Thursday, June 30, 2011

Second Webinar in Patient Safety Webinar Series

Efforts to improve care coordination and decrease hospital readmissions will be the topic of the second webinar in the Partnership for Patients-National Priorities Partnership (NPP) Patient Safety Webinar Series.  “Reducing Readmissions through Care Transitions,” will address reducing hospital admissions by 20% through the reduction of preventable complications which often occur during the transition from one care setting to another.

As part of an ongoing series hosted by the NPP, which is convened by the National Quality Forum, and the Department of Health and Human Services (HHS), the interactive webinar will take place on July 6 from 3:00 – 4:30pm ET. Advance registration for the event is recommended, and is now available online.

Hospital readmissions cost the federal government more than $26 billion annually, representing a large Medicare expenditure that, with the correct precautions, can be largely preventable. The “Reducing Readmissions through Care Transitions” webinar will identify key barriers to widespread adoption of successful models and programs that improve care transitions, and corresponding policy drivers that could accelerate progress nationally. Key thought leaders in the field of patient safety will have the opportunity to share best practices, success stories, and strategies for getting started. Speakers will also provide examples of public-private partnerships working to address barriers at the policy and/or implementation levels.

NPP, consistent with the aims of the National Quality Strategy, continues to focus its efforts on catalyzing action that will help improve care coordination. Earlier this year, NPP released a Compact Action Brief recommending specific actions, such as improved procedures for admitting and discharging patients, delivering better follow-up care, and utilizing health information technology, that can help reduce healthcare costs through the prevention of hospital readmissions.

The inaugural webinar in the series, “An Overview of the Partnership for Patients and Getting Started in Your Organization,” featured Donald Berwick, MD, MPP, Administrator, and Joseph McCannon, BA, Senior Advisor, at the Centers for Medicare & Medicaid Services (CMS). A full recording of the webinar is available online.

Additional upcoming webinar topics will include:

        Adverse Drug Events – July 19 at 1pm ET

o    Speaker: Michael Cohen, MS, ScD, RPh, President, Institute for Safe Medication Practices

        Infections in the Intensive Care Units – August 3 at 2pm ET

o    Speaker: Peter Pronovost, MD, PhD, Medical Director, Johns Hopkins University School of Medicine

        Surgical Site Infections
        Pressure Ulcers and Injuries from Falls
        Venous Thromboembolism
        Obstetrical Adverse Events

With each of these sessions, national experts will present effective solutions, and an expert panel of NPP partners will contribute to the follow-up discussion of how to realize these solutions nationally. The webinar series will be available, free of charge, for audio streaming. Space is limited, and advance registration is recommended to ensure real-time participation. All webinars will be recorded, archived, and made available on NQF’s website after each event.

Learn more about this webinar series and register for the second event: http://www.qualityforum.org/Events/Webinars/Patient_Safety_Webinars/Webinar_2/Webinar_2__Reducing_Readmissions_through_Care_Transitions.aspx. To learn more about the Partnership for Patients pledge, please visit their website. Learn about other activities and programs at NQF to enhance care coordination and patient safety.

The National Priorities Partnership, convened by the National Quality Forum, is a multi-stakeholder group including organizations representing the interests of consumers, purchasers, healthcare providers and professionals, state-based associations, community collaborative and regional alliances, government agencies, health plans, accreditation and certification bodies, and supplier and industry groups. To learn more, please visit: http://www.qualityforum.org/Setting_Priorities/NPP/National_Priorities_Partnership.aspx.

Read more: http://www.digitaljournal.com/pr/350838#ixzz1QlDjbNyb

Wednesday, June 29, 2011

The National Patient Safety Foundation Announces Launch of a CME-accredited Education Module: Reducing Diagnostic Errors

Diagnostic errors are a top concern in the patient safety field. Studies have shown that malpractice claims related to diagnostic errors outnumber all other classes of medical error.  Healthcare organizations need a more systematic approach for identifying diagnostic errors and educating clinicians on strategies for reducing the prevalence of these errors.

Compiled by leading experts, this resource-rich module provides a diverse set of tools and resources to educate healthcare professionals on diagnostic errors, including basic principles, common theories, and key strategies for reducing these errors at both the individual practice and system levels. In addition, the module provides a dedicated set of materials to engage patients and families in the prevention of diagnostic errors.

For more information please visit www.npsf.org.

Patient Safety & Quality Healthcare recently published a Directory of Patient Safety Courses, Training Programs and Degree programs. The directory listings are available at www.psqh.com

Monday, June 27, 2011

James Welch VP of Patient Safety with Masimo Wins Prestigious Award

Masimo Corporation announced  that two of the industry's top patient safety leaders—James Welch, Vice President of Patient Safety Initiatives at Masimo, and George Blike, Medical Director of Patient Safety Training at Dartmouth-Hitchcock Medical Center—are the recipients of the AAMI Foundation's Institute for Technology and Healthcare Clinical Application Award.  Honored for their cross-industry collaboration in the implementation of Masimo Patient SafetyNet™ at Dartmouth-Hitchcock, Welch (Masimo) and Blike (Darmouth-Hitchcock) combined their high-tech and human-touch expertise to install the remote monitoring and wireless clinician notification system based on Masimo SET® Measure-Through Motion and Low Perfusion pulse oximetry monitoring that led to a "significant drop" in key clinical outcome measures—including 65% fewer rescue events, 48% fewer ICU transfers, and reduced annualized ICU time by 135 days. (1)

"James Welch (with Masimo) and George Blike (with Dartmouth-Hitchcock) exemplify the term effective collaboration," stated Mary Logan, President of the Association for the Advancement of Medical Instrumentation.  "What is particularly powerful about this duo is that they have modeled for all of us what can be accomplished when you have an effective collaboration between clinical engineering and front-line clinicians, between industry and patient safety experts, and between technology developers and a clinician who knows how to assess in a clinical setting the impact of a technology solution to a vexing safety problem. We can all be grateful for the power of what they have accomplished here."

Designed to improve patient safety through continuous pulse oximetry monitoring, Patient SafetyNet keeps general care floor patients safer by continuously, noninvasively, and remotely monitoring multiple physiological parameters, including arterial oxygen saturation and pulse rate, and automatically alerting clinicians to changes that signal patient distress or deterioration via pager or phone.  The system's alarm escalation process is an important feature that notifies additional clinicians if a life-threatening alarm persists—ensuring that alarms are escalated to other clinicians in the event the assigned primary clinician is busy or unresponsive.  With the system in place, Dartmouth-Hitchcock clinicians receive a pager notification when a patient's condition is worsening—allowing them to intervene before the condition becomes critical and requires more acute levels of care. This is particularly important for post-surgical patients who are at increased risk of serious injury or death resulting from the respiratory depression effects of patient-controlled analgesia (PCA) and opioids used for sedation and pain management.

Nebraska Medical Center to Implement Voalte Solution

The Nebraska Medical Center will soon be using iPhones to improve their communication and increase efficiency. The Nebraska Medical Center is the first academic-based medical center in the country to implement the Voalté solution. Voalté, an application that consolidates voice, alarm and text on the versatile iPhone platform, was selected by the Medical Center after a year-long mobile technology review and assessment of legacy handsets and voice badges.

“We’re thankful The Nebraska Medical Center selected Voalté after a rigorous selection process,” said Trey Lauderdale, vice president of innovation at Voalté. “Partnerships of this sort continue to validate our commitment to increasing nursing excellence and patient safety.”

http://www.psqh.com/business-news/873-iphones-adopted-by-the-nebraska-medical-center.html

Improving Patient Safety with Portals, Clinical Analytics and More

Improving Patient Safety with Portals, Clinical Analytics and More

Health information technology value can be determined by looking at how it was employed in real-life situations.Four examples  of HIT value from new case studies in the Stories of Success! program from HIMSS and co-sponsors American Society for Quality (ASQ), National Committee for Quality Assurance (NCQA) and National Patient Safety Foundation (NPSF).

1.The Institute for Family Health, New York, NY- tracking data showed that patients using the portal sent over 27,000 messages to their providers requesting 4,500 prescription refills and scheduling 4,100 appointments.

2.Miramont Family Medicine, Ft. Collins, Colo.- has more than doubled, from 41% to 91%, the number of ?documented A1c tests, measuring blood sugar control for several months, for its patients with diabetes.

3. Riverside Regional Medical Center in Newport News, Va.- used embedded analytics to study and help ?prevent multi-drug-resistant infections.

4. Weill Cornell, part of Weill Cornell Medical College in New York,- mapped data from over 19 agencies to a ?standard name to transform more than 12 million lab results so that providers can trend their data regardless of the agency.

To read the full article please visit-

http://www.psqh.com/news/current-news/870-improving-patient-care-with-portals-clinical-analytics-and-more.html

ISMP to Assess U.S. Hospitals Regarding Medication Safety Practices

The Institute for Safe Medication Practices (ISMP) is  partnering with the HRET, (Health Research and Educational Trust)  and the AHA to assess  hospital's medication safety practices. The 2011 ISMP Medication Safety Self Assessment® will heighten awareness of distinguishing characteristics of a safe hospital medication system, create a new baseline in 2011 of hospital efforts to enhance medication safety, and evaluate our nation’s progress in medication safety over the last decade.

The self assessments provide hospitals with a way to evaluate their medication safety practices, identify opportunities for improvement, and compare their experiences over time with the aggregate experience of demographically similar organizations. Hospitals can participate anonymously via a secure, password protected website and will have unlimited opportunity to view and download their scores.

The submission deadline is August 31, 2011.. For more information, email selfassess@ismp.org, call 215-947-7797, or visit http://www.ismp.org/selfassessments/Hospital/2011/Default.asp.


To read this news item please visit http://www.psqh.com/news/current-news/867-ismp-to-assess-us-hospitals-regarding-medication-safety-practices.html

Friday, June 24, 2011

Precision Dynamics Releases New Patient Identification Product

Precision Dynamics Corporation, recently released their new Write On Version of the Securline® Bar Code Blood Band, a blood recipient ID wristband system that provides automated patient identification for blood transfusion, specimen collection, and tracking. Using bar coding technology, the Securline® Bar Code Blood Band meets the revised Elements of Performance (EP) as outlined in The Joint Commission's National Patient Safety Goal for blood transfusions, NPSG.01.03.01, for a one-person verification process (versus two-person verification). The revised EP was released in September 2010 after The Joint Commission consulted healthcare and safety experts and literature to determine that automated identification technology can and does contribute to patient safety.

The Securline®Bar Code Blood Band is pre-printed with alpha-numeric bar codes to accurately match the right patient to the right blood. This improves patient safety by reducing identification related human errors that can occur during the blood transfusion process. The Write On version features a patient identification information area with a draw tube label. Once removed, a carbonless copy remains on the patient wristband.

"As hospitals continue to focus on patient safety and reducing errors, bar coding technology will play a key role in replacing some of the human dependant verification processes with automated identification,"

Karen Joseph, Marketing Manager for Precision Dynamics. 

The Securline® Bar Code Blood Band features an easy-to-use snap style closure which saves hospital staff time. Its secure bar code labels with permanent adhesive also prevent hospitals from having to re-work blood specimen collections caused by misplaced labels. Mary Ann Sharpe, Blood Bank Manager at Research Medical Center which belongs to HCA Midwest Health System, stated, "Securline® Bar Code Blood Bands are easy to apply because the bands snap closed just like our admission wristbands. Plus, the bar code labels on the Securline® product are very secure and don't peel off accidentally like we experienced with the other band."

Virginia Hospitals Reduce Hospital Acquired Infections with Hand Hygiene Program

Four Virgina hospitals reduced healthcare-acquired infection rates (HAIs) a collective 41 percent within ninety days. This reduction in HAI's  resulted in a savings of $1.2 million in additional costs. By implementing an  action plan in addition to existing federal hand washing protocols, these hospitals improved patient safety and quality, reported 59 fewer infections and reduced patient length-of-stay and unnecessary readmissions.

VHHA Services, a subsidiary of the Virginia Hospital & Healthcare Association, coordinated a study among the four hospitals to determine if adding a persistent hand sanitizing lotion and a persistent surface disinfectant to current practices reduces HAI rates. The products, developed by Germ Pro Products, Inc., offer continual, long-acting (persistent) effects that kill germs on hands for four hours and on surfaces for up to 28 days.

Health care workers at the four hospitals were instructed to apply Germ Pro Hand Sanitizing Lotion at the start of their workday and reapply every four hours. They were told to continue washing their hands or using an alcohol sanitizer as recommended in Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidelines. Environmental Services employees were instructed to apply the surface disinfectant to "touch points" only. Rooms were disinfected after patient discharges and common hospital areas were treated monthly. No capital investment was required by the participating hospitals.

The study ran three months and compared HAI rates during the study to the three months prior to the study period. After the three-month trial period, results showed an average of 41.5 percent fewer infections per 1,000 patient days. Individual hospitals reduced infections 29.4 percent, 32.4 percent, 50 percent and 54.2 percent respectively.

For more information on hand hygiene and patient safety please visit www.psqh.com

Sunquest Information Announces New Patient Safety Product

Sunquest Information Systems®, recently announced its Collection Manager solution (for blood and specimen collection) and the Transfusion Manager solution (for blood products). These solutions contribute to patient safety, positive patient identification, transparency, and accountability. Collection Manager, accessed from a handheld device, verifies the patient’s identification, test orders, and tube types being collected. It then prints the appropriate labels, in real-time, right at the bedside.This enhances care provider productivity and eliminates costs associated with preventable medical errors.


Sunquest Transfusion Manager enables trained healthcare professionals to verify both patient and blood product to ensure safe, intended outcomes. Operating on a portable, hand-held devices, Transfusion Manager assists laboratories and caregivers in positively identifying transfusion recipients, matching blood products to recipients, recording recipient pertinent transfusion information, and recording recipient transfusion reactions and caregiver comments.

For more information on Patient Safety and Barcoding please visit Patient Safety & Quality Healthcare

Thursday, June 23, 2011

Express Scripts Uses SAS Analytics to Predict Medication Problems

Express Scripts trusts SAS Analytics to keep patients on their drug regimens to live healthier lives.When patients stop taking prescribed drugs or reduce frequency or dosages, the effect can be devastating.  Express Scripts handles millions of prescriptions annually. Using software from SAS, the leader in business analytics, the company predicts patients likely to abandon medication, offering intervention programs to address potential patient safety issues before the patient becomes noncompliant.

"When patients stop taking a prescribed drug against doctors' advice, it can significantly set back treatment," said Jason Burke, Managing Director and Chief Strategist for the SAS Center for Health Analytics and Insights (CHAI). "It's a widespread problem. A Harris Interactive poll estimated that between 14 and 30 percent of US patients have stopped or altered their prescription drug regimens."

SAS predictive models developed by Express Scripts analyze more than 400 factors related to patients, drugs, conditions, physicians and other issues. Based on that analysis, Express Scripts tailors proactive interventions to an individual's likely barriers to compliance. Actions might include automated reminder calls, individualized education and support, or automated refills, for example.

"For patients requiring medications with chronic disease classes, such as hypertension, diabetes or high cholesterol, it's in their best interest for better health outcomes, as well as in the payer's best interest, that they continue their prescription regimens," said Express Scripts Director of Advanced Analytics Dave Tomala. "Even if medication costs increase marginally, overall medical costs are minimized through better health outcomes."

Express Scripts uses the predictive models created with SAS Analytics to continually improve its services and become a proactive partner in patients' health.

"We're talking about treating patients proactively. We can predict who will comply with their medication or not,"

Tomala explained. "Our outreach programs address an individual's risk factors. People too busy to order a refill can be moved into an automated refill program before a lapse occurs. Patients concerned about side effects might benefit from talking to a pharmacist. We analyze each patient to offer the most effective programs to keep them healthy."

IBM Healthcare Milestones Celebrated During IBM 100 Year Anniversary

IBM is marking the 100-year anniversary of its founding on June 16, 1911. Few areas of health and medicine have gone untouched by the technology, research and innovation generated by IBM over the past century.
From the first continuous blood separator which led to treatment for leukemia patients, the first heart lung machine to keep patients alive during surgery, the excimer laser used in LASIK eye surgery, to technologies of the future that will one day allow nano-sized particles to enter the bloodstream and fight drug-resistant infections, IBM touches more points in healthcare than anyone else.

IBM created hardware and applications specifically designed to improve care, improved diagnostics and treatment of disease, and advanced how medical knowledge is shared. This goes far beyond computers. New areas of Research including breakthroughs in gene sequencing and nanotechnology and even innovations in chip design are improving healthcare around the world.

--In the 1950s, IBM built the first heart-lung machine to be used successfully on a person during surgery.

--IBM and the National Cancer Institute collaborated in the 1960s to invent the first continuous blood cell separator, which was used for harvesting white cells (and, later, platelets) to treat leukemia patients.

--Working with the World Health Organization, IBM precisely mapped outbreaks of smallpox in 1976, enabling WHO to allocate its limited personnel and resources to the most urgent locations. The system later became a global model for demographic tracking.

--IBM invented the method for using excimer lasers that eventually became photorefractive (LASIK) eye surgery.

--In the early 1990s IBM and the University of Washington built a prototype of the first medical imaging system.

--IBM’s World Community Grid, released in 2004, uses pervasive networking and crowdsourcing to apply supercomputer levels of processing power to urgent healthcare and societal needs such as fighting AIDs, cancer and dengue fever and malaria.

--Using IBM’s Blue Gene supercomputing simulations, researchers at IBM and the University of Edinburgh are currently collaborating on lab experiments to design drugs aimed at preventing the spread of the HIV virus. Until recently, doctors had to make an educated guess about what mix of drugs would work for patients. By simulating the effect of drug cocktails virtually, IBM is helping patients and breaking new barriers in personalized medicine.

--IBM is currently working with Roche on a DNA Transistor, a high-tech and low-cost way of reading the human genome sequence. This technology may soon be used to create better patient profiles, tailor-made diagnoses and treatments informed by genetics—driving down the cost of healthcare while drastically improving quality of care and quality of life.

Using principles and technologies from computing, physics, material sciences and chemistry, IBM Research has a track record of successfully transferring technology to create new solutions for healthcare. The company spends more than $6B a year on R&D, much of it on healthcare, and IBM is one of the few technology companies with large teams of physicians and other clinicians on staff to ensure we are addressing healthcare’s most pressing needs. www.us.ibm.com



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York Hospital Improves Patient Safety With Bedside Barcoding System from Talyst

York Hospital in York, Pennsylvania, recently announced they have adopted new technology by Talyst. The hospital will implement AutoPharm3, AutoCarousel HD, AutoPack and AutoLabel to increase its efficiency and improve patient safety. The hospital's central pharmacy on the North side of the hospital, needed a solution that would ensure accurate, timely deliveries to hospital patients on the South side of the hospital. With enterprise-class software with bedside barcode scanning, York Hospital will ensure virtually 100% of the medications leaving the pharmacy are scan-ready at the bedside to improve accuracy and reduce medication errors.

"Over the last 30 years, our hospital has seen increasing demands with our pharmacy services and population growth," said Thomas Brenner, Director of Pharmacy at York Hospital in York, Pa. "With Talyst's automated technology, our pharmacy is now able to adapt to this growth and improve patient safety at the bedside."
Other challenges the hospital pharmacy experienced were the limited amount of available space and increasing efficiency in its inventory. With AutoPharm3 and AutoCarousel HD, York Hospital will be able to decrease inventory by at least 10% and be able to store more in a smaller space. The automated carousel provides maximum storage in an organized, accessible and compact footprint.

"We often hear from our customers about their increasing demands and limited space in their pharmacies," said Carla Corkern, Chief Executive Officer. "Talyst products help our customers minimize storage footprint, while also improving patient safety with our barcoding technology."

The perpetual inventory system provided by Talyst's enterprise-class AutoPharm software will also have significant impacts on the way York Hospital stocks, manages and tracks medication. The implementation will be finished by the end of fiscal year 2012.

HHS to Provide $500 Million Dollars in Funding for Patient Safety Program

The U.S. Department of Health and Human Services (HHS) confirmed that up to $500 million in funding for the Partnership for Patients program will be available to help improve patient safety and reduce millions of preventable injuries and complications related to health care acquired conditions and unnecessary readmissions. This funding, made available by the Affordable Care Act, will be awarded by the Centers for Medicare & Medicaid Services (CMS) Innovation Center through a solicitation and other procurements for federal contracts announced today.

    “Since the Partnership for Patients was announced, we have had an overwhelming response from hospitals, doctors, employers, and other partners who want to be a part of this historic effort to improve patient safety
“Since the Partnership for Patients was announced, we have had an overwhelming response from hospitals, doctors, employers, and other partners who want to be a part of this historic effort to improve patient safety,” said CMS Administrator Donald M. Berwick, M.D. “We are now looking to contract with local and statewide entities that can foster and support hospitals’ efforts to improve health care and reduce harm to patients.”

The Partnership for Patients is a new public-private partnership that will help improve the quality, safety, and affordability of health care for all Americans. The Partnership’s two goals are reducing harm in hospital settings by 40-percent and reducing hospital readmissions by 20- percent over a 3-year period. To achieve these goals, the Partnership is seeking to contract with large health care systems, associations, state organizations, or other interested parties to support hospitals in the hard work of redesigning care processes to reduce harm. “Hospital Engagement Contractors” will be asked to conduct the following:

    Design intensive programs to teach and support hospitals in making care safer;
    Conduct trainings for hospitals and care providers;
    Provide technical assistance for hospitals and care providers; and
    Establish and implement a system to track and monitor hospital progress in meeting quality improvement goals.

In addition to the Hospital Engagement Contractors, CMS will also be working with other contractors to develop and share ideas and practices that improve patient safety. These efforts include work with patients and families to understand their thoughts on how to best improve patient safety and transitions between different health care settings – such as when a patient is discharged from a hospital to a nursing home.

These contracts make available the first round of funding – which will ultimately total up to $500 million – that the Innovation Center has committed to this effort. Solicitations for proposals are available on the Federal Business Opportunities website at: www.fbo.gov.

When the Partnership for Patients was announced, the Obama administration committed up to $1 billion in Affordable Care Act funding to help achieve the two goals. At the time of the announcement, up to $500 million was made available through the Community-based Care Transitions Program to ensure patients safely transition between settings of care (access the Transitions Program solicitation here). Today’s announcement makes available the start of $500 million additional Innovation Center funds to help reduce health care acquired conditions and reduce unnecessary readmissions.

For more information on Patient Safety programs and case studies please visit Patient Safety & Quality Healthcare

Wednesday, June 22, 2011

Regence Foundation Provides Grant to Oregon Hospitals To help Improve Disclsure

Joe Rojas-Burke
The Oregonian

Most Oregon hospitals are failing to give every patient harmed by a serious medical error a written notification as required by a statewide patient safety program. The Oregon Patient Safety Commission on Tuesday said it received a $20,000 grant from the Regence Foundation to help hospitals establish more effective disclosure practices. Hospitals last year provided written notification less than half the time, 36 out of 80 cases in which it was required. The Oregon Association of Hospitals and Health Systems says written notification isn't always possible or appropriate. But nine hospitals have shown that compliance is possible. They've notified patients of adverse events in writing about every serious harm event reported.

The Patient Safety Commission plans to work with the hospital association and other medical groups to develop technical support to help hospitals overcome the obstacles to written disclosure. Hospital leaders have expressed concern that written notifications could alienate patients. It's possible that hospital leaders are concerned about exposing their institutions to greater legal liability.
To read the full article please visit http://www.oregonlive.com/health/index.ssf/2011/06/most_oregon_hospitals_failing.html

Cardinal Health Foundation Provides Patient Safety Grants

The Cardinal Health Foundation announced the recipients of 39 grants, totaling nearly $1.2 million, to help U.S. hospitals, health systems and community health organizations improve the effectiveness, efficiency and excellence of patient care.  For the second consecutive year, this competitive grant program specifically encouraged providers to submit funding requests for programs that seek to improve medication management or operating room patient safety.

"E3 Grant Program funding has been used by hundreds of health care organizations over the past three years to implement meaningful, long-term improvements in the effectiveness, efficiency and excellence of the care they provide patients," said Shelley Bird, executive vice president of public affairs for Cardinal Health and chairperson of the Cardinal Health Foundation. "We commend each of this year's grant recipients for their commitment to implementing proven strategies that can improve patient care and save lives."

Read more: http://www.sacbee.com/2011/06/21/3716152/cardinal-health-foundation-provides.html#ixzz1Q0OJG3Hh

Tuesday, June 21, 2011

KaiserHealth Reports that Numbers of Wrong Site Surgery has not Decreased

By Sandra Boodman

When the president of the Joint Commission, the Chicago-based group that accredits the nation's hospitals, unveiled mandatory rules to prevent operations on the wrong patient or body part, he did not mince words.
"This is not quite 'Dick and Jane,' but it's pretty close," surgeon Dennis O'Leary declared in a 2004 interview about the "universal protocol" to prevent wrong-site surgery. These rules require preoperative verification of important details, marking of the surgical site and a timeout to confirm everything just before the procedure starts.

Mistakes such as amputating the wrong leg, performing the wrong operation or removing a kidney from the wrong patient can often be prevented by what O'Leary called "very simple stuff": ensuring that an X-ray isn't flipped and that the right patient is on the table, for example. Such errors are considered so egregious and avoidable that they are classified as "never events," because they should never happen.

But seven years later, some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse, although spotty reporting makes conclusions difficult. Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting organization, compared with 49 in 2004. Reporting to the commission is voluntary and confidential -- to encourage doctors and hospitals to come forward and to make improvements, officials say. About half the states, including Virginia, do not require reporting. In two states that track and intensively study these errors, 48 cases were reported in Minnesota last year, up from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few years.

To read full article please visit
http://www.kaiserhealthnews.org/Stories/2011/June/21/wrong-site-surgery-errors.aspx

Nevada Hospitals Now Have To Report Patient Safety Errors

As reported on rgj.com

By Frank X. Mullen Jr.

Nevada hospitals say they are improving their patient-safety records and that fewer patients are being injured in hospitals than ever before, but they don't back up those claims by releasing hard numbers of specific types of hospital errors from year to year. With the passage of new hospital transparency laws in this year's legislative session, that's about to change. Hospitals are now required to report to the public specific numbers of types of errors -- such as wrong-patient or wrong body part surgeries, falls resulting in severe injuries, and numbers of preventable infections and preventable bedsores.

That way, lawmakers said, prospective patients can compare hospitals' safety records.

Nationally and in Nevada, experts say many sentinel events -- the things that are "never" supposed to happen in hospitals -- happen fairly frequently but just aren't reported.

Last year, the Las Vegas Sun analyzed Nevada hospital billing records that contained no personal information about patients. According to the Sun, hospitals billed to treat 1,363 occurrences that could fit the definition of sentinel events in 2008 and 2009. But hospitals reported only 402 sentinel events to state health officials for those years.

Suzanne Henry, spokeswoman for the Texas-based Consumers Union's Safe Patient Project, said Nevada's new laws will help Nevadans make decisions about care and shed light on whether hospitals are reporting their errors accurately.

To read full article please visit http://www.rgj.com/article/20110621/NEWS/106190359/1002

Researchers Report on Success of Patient Safety Program In Michigan

Medical and nursing researchers and social scientists in the United States and the United Kingdom have concluded that a patient safety program, which ran in more than one hundred hospital ICUs in Michigan, dramatically reduced the rates of central line bloodstream infections. Funded in part by the Health Foundation in the U.K., the collaboration between researchers at the University of Pennsylvania, Johns Hopkins University and the University of Leicester has led to a deeper understanding of how patient safety initiatives like the Michigan program can succeed.

The researchers found that one of the Michigan program’s most important features is that it explicitly outlined what hospitals had to do to improve patient safety, while leaving specific requirements up to the hospital personnel.  A critical aspect of the program was convincing participants that there was a problem capable of being solved.

“We knew this program worked. It not only helped to eliminate infections, it also reduced patient deaths,” said program leader Peter Pronovost of the Johns Hopkins University School of Medicine, named one of Time Magazine’s 100 most influential people in 2008 and a MacArthur Fellowship recipient. “The challenge was to figure out how it worked”.

Infection rates were continuously monitored at hospitals participating in the program, making it easier for hospital workers to track how well they were doing and where they needed to improve.The authors conclude that that there are important lessons for others attempting patient safety improvements.  Checklists were an essential component but not the most important component of the Michigan program.

“It was much more than that,” said lead author Mary Dixon-Woods, professor of medical sociology at the University of Leicester. “It involved a community of people who over time created supportive relationships that enabled doctors and nurses in many hospitals to learn together, share good practice and exert positive pressure on each other to achieve the best outcomes for patients.”

The Michigan program, also known as the Keystone study, was designed to minimize the risk of patients getting catheter-related bloodstream infections in intensive care units. Each year, about 80,000 patients in the U.S. get these infections.  Between 30,000 and 60,000 of them die.  During the 18-month period when the Michigan program was implemented in 103 hospital intensive care units, infection rates dropped 66 percent, resulting in estimated savings of 2,000 lives and $200 million.

Thursday, June 16, 2011

Peter Angood, MD joins Winkenwerder LLC.

Peter B. Angood, MD has joined Winkenwerder Company LLC as Senior Advisor for Patient Safety and Health Care Quality. Dr. Angood is a recognized national expert in patient safety, healthcare quality and medical standards, and health policy development. Previously he served as Chief Patient Safety Officer and Vice President at the Joint Commission, and since then as Senior Advisor for Patient Safety at the National Quality Forum. Dr. Angood also is currently serving as the Medical Director of the GE Patient Safety Organization with GE Healthcare, and continues his longstanding work with the World Health Organization’s Initiative for Patient Safety.

Dr. Angood has a distinguished career in medicine. He served as Professor of Surgery, Anesthesia, and Emergency Medicine, and also held positions at the University of Pennsylvania, Yale University, and Washington University in St. Louis.

For The Winkenwerder Company, Dr. Angood will strengthen the company’s ability to support clients’ needs in patient safety, quality improvement, measurement, and compliance. With the growth of quality and performance-oriented payment systems, the needs of both providers and payers have grown and changed.

“I am delighted that Peter has joined The Winkenwerder Company. He brings extraordinary experience in patient safety, quality, care measurement, and compliance with standards. His unique expertise will improve our services to existing clients and help us better serve new clients. We see great opportunities to reduce medical errors and improve the quality of health care in America," said Dr. Bill Winkenwerder, Chairman & CEO of The Winkenwerder Company.

Wednesday, June 15, 2011

Findings from HIMSS 2011 Clinical Transformation Study

As reported by healthcareIT news

Healthcare organizations are embracing the need for information transparency to drive clinical transformation, but they are lacking the tools and capabilities to make data available in real-time to make it happen.These are among the key findings from the HIMSS 2011 Clinical Transformation Survey, sponsored by McKesson.

Three-quarters of respondents indicated they already have in place or are establishing a formal leadership team to address clinical transformation. However, less than half of the organizations reported sharing clinical measures with their staff and less than a third share financial data with employees, indicating an opportunity to improve transparency across stakeholders.


"Advanced clinical systems exponentially increase the amount of clinical information that is available to drive quality improvement," said Deborah Bulger, executive director, product management, Health Systems Performance Management, McKesson Provider Technologies. "But while data may be more widely available, this study suggests that many organizations still have a long way to go before it is accessible in a way that facilitates analysis and rapid, sustainable performance improvement. The government's program for meaningful use of EHRs, with its requirement to report on clinical quality measures as a byproduct of care, may bring about the tipping point we need to see real clinical transformation."

All respondents had to play a role in the clinical informatics environment at their organization, resulting in 175 usable responses to the survey. Respondents assessed the degree of clinical transformation within their organizations in terms of measurement, governance and leadership, organizational behavior and data access. Among the key findings:

• Just over 49 percent indicated their focus is on ensuring the organization has a fully operational electronic health record in place.
• 78 percent of respondents share clinical data with clinical executives through a scorecard and/or dashboard; 69 percent share financial data through a scorecard/dashboard.
• 58 percent of respondents say they use business intelligence tools to facilitate quality reporting.
• 53 percent of respondents indicated their organization has documented efficiencies and cost savings related to clinical quality.
• 78 percent of respondents say they have a formal leadership team that addresses clinical transformation.  Another 57 percent said clinical transformation is part of the organization's strategic plan.
• Almost 75 percent of respondents noted they need additional IT resources to better report on quality measures, followed by more staff (61 percent) and more money (58 percent).
• Only 35 percent of respondents report that data at their organization are imported into a data repository or warehouse.
• More than 40 percent of respondents rely on some level of manual analysis to facilitate quality reporting.

To read the full article please visit:
http://www.healthcareitnews.com/news/access-real-time-data-stumbling-block-clinical-transformation

Mercy Hospital Win Prestigious Award from HHS

Mercy Hospital, part of Allina Hospitals & Clinics, is only one of four hospitals in the U.S. to be awarded an Outstanding Leadership Award from the U.S. Department of Health and Human Services (HHS) for achievements in eliminating two types of hospital acquired infections (HAI).Mercy is the only hospital in Minnesota to earn an Outstanding Leadership Award, the highest level, for eliminating central-line associated blood-stream infections (CLABSI) and ventilator associated pneumonia (VAP). Out of 2,400 patients who receive care at Mercy’s intensive care unit every year, there have been no cases of CLABSI for nearly three years and only one case of VAP per year.

“This is an impressive accomplishment that few hospitals have earned because of the difficulty and complexity involved in eliminating these infections,” said Mary Jo Morrison, Allina’s vice-president of performance improvement. “It’s also important because these are key quality measures and CLABSI is also one of the proposed measures for accountable care organizations.”

Hospital Acquired Infections National Priority

Hospital acquired infections affect about one in twenty hospitalized patients and HHS has set a goal of reducing them by 40 percent by the end of 2013, which could save more than 60,000 lives. Eliminating hospital acquired infections is also a focus of the federal Affordable Care Act. The law includes the Hospital Value Based Purchasing Program which will reward larger payments to high performing hospitals. HHS awarded a total of 37 hospitals for making progress in eliminating HAI.

“This award reflects the leadership support and collaboration of our team to continually seek ways to eliminate all healthcare-associated infections, and to ensure every patient receives safe, reliable, yet cost effective care,” said Michelle Farber, board certified infection preventionist at Mercy Hospital.

Eliminating CLABSI at Mercy Hospital Reduced Expenses by More Than $ 400,000

The Center for Disease Control and Prevention reports that a 58 percent reduction of CLABSI in US ICUs saved $414 million in extra costs from 2001-2009. Eliminating CLABSI at Mercy Hospital reduced medical expenses by an estimated $424,000 and resulted in 96 fewer days in the ICU for patients between 2007 and 2010. Preventing VAP saves about $18,000 per patient, according to the 2008 Advisory Board.

The effort to eliminate VAP and CLABSI at Mercy began in 2003 with initiatives that include:

    New infection prevention protocol. Mercy was one of the first hospitals in 2009 to implement a protocol to bathe ICU patients daily with the antiseptic Chlorhexidine Gluconate. Scientific research* has since proven the effectiveness of this practice in several multicenter trials and is evolving as a best practice among other hospitals in the nation.

    Early removal of catheter or ventilator. Protocols and order sets allow the ICU staff to wean patients from ventilators and to remove catheters as early as possible. Mercy has shared this early extubation protocol with hospitals across the U.S. and England.

    Clinical Action Teams. CAT teams focus on one area or opportunity. Teams review literature, implement evidence-based improvements and then hard-wire practices into work-flows. For example, a “Scrub the Hub” campaign highlighted the need to use friction with an alcohol pad for 15 seconds before accessing a port.

*Daily chlorohexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. Dixon JM, et al. Am J Infect Control 2010; 38:817-21.

About Allina Hospitals & Clinics

Allina Hospitals & Clinics is a not-for-profit system of hospitals, clinics and other health care services, providing care throughout Minnesota and western Wisconsin. Allina owns and operates 11 hospitals, more than 90 clinics and specialty care centers, and specialty medical services that provide hospice care, oxygen and home medical equipment, pharmacies, and emergency medical transportation services. Allina Hospitals & Clinics and the latest health information can be found online at allina.com.

Bob Connors, MD Receives Patient Safety Award from NPSF

As reported in MD news

At the recent NPSF 2011 Patient Safety Congress, Bob Connors, M.D., president, Helen DeVos Children’s Hospital and practicing pediatric surgeon, received the 2011 Chairman’s Medal from the National Patient Safety Foundation (NPSF).

“The NPSF Chairman’s Medal recognizes emerging leadership in the patient safety field,” said Diane C. Pinakiewicz, MBA, NPSF president. “The recipients are chosen for their ability to inspire and lead the change necessary to successfully implement patient safety improvements while creating a culture of respect, openness, learning and a positive team dynamic. Bob Connors’ guidance at Helen DeVos Children’s Hospital has done just that; he has fostered a climate of positive change for accelerating the delivery of safe patient care.”

    “Safety is now an integral part of our strategic planning and daily operations. We have appointed an executive director of quality and safety, created unit based safety champions and forged partnerships with other leading children’s hospitals engaged in safety work best practices.”

 Bob Connors, M.D.; Pediatric Surgeon and President, Helen DeVos Children’s Hospital



To read full article please visit

http://www.mdnews.com/news/2011_06/bob-conners-honored-for-patient-safety-leadership

For complete coverage of patient safety programs, case studies and new solutions please visit Patient Safety & Quality Healthcare 

Monday, June 13, 2011

IBM Expanding Health Analytics Solution Center

IBM  announced the expansion of its Health Analytics Solution Center last May. The Dallas-based center is adding new technology and has doubled the number of healthcare solution architects and technology specialists. Teams there are working to help physicians connect smart phones, tablets and other devices to electronic medical records (EMRs) while also helping healthcare providers build new solutions for remote patient monitoring.

With this expansion, the IBM Analytics Solutions Center is incorporating some of the same technology used in IBM's Watson, the experimental computer system that defeated the two best human contestants in the game show Jeopardy! earlier this year. Using sophisticated analytics to understand the meaning and context of medical information, advanced health analytics is increasingly being used to help healthcare organizations gain new insight from the explosion of health data growing at a rate of 35 percent per year, according to a recent study by Enterprise Strategy Group.

As clinicians adopt smart devices at five times the rate of the general population, they will increasingly need to connect to EMRs for instant access to patient records in their office, during hospital rounds, or on call. This growing use of mobile devices however creates new challenges. Updating medical records, entering notes and accessing information on small devices with tiny keys can be challenging. Physicians may choose to interact using their phone via text, voice or a combination of both.

Using clinical voice recognition from Nuance Communications, Inc. (NASDAQ: NUAN) and medical terminology management from Health Language, Inc., IBM is working to improve the mobile EMR experience through voice recognition and technology that provides understanding of medical text, similar to the way Watson analyzed hundreds of millions of pages of text from books, encyclopedias and periodicals to compete on Jeopardy!. This will allow caregivers to derive more insight from medical notes, exams and pathology reports that now can be evaluated and compared electronically.

By using analytics to determine hidden meaning buried in medical records, pathology reports, images and comparative data, computers can extract relevant patient data and present it to physicians, ultimately leading to improved patient care.

Remote Analysis of Patient Data

IBM is also expanding its work in remote patient monitoring at the center, helping hospitals integrate and connect devices from among different manufacturers, enabling patients to be closely monitored from home. For example, remote monitoring can be used after a patient leaves the hospital to watch for complications post-discharge. By feeding important data such as temperature, blood pressure, pulse oximeter readings, and even when medications are taken automatically by an application on a Bluetooth smart phone, a nurse care coordinator can monitor the patient in real-time. This allows patients to recover in a comfortable setting, while still enabling caregivers to take action if and when needed. These and other health analytics technologies are designed to help healthcare organizations make sense of the massive volumes of data they generate every day.

With the rapid adoption of electronic medical records and other health IT applications, the amount of data associated with health care providers in North America is expected to reach close to 14,000 petabytes by 2015. The massive increase in health data and the need to gain insight from it has made the field of health analytics increasingly important as leading hospitals use analytics to transform many aspects of their business such as clinical decision making, coordination of care and for measuring performance and patient safety.

The Health Analytics Solution Center has worked with more than 150 hospitals, health plans and other healthcare organizations since its opening in late 2009. The center provides clients access to health analytics experts, technical architects and specialists, with access to hundreds more health industry experts from across IBM, including experts from IBM's Business Analytics and Optimization consulting organization and IBM Research.

It is the first center of its kind to address the need for advanced analytics across the health care industry, taking advantage of increased computing power to collect and analyze data streaming in from sensors, patient monitoring systems, medical instruments and handheld devices as well as the volumes of data generated by hospitals every hour. This year marks IBM's centennial and healthcare continues to be one of its most important areas of industry focus.

The company spends more than $6 billion a year on R&D, much of it on healthcare, and IBM is one of the few technology companies with large teams of physicians and other clinicians on staff to ensure healthcare's most pressing needs are met.

About IBM For more information about IBM, visit: http://www.ibm.com/smarterhealthcare Follow us on Twitter @IBMHealthcare or www.twitter.com/ibmhealthcare Join in the discussion on the Smarter Healthcare LinkedIn Group Watch our videos at www.youtube.com/ibmhealthcare Contact(s) information Holli Haswell IBM Media Relations 720-396-5485

GE Healthcare Next Generation Post-Processing Software receives FDA clearance.

GE Healthcare announced FDA clearance of READY View, a new MR advanced visualization platform to help clinicians process and analyze images anytime and anywhere. A part of the Dexus workflow, READY View is accessible through any PC, PACS or RIS workstation, allowing access to process and analyze images in any office, meeting room or even at home.

The READY View advanced visualization platform provides a combination of protocols, applications and advanced tools that enable a fast, easy and quantified analysis. In addition to standard and advanced protocols, such as 4D review and image averaging, READY View offers fast and accurate multiparametric protocols, such as Brain Oncology, knee, liver and many more. Multiparametric protocols offer a new, simple and intuitive workflow to process all functional data from a single screen without having to leave a reading station.

“MR is moving to quantitative analysis to improve lesion detection, characterization or monitoring,” said Jim Davis, general manager, global MR business GE Healthcare. ”The READY View platform is the first step in bringing clinicians a fast and easy way to process and analyze MR data anytime and anywhere.  With READY View, clinicians can automatically segment an abnormality, convert into a 3-D volume and then quickly see and export the curve and associated statistics to the segmented area. ”

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

Tim Appenheimer Appointed VP and Chef Medical Officer at KSB Hospital

As reported by WREX.com

Katherine Shaw Bethea Hospital promoted Tim Appenheimer, MD,  to Vice President and Chief Medical Officer, effective July 3, 2011.KSB Hospital President and CEO Dave Schreiner explained that Dr. Appenheimer's promotion was done to address the growing focus on improving healthcare quality and patient safety across the country.

"We wanted a physician-led division of quality," Schreiner said, "Dr. Appenheimer understands the entire clinical side and he can help shepherd quality improvement issues through the process."

As such, Appenheimer's division will now include the Quality and Medical Staff Services Department, the Safety Department, the Infection Control Department, the Family Medicine Residency program, Home Care and Hospice, and the Hospital Medicine program.

http://www.wrex.com/Global/story.asp?S=14898480

Atlanta Newspaper Covers on Hospital Acquired Infection Reporting in Georgia

By Carrie Teegardin

The Atlanta Journal-Constitution

In twenty eight states, hospitals are required by law to make a public report on at least some of the infections patients pick up while under the hospital's care. Georgia is not one of those states, and patient advocates say that makes it difficult for consumers to make informed choices about where to go for health care.

"This should be something the state does for its consumers," said Holly Lang, director of the Hospital Accountability Project at Georgia Watch, a statewide consumer organization.If restaurants must post their inspection scores on their walls, then hospitals should have to disclose rates of potentially deadly infections within their facilities, Lang said. That would help patients choose a hospital, she said, while also pressuring hospitals to improve patient safety.


Legislation to require reporting on infections at hospitals has been proposed in Georgia but not passed, said Pam Keene, a spokeswoman for the Georgia Department of Community Health."I think hospitals felt very defensive about releasing information because they felt it would be bad for their marketing," said state Rep. Pat Gardner, D-Atlanta.But Gardner said that needs to change. "This is the age of consumer directed health care and if we want consumers to take a more active role in their health care, they need access to all kinds of information that is not currently available to them," she said.

Kevin Bloye, spokesman for the Georgia Hospital Association, said the state's hospitals are cautious about public reporting of infection and quality data because hospitals are still working to develop accurate systems for collecting such information that allows for fair comparisons. "More transparency is what the public wants and we're responsive to that," Bloye said. "But the key is making sure what we report is right and fair to each of the stakeholders involved."

http://www.ajc.com/news/georgians-kept-in-dark-975123.html?printArticle=y

Thursday, June 9, 2011

WSJ Article -Programs To Prevent Hosital Re-Admissions

Can a virtual nurse named Louise help keep patients from landing back in the hospital after they are discharged?

By Laura Landro
Wall Street Journal

Louise walks hospital patients through plans for their recovery at home.

It's part of a push to reduce the 4.4 million hospital stays that are a result of potentially preventable re-admissions, which add more than $30 billion a year to the nation's health-care tab, or $1 of every $10 spent on hospital care, according to the federal Agency for Healthcare Research and Quality.

With hospital stays shorter than they used to be, patients may be sent home in frailer states. They may not understand instructions on how to take care of themselves and face unexpected medical problems after leaving the hospital. More than a third of patients don't get the lab tests, specialist referrals or follow-up care they need.

With one in five of its elderly hospital patients re-admitted within a month of discharge, the federal Medicare program plans next year to reduce how much it will pay hospitals for certain preventable re-admissions. In April, Medicare announced it will provide $500 million in grants for organizations that work with hospitals on programs to reduce re-admissions. The government is funding an effort to help hospitals adopt Project RED, a discharge-planning program developed by Boston University that helped cut re-admissions at Boston University Medical Center by 30% in a 2008 study. Researchers there have developed the "virtual discharge advocate," Louise, to help explain home care to patients.

Re-admissions often occur because of poorly communicated instructions, such as when a rushed staff member hands a pamphlet or a printout with scant information to a patient or relative. "I got more instructions on how to take care of a goldfish I took home from the pet store as a kid than we give some people we send home from the hospital," says Victor Caraballo, senior medical director of Independence Blue Cross in Philadelphia. It is providing $5 million to a patient-safety initiative involving more than 70 hospitals and aiming to reduce re-admissions by 10% by next spring.

To read full article please visit www.wsjonline.com


Correction & Amplification
The portion of Medicare patients who are readmitted within a month after a hospitalization is 20%, or one in five. An earlier version of this article incorrectly said that one in 20 end up back in the hospital.

Missouri Center for Patient Safety Launches New Patient Safety Website

New Patient Safety Website Launched

The Missouri Center for Patient Safety (MOCPS) has introduced a  new website,- www.mocps.org for health care providers and health consumers to provide a greater focus on important patient safety related issues and services. MOCPS' mission is to be a leader in providing solutions and resources that improve patient safety and the quality of health care delivery.

The new websitesite complements MOCPS' patient safety improvement activities, in addition to enhancing its services as a federally designated Patient Safety Organization (PSO), in partnership with organizations throughout the nation.The site now offers a blog format providing up-to-date information about MOCPS activities, programs and patient safety news, as well as audio and video content and a new Facebook presence.

Recently, the MOCPS sponsored, Patient Safety Awareness Month, in April, featuring an online recorded tele-forum with patient safety experts, Judy Baker, Department of Health and Human Services, Dr. Sean Berenholtz, Johns Hopkins, David Marx, Outcome Engineering, Becky Miller, MOCPS, and Diane Cousins, Agency for Healthcare Research and Quality. The brief and information-packed discussions are available on the new website to encourage the public to learn about important patient safety issues.

More About MOCPS – The Missouri Center for Patient Safety was founded by the Missouri Hospital Association, Missouri State Medical Association and Primaris as a private, nonprofit corporation to serve as a leader to fulfill its vision of a health care environment safe for all patients, in all processes, all the time.

For more information about patient safety please visit www.psqh.com

Thursday, June 2, 2011

Kaiser Permanente Joins Partnership For Patients

Kaiser Permanente has joined the federal government's Partnership for Patients program - a $1 billion patient safety initiative aimed at improving care and reducing costs.
Partnership for Patients: Better Care, Lower Costs is a new public-private coalition announced in April by HHS Secretary Kathleen Sebelius. The program is designed to help improve the healthcare quality, patient safety, and affordability of health care for all Americans.

"Patient safety is one of our top priorities and is a critical component of all our quality improvement programs," said Jed Weissberg, MD, senior vice president, Hospitals, Quality and Care Delivery. "We believe this initiative is a great step forward in elevating patient safety as a high priority nationally, and we hope that it will help place greater emphasis on the importance of continual development, testing and implementation of new programs that are aimed at the achieving the goals of reducing harm."

Partnership for Patients will focus on hospital safety with the goal of reducing preventable hospital-acquired conditions by 40 percent. This is expected to save 60,000 lives, and reducing hospital readmissions by 20 percent over the next three years. The partnership has the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare.

The initiative aligns with Kaiser Permanente's dedicated emphasis on patient safety and its organizational goal to prevent adverse events and health care-associated infections.
"Every patient has the right to safe and reliable health care," said Amy Compton-Phillips, MD, associate executive director, The Permanente Federation. "We are proud to support this new national initiative that aims to bring us one step closer to that goal."