira.com.Hospira

Coral Springs Surgical Center Updating Patient Safety Standards

A commitment to both employee and patient safety is a fundamental focus for all healthcare facilities. Coral Springs Surgical Center is updating its patient safety and workplace safety standards in a new partnership with Custom Linen Solutions, an Orlando-based distributor of textiles and uniforms for the healthcare industry. The partnership provides Coral Springs Surgical Center with Vestex™ uniforms – the innovative, high-performance medical apparel that provides effective, comfortable fluid barrier protection for healthcare workers.

“We are committed to using the latest technology to maintain the safety of our workers and patients," said Randy L. Huffman, RN, MSA, CMPE, administrator for Coral Springs Surgical Center. “Our partnership with Custom Linen Solutions and Vestex furthers our ability to provide friendly, highly responsive and attentive service."

According to the Center for Healthcare Worker Safety, healthcare professionals are exposed to blood and bodily fluids an average of 56.5 times each year. It’s not surprising that, in a recent study, health care workers ranked protection against exposure to blood and bodily fluids as a top concern and the most important characteristic in medical apparel.

Vestex high-performance medical work wear, developed by Orlando-based Vestagen Technical Textiles, provide comfortable fluid barrier protection for healthcare workers. Vestex uses exclusively licensed and patented technology to repel blood and bodily fluids, and contains an antimicrobial that protects the fabric from degradation due to microorganisms. In addition, Vestex is breathable, perspiration-wicking and naturally self-cleaning, helping to keep medical personnel clean, cool and dry.

“Because Vestex provides both comfort and safety in work wear, healthcare workers can feel confident about putting more focus on what matters most – taking care of patients," said Craig Mayo, president and CEO of Custom Linen Solutions.

Earlier this year, Coral Springs implemented another measure to safeguard patient safety and healthcare worker safety. “The STERRAD® NX sterilization system is the fastest low-temperature hydrogen peroxide gas plasma sterilizer available for medical instruments," said Huffman. The STERRAD® sterilization system from Advanced Sterilization Products, provides speed, safety and simplicity in the sterilization process.

BJC Healthcare and Washington University School of Medicine using IBM Analytics

IBM announced that BJC Healthcare (BJC) and Washington University School of Medicine (WUSM) are using IBM business analytics software to quickly extract key data from more than 50 million documents in medical records, speeding up research to ultimately provide better care for patients worldwide.

BJC Healthcare, one of the largest nonprofit healthcare organizations in the U.S., and the WUSM Center for Biomedical Informatics are collaborating to ensure researchers get answers to critical research questions from large sets of unstructured genomic and clinical data such as clinical notes, admission/discharge summaries and diagnostic reports.

Like most institutions, BJC and WUSM faced the challenge that existing biomedical informatics resources were disjointed, frequently redundant, and only available to a small fraction of researchers. As a result, millions of patient notes and records sat unavailable in separate clinical databases and the sheer volume of information resulted in research assets that were underutilized. All this content contained valuable information, but there was no easy way to get to it.

"With IBM Content Analytics software, BJC Healthcare and Washington University researchers are now able to find fast answers to critical research questions using the same technology that powers the IBM Watson deep question and answer system," said Ken Bisconti, Vice President, IBM Enterprise Content Management Strategy.


To read full article please visit the Analytics website at www.analytics-magazine.com

Consumer Reports Poll Shows Public Very Concerned about Patient Safety

Consumer Reports National Research Center released information from a new study that found that the public is very concerned about patient safety,hospital-acquired infections and other forms of medical harm. According to the poll, 77 percent of respondents expressed high or moderate concern that they or someone in their family might be harmed by a hospital infection during treatment in the hospital.  Seventy-one percent expressed high or moderate concern about being harmed by a medication error, and 65 percent were similarly concerned about surgical errors.

Virtually all consumers -- 96 percent -- said that hospitals should be required to report medical errors to state health departments, and 82 percent wanted each hospital's medical error record to be available to the public."It's not surprising to find such high levels of public concern about hospital-acquired infections and medical errors given that one in four patients is harmed during treatment," said Lisa McGiffert, director of Consumers Union's Safe Patient Project (www.safepatientproject.org).  "Our poll found that the vast majority of the public wants to know more about their local hospital's record for keeping patients safe and supports efforts to require disclosure of this critical patient safety information."


A November 2010 New England Journal of Medicine study in North Carolina hospitals found that one in four patients were harmed by the care they received, ranging from hospital acquired infections to surgical errors to medication mistakes.  Other medical errors include serious bed sores, patient falls in the hospital from inattentive care, and diagnostic mistakes.  The study, which covered a six-year period, found no significant improvement in patient safety.

Since 2003, Consumers Union's Safe Patient Project has advocated for and helped pass hospital infection reporting laws throughout the nation.  Twenty-seven states and the District of Columbia now require hospital-specific public reports on certain infection rates.  So far, twenty-three states have issued reports.  

Starting this year, hospitals throughout the country must track and report when patients get central line-associated bloodstream infections (CLABSIs) in intensive care units in order to get an annual two percent Medicare payment increase.  Hospitals must report to the Centers for Disease Control and Prevention's National Healthcare Safety Network, the same system being used under most state reporting laws.  A national report on each hospital's CLABSI infection rate is expected later in the year.

Twenty-six states require hospitals to report certain medical errors, but only 10 require public disclosure of hospital-specific information.  The other 16 simply report statewide aggregated data to the public.  Most of the states with reporting laws require hospitals to disclose errors that appear on the National Quality Forum's "never event" list, which includes 28 errors that can be prevented and should never happen.  This list is updated periodically.

"Most Americans have no way of finding out whether their hospital does a good job or not at preventing medical errors," said McGiffert.  "We need to hold hospitals accountable for the harm done to millions of patients each year through mandatory, public reporting of medical errors and of health care-acquired infections."

Consumers Union has developed a model medical error reporting law and has been working this year to encourage states to adopt it. The model law attempts to address underreporting of these errors by requiring hospitals to report all medical harm rather than those covered by the "never event" list, and by requiring states to validate the accuracy of the data.  It also establishes penalties for hospitals that fail to report medical harm.

For more information about Consumers Union's patient safety campaign, see www.safepatientproject.org.

SOURCE Consumers Union

Patient Safety Technologies Closes New Funding

Patient Safety Technologies, Inc. announced the closing of a $7.1 million common stock financing.  The investors purchased 9.48 million shares of common stock at a price of $0.75 per share.  Proceeds from the offering will be used for general corporate purposes including investing in the continued market penetration of the Company's core offering, the SurgiCount Safety-Sponge® System, a solution proven to improve patient safety and reduce healthcare costs by preventing retained surgical sponges.

"After successfully implementing an aggressive cost reduction and restructuring initiative last year, the subsequent goal of this new management team was to properly capitalize the company to help us achieve our growth objectives.  This offering will help us continue to execute our growth plans and positions us well to accelerate our market expansion and new product development," said Brian E. Stewart, President and Chief Executive Officer of Patient Safety Technologies.

For more information on patient safety products please visit Patient Safety & Quality Healthcare magazine