EarlySense Included in New Study On Reducing Risks of Pressure Ulcers

A post regulatory approval clinical and interventional study results confirm the EarlySense contact-free patient monitoring system's value as a risk assessment tool for preventing pressure ulcers. The clinical study data is published in the December 2011 issue of the Journal of Patient Safety. It can also be accessed on line at:

http://journals.lww.com/journalpatientsafety/Abstract/2011/12000/Using_Continuous_Motion_Monitoring_Technology_to.3.aspx .

The EarlySense contact-free patient monitoring system automatically and continuously records and documents a patient's cardiac, respiratory and motion parameters using a compact sensor placed under the patient's mattress. The system alerts the nursing staff when there are significant changes in a patient's condition, if a patient has left or is in the process of exiting the bed, or if a patient needs turning in order to avoid pressure ulcers.

Nurses are informed of patient status changes, bed entries and exits as well as turn requirements, via a wired or wireless communication system, on the patient's bed side monitor, at the nurse's station, on their handheld devices and on a large screen display mounted in a prominent spot on the wall in the department.

The quoted clinical study was a non-interventional study performed in two medical departments at two separate medical centers. The movement of 116 patients enrolled in the study was recorded and retrospectively analyzed.

"We found that the pressure ulcer risk score correlated highly with the EarlySense measured motion rate. Based on this, we have concluded that the EarlySense system has potential to serve as a risk assessment tool to be used to prevent pressure ulcers," said Eyal Zimlichman, M.D., a lead researcher from the Center for Patient Safety Research and Practice, Brigham and Women's Hospital and Harvard Medical School in Boston, MA.

The interventional study, conducted at a US hospital, evaluated the implementation of the EarlySense contact-free patient monitoring system in a 33-bed medical-surgical unit. Here, data from 666 patients in the pre-implementation period were compared with data generated from the 993 patients in the post implementation period. The researchers found a reduction of about 65% in incidence of pressure ulcers attributed to the use of the technology. Of the 41 staff nurses who routinely worked on the floor with the technology, 88% agreed that the turn alerts provided by the EarlySense system helped nurses to reduce risk of pressure ulcers.

"EarlySense continues to set the standard for technologies that help clinicians provide proactive care on hospital floors by monitoring, communicating and facilitating the management of timely clinical interventions - all without ever touching the patients. Our system has been repeatedly reported by medical professionals to assist in their effort to save lives and secure better clinical outcomes. Today's data pertaining to pressure ulcers is another example of how the EarlySense system can make a valuable contribution to patient safety and the hospital's bottom line," said Avner Halperin, CEO of EarlySense.

Bloomberg Business Week- New Study On Hospital Readmission Rates

A study in the New England Journal of Medicine  supports federal efforts to improve the coordination of care between doctors and hospitals to cut admissions, said the author, Arnold Epstein, a professor of health policy at the Harvard School of Public Health in Boston.The government will reduce Medicare payments to hospitals with higher-than-average readmission rates beginning in October because returning patients are seen as an indicator of poor care.

Initial admissions are the strongest predictor of readmission rates, not whether hospitals instruct discharged patients on how to care for themselves, the study showed. The link between admissions and readmissions is “a real phenomenon and it’s quite a strong effect,” said David Goodman, the director of Dartmouth College’s Center for Health Policy Research in Lebanon, New Hampshire. Admissions tend to be higher in places like New York, where there are many hospital beds, he said in a telephone interview.

Variations In Readmissions

Nationwide, rates of readmission within 30 days after hospitalization for congestive heart failure range from 11 to 32 percent of patients, Epstein’s study showed.

Epstein and his co-authors analyzed Medicare data from the first half of 2008 to identify four factors that could predict a readmission and help explain the variation. They include whether patients in an area with high numbers of readmissions were sicker than average, whether they receive discharge instructions, whether doctors or hospital beds are in short supply and overall hospital admission rates.

Only admission rates showed a strong correlation with readmissions in analysis that included all of the variables, the study showed. Admission rates explained 16 percent of the variation between different regions, the study said. Discharge instructions by comparison only accounted for about half a percent of the difference, according to the study.

“Programs directed at shared savings from lower utilization of hospital services might be more successful in reducing readmissions than” the planned payment reductions, the study said.

Medicare will begin paying bonuses next year to hospitals and physicians who can reduce medical spending by their patients as part of so-called accountable care organizations.

Goodman agreed that the program may help stem readmissions. Policy makers should also try to address differences in admissions across the country, he said.

“A bed that’s not filled by readmission by good efforts just gets filled up by another patient who, in another region, wouldn’t be admitted at all,” he said. “We run the risk of ignoring some of these broader and arguably more important patterns” by focusing on readmissions, he said.

--Editors: Adriel Bettelheim, Bruce Rule

To contact the reporter on this story: Alex Wayne in Washington at awayne3@bloomberg.net

To contact the editor responsible for this story: Adriel Bettelheim at abettelh

PharMEDium Announces Medication Safety Solution for Operating Room

PharMEDium announced the first generation solution designed to support medication safety and documentation in the Operating Room . PharMEDium has developed the first bar code scanner to support medication verification administration. "Our certiMED™ system is designed to be used with the extensive line of PharMEDium Ready-to-Use O.R. syringe medications by providing a visual and audible double check at the point of administration," said David Jonas, PharMEDiumChairman and CEO.

In the O.R., anesthesia providers prepare and administer critical medications in a complex environment. The certiMED™ scanner is designed to function as an extension to the market leading PharMEDium O.R. anesthesia syringe labels featuring the American Society of Anesthesiologists' endorsed ASTM color standard to differentiate drugs within a class. The certiMED™ scanner was also developed with pharmacy requirements in mind. certiMED™ provides a means to reconcile medications in real time while supporting the anesthesia provider by integrating pharmacy resources into the medication use process in the O.R. through the drug library.

Problems With Ventilator Alarms Have Led to More Than 100 Patient Deaths

More than one hundred patients have died in the past six years as a result of problematic alarms on ventilators, which are designed to beep warnings to caregivers when something goes wrong with the machine or the patient’s breathing.The Boston Globe reports that the problems seem to be related less to the devices themselves and more to human error.  An analysis conducted by the Globe and the ECRI Institute, a nonprofit patient safety organization, found that 119 people died between 2005 and May 2011 in incidents involving ventilator alarms. According to the analysis, an actual malfunction of the ventilator was the cause in only two of those deaths; all others were the result of caregivers’ ignoring the alerts, failing to hear them or setting the alarms incorrectly.

The report is the latest development in alarm fatigue, a problem that occurs when hospital and home-based caregivers become overwhelmed by the number of alarms that blare constantly  from medical devices, such as ventilators or cardiac monitors.

“Alarms occur frequently, and many times they’re false, and because of that many times people fail to act as quickly as they should when an alarm goes off,” Maria Cvach, assistant director of nursing and clinical standards at Johns Hopkins Hospital, told ABCNews.com.



To read the full article please visit-http://abcnews.go.com/blogs/health/2011/12/12/ventilator-alarms-linked-to-patient-deaths/

Patient Safety & Quality Healthcare has extensively covered medical alarm fatigue. Please visit our website at www.psqh for more information.

White Plains Hospital To Use Communication System from Amcom

White Plains Hospital in White Plains, N.Y., has selected the Amcom MediCall Select to significantly improve communications throughout the hospital.. They will  use the Amcom operator console and Web-based on-call scheduling solutions to automate and speed communications for external callers as well as their staff. MediCall Select will also eliminate paper-based procedures for time-sensitive communications.

Amcom designed MediCall Select for community and regional hospitals that face the same critical communication requirements as larger hospitals. "Hospital communications require speed and accuracy at all times, and MediCall Select will help us achieve this," said Brian Chiodo, Director of Telecommunications, White Plains Hospital. "Not only will staff and patients benefit from improved communication capabilities, but we will also have the technology backbone in place to support our growth."

"Like many community hospitals seeking to maintain and enhance quality as they grow, White Plains Hospital is migrating to a more advanced approach to helping staff, patients, and guests interact," said Chris Heim, President, Amcom Software. "Whether a patient's family member is calling for an update, a nurse is searching for the right on-call specialist at 2 a.m., or a caller just needs directions, White Plains Hospital will be able to put the right people in touch quickly and easily. They also have the right platform in place to incorporate emerging communications technologies as needed down the road such as messaging securely to smartphones and tablets."

Please visit Patient Safety & Quality Healthcare for more information on patient safety and healthcare quality improvement programs

Nason Hospital Turns to Access Intelligent for EMR Program

When Nason Hospital, in Roaring Spring, Pa., decided to pursue an electronic medical records initiative, administrators realized that the project would require barcoding for electronic and paper forms. They also identified barcoded patient wristbands and medication labels as an area of need.

“We chose Access Intelligent Forms Suite to meet our forms, wristband and medication barcoding requirements,” said Deb McGraw, VP, Nursing/Patient Care Services at Nason.“The forms barcoding that Access Intelligent Forms Suite provides allows our HIM staff to get forms into Siemens EDM easily,” McGraw said. “This has helped us incorporate e-forms into the patient’s electronic record.”

As it is generating e-forms on demand, Access Intelligent Forms Suite also produces barcoded patient wristbands, which has helped the Special Delivery Unit to improve their patient safety efforts.“We utilize the Access solution to produce a mother's armband, two baby armbands and a crib card with the same ID number,” McGraw said. “This number is used prior to discharge to ensure that the correct mother and baby are paired before leaving the hospital and the mother signs that this comparison has been completed.”

About Nason Hospital
For over a century, Nason Hospital has been providing services to meet the healthcare needs of surrounding communities in Blair, Bedford, and Huntingdon counties. Located in a peaceful rural area in the hills of Pennsylvania, the facility provides an ideal setting for patients' care, and their families' and visitors' comfort.

About Access
Access is the world’s leading electronic forms (e-forms) management, automation and workflow software provider. Our solutions transform any paper-intensive forms process into a paperless, collaborative workflow. Hundreds of hospitals worldwide are using Access solutions to improve patient care and safety, cut costs and enhance electronic health records (EHR), patient safety and downtime planning initiatives.

Michael Appel MD Named Chief Patient Safety Officer at Northeast Georgia Health System

Northeast Georgia Health System, Inc. has hired Michael Appel, M.D. as Chief Patient Safety Officer. Combining his expertise in the cockpit with more than 20 years experience in healthcare, Dr. Appel brings the right recipe for innovative improvements in patient safety. “You don’t often get the chance to work with a person who has been an Ivy League professor, has flown thousands of hours for Delta Airlines and continues to practice anesthesiology,” says Carol Burrell, President and CEO of NGHS. “We’re excited by the ideas Dr. Appel brings to the table and proud of how he’s already helped make NGMC a safer place for patients.”

Dr. Appel credits his expertise in aviation safety as the foundation for his passion to improve healthcare. “I began reading aircraft accident reports at a young age, and couldn't afford to fly real airplanes" says Dr. Appel. "So I learned about aviation from a safety perspective first...long before I touched the controls of a real airplane. I read every accident report I could get my hands on."

Appel's deep understanding of aviation safety is what set the stage for his huge disappointment with the healthcare system. “It was chaos...what I witnessed when I first stepped foot into a hospital as a medical student. It was at that moment that I realized my mission in life was to make healthcare systems safer for patients."

“Sometimes it’s easy to get numb to terms and tools you use every day, and forget the real meaning behind those terms and the true reason for using those specific tools,” says Sam Johnson, MD, Vice President of Medical Affairs and Chief Medical Officer of NGHS. “Dr. Appel’s experiences help us all look at our jobs from a fresh perspective and ask ourselves what we can do to improve human performance.”

Having considered other offers from around the country, Dr. Appel chose Northeast Georgia Medical Center because "the climate is right at this hospital to be real pioneers in patient safety," says Appel. He credits a team of world-class physicians, a supportive administration, an involved and progressive board of directors, but most importantly the employees of the 5,000 staff referral center who, he says, "create a unique environment, ripe for groundbreaking improvements in patient safety."

Among the many patient safety projects at NGHS, several encompass techniques borrowed directly from aviation. One example uses "root cause analysis" in a way similar to aircraft accident investigations performed by the National Transportation Safety Board. By identifying a patient safety concern and working backward to fix the process itself, Dr. Appel's team makes errors less likely to be repeated.

Another approach inspired by aviation is the use of standard phraseology. Like aviation, healthcare needs a glossary of sacred terms which have specific meaning. "The word 'STAT' has been so abused as to be rendered meaningless", says Appel. In 2012, NGHS will launch a ‘Minutes Count’ campaign to tap into the efficiency that comes from using standard words with specific meanings. "When lives are at stake, communication needs to be crisp and concise," says Appel. "Listen to the exchanges between air traffic control and pilots. They speak a language created with safety at its core."

But Dr. Appel, who is frequently invited to speak nationally on patient safety, will be the first to tell you there are no short cuts. "No lecture is going to do anything for patient safety. The change we're after is one of culture, and that will take decades of hard work."

###

Hospital Association of Southern California Launches SCORE Program with Safer Healthcare

The Hospital Association of Southern California has launched a new initiative to help improve healthcare quality  and reduce costs in the operating room. The Surgical Care and Operating Room Excellence (SCORE) Initiative is a nine-month program focused on creating operational efficiencies and enhancing the culture in the perioperative services area.

SCORE is designed to give hospitals the practical tools and skills needed for developing and sustaining effective, high-reliability processes in the OR.  By teaching high-reliability teamwork and communications skills and implementing innovative tracking technology and Lean Six Sigma improvement tools, SCORE will increase patient safety and reliability while reducing operational costs.

"Hospital operating rooms are highly complex and fast-paced by nature, requiring effective people, processes and technology all working together to achieve efficient, affordable and safe surgical care," said HASC VP of Hospital Operations and Performance Excellence Michele Graynor. "SCORE gives hospitals the ability to achieve these goals in a collaborative environment where administrators, staff members and physicians can all participate and leverage their collective wisdom."

SCORE was developed by a team of high-reliability experts and Lean practitioners to deliver quality improvements for hospitals. Developed in association with Safer Healthcare, a Denver, Colo.-based company, SCORE gives participating hospitals the ability to simultaneously improve patient safety, increase levels of quality, and reduce costs.

"We are extremely pleased to launch the SCORE initiative," said Tony Gorski, CEO of Safer Healthcare.  "For the first time, California hospitals will be able to benchmark and share their progress and best practices in the OR when it comes to quality improvement and patient safety."

SCORE will also leverage the innovative technology of TAGNOS, a Southern California-based company, to provide continuous visibility of the hospital's assets and patients using location-tracking and patient-flow software.  This solution will not only give the patient's location at all times, but also determine the patient's progress in the overall treatment process, the length of time needed to complete each step, and the remaining steps.  Any delays are flagged immediately, and the hospital staff is notified. This level of application intelligence allows hospitals to improve patient throughput, asset and staff utilization, and overall patient satisfaction.

"According to the Association of periOperative Nurses, one additional procedure per day can generate $4 million to $7 million of revenue in an average-sized facility in one year," said Neeraj S. Bhavani, CEO of TAGNOS. "Hospitals are faced with a limited number of operating rooms and ever-increasing surgical volume. Expediting patients through the surgical process will maximize allocation of limited resources by reducing scheduling delays and gaps in OR time."

Antelope Valley Hospital Converts to Masimo Patient Monitoring System

Antelope Valley Hospital and Masimo  announced the hospital's conversion to Masimo rainbow® SET Pulse CO-Oximetry™ technology—enabling advanced noninvasive patient monitoring capabilities that offer immediate, pain-free clinical data and physiological information. The hospital-wide conversion equips Antelope Valley's only full-service hospital with the most technologically and clinically-advanced oximetry and noninvasive patient monitoring solutions available—making patient monitoring both pain-less and cost-effective.

"Converting to Masimo rainbow® SET enables Antelope Valley Hospital to provide a higher level of monitoring care that is pain-free and less invasive than traditional capabilities," stated Edward Mirzabegian, CEO of Antelope Valley Hospital. "This new technology allows us to continuously track key blood, fluid, and respiration parameters without using invasive techniques to collect blood. It's like an invisible lifeline that provides our clinicians with immediate, real-time access to advanced clinical intelligence and continuous physiological measurements that were not available 10 years ago. And, because this technology is completely noninvasive, the cost-of-care is reduced to both the hospital and patient—enabling us to deliver an exceptional level of care and patient safety to our patients cost-effectively."

QuadraMed Expands Agreement with HANYS

QuadraMed Corporation, a provider of health care technologies and services that improve the healthcare quality, patient safety, and efficiency of patient care, has signed an expanded agreement with HANYS Solutions, a subsidiary of the Healthcare Association of New York State to include QuadraMed's identity management solutions.

HANYS Solutions, which has marketed QuadraMed's Quantim(R) suite of health information management (HIM) coding, compliance, and record management solutions since 2000, will now also offer QuadraMed's enterprise master patient index (MPI) solutions to New York-based hospitals and health systems. By adding QuadraMed's (#1 in KLAS*) identity management offerings to the products and services it currently resells, both entities will help New York health systems achieve a variety of financial, clinical, and regulatory objectives.

"Through this partnership, New York's hospitals will be able to leverage proven technologies that ensure data integrity and promote interoperability," said Duncan W. James, QuadraMed Chief Executive Officer (CEO). "Beyond playing a critical role in health information exchange and supporting compliance with 'meaningful use' guidelines, a reliable and accurate MPI paves the way for improved patient safety and care within and among health care facilities." 

QuadraMed's suite of identity management solutions, which includes enterprise MPI and clean-up services, work together to ensure one accurate clinical record is retained per patient, regardless of the data source, application, or facility being visited. By detecting and resolving erroneous or duplicate patient records, medical staff can quickly access a complete view of a patient's treatment history, helping to enhance coordination between caregivers within one organization or across multiple facilities, while improving overall patient safety.

Patient Safety Technologies Announces Third Quarter Results

Patient Safety Technologies, Inc.  announced financial results for its third quarter of 2011 ended September 30th, 2011.During the third quarter of 2011, the number of institutions using SurgiCount Safety-Sponge® System surpassed 78. This compares to approximately 57 institutions using the solution at the end of the third quarter of 2010. To date in the fourth quarter, Patient Safety Technologies has implemented 9 additional facilities with 12 additional facilities scheduled during the remainder of the fourth quarter. In total, the number of facilities currently using the Safety-Sponge® System and those with signed agreements and scheduled implementations is over 230.


For more information on retained surgical instruments and Patient Safety please visit our website at www.psqh.com

St Joseph Mercy Hospital Emergency Department Wins 2011 MITSS HOPE Award

The winner of the 2011 MITSS HOPE Award is the NEXT STEP Program at St. Joseph Mercy Hospital Emergency Department in Ann Arbor, Michigan. The HOPE Award Honors Outstanding People Everywhere who have furthered the MITSS mission of Supporting Healing and Restoring Hope to patients, and families, and clinicians who have been impacted by adverse medical events. RL Solutions’ President and CEO, Sanjay Malaviya, presented the award at the MITSS 10th Annual Dinner and Fundraiser held at the Westin Copley Place, Boston.

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

Nancy Kielhofner New Executive Director at Minnesota Alliance for Patient Safety

Minnesota Alliance for Patient Safety Hires First Executive Director.
With the addition of Nancy Kielhofner, the Minnesota Alliance for Patient Safety  is also undergoing a restructure of its governance model by incorporating to become its own independent organization.Founded by the Minnesota Hospital Association , the Minnesota Department of Health and the Minnesota Medical Association, the partnership works to promote patient safety through supportive efforts among all participants of the health-care system.

Kielhofner brings a wealth of experience and knowledge to an organization that is stepping up its efforts to meet new challenges, said MHA President and Chief Executive Officer Lawrence Massa."Nancy's extensive work advancing patient safety at hospitals in Minnesota, Wisconsin and Illinois will be invaluable as she leads MAPS to the next level," he said. "Her track record in implementing quality improvement strategies and processes, coupled with her absolute passion for patient safety, will serve Minnesota patients well."

RF Surgical Announces New Agreement with Premier Healthcare Alliance

RF Surgical, Inc.announced a three year agreement with the Premier healthcare alliance.  Under the terms of the agreement, the more than 2,500 U.S. hospitals, and 78,000 additional healthcare sites in the alliance, can select RF Surgical Detection Technology to prevent and detect retained surgical instruments from occurring in the operating room.

 The RF Assure™ Detection System utilizes evidence-based radio-frequency (RF) detection technology to prevent and detect RSIs from remaining inside a patient post-surgery. It can safely, accurately and efficiently read through deep cavity tissue, fluids and bone to detect if radio frequency-tagged surgical sponges, gauze or towels remain in a patient following surgery, a dangerous and incredibly costly medical error.

“RF Surgical’s relationship with Premier is further evidence of the growing value placed on the use of adjunctive technology to avoid surgical error,” said Dr. Jeffrey Port, co-founder and chairman of RF Surgical. “We are pleased to partner with Premier to make RF Assure available to a greater number of healthcare providers, continuing to work towards the goal of eliminating the incidence of RSIs in the operating room setting.”








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Alabama Partners With Thomson Reuters for Statewide HIE

Alabama Medicaid and the State of Alabama are partnering with the Healthcare business of Thomson Reuters to build the infrastructure for a statewide health information exchange (HIE). The partnership is designed to to develop a  functional, user-friendly design for the HIE known as One Health Record®.
One Health Record® will securely capture real-time clinical and administrative data from electronic medical records, health care claims, and other sources and provide clinicians with comprehensive patient histories at the point of care so they can make better-informed medical decisions.

The statewide information exchange can improve the coordination of care, improve clinical outcomes, reduce unnecessary and redundant diagnostic tests, create a less fragmented clinical and administrative workflow, and reduce costs. Participation in the exchange helps providers earn federal meaningful use incentives.

"The state of Alabama is clearly committed to the creation of a robust HIE that will help practitioners deliver high quality, cost-effective care," said Jon Newpol, executive vice president for the Healthcare business of Thomson Reuters. "And we are committed to supporting that vision and achieving an aggressive, accelerated implementation schedule."

"We are pleased to start building the infrastructure for a comprehensive and sustainable health information exchange for Alabama," said Alabama HIT Coordinator Dan Roach III, MD. "Thomson Reuters was selected after a rigorous evaluation process due to its experience, quick implementation, and sophisticated analytic capabilities."

For more information on the efforts to improve Health Care Quality and Patient Safety please visit www.psqh.com

Meta Healthcare IT Solutions Celebrates 20th Anniversary

Meta® Healthcare IT Solutions is celebrating twenty  years of providing fully integrated software solutions and hospital information systems to healthcare institutions to promote and improve patient safety outcomes.
The company began with a mission to improve patient care by developing and supporting pharmacy information systems that streamline operations, increase productivity, improve patient outcomes and reduce medication errors. Meta Healthcare IT Solutions now offers a complete suite of enterprise patient safety solutions, including its meaningful use approved MetaCare Enterprise™ EHR suite of products. MetaCare Enterprise EHR equips physicians, nurses and pharmacists to better care for patients while achieving high clinician satisfaction.

"I'm proud that we have been able to have a considerable impact on how healthcare automation can be used clinically to improve patient care,” remarked Sal Barcia, CEO of Meta Healthcare IT Solutions and a pharmacist by training.  We have a team of talented and knowledgeable individuals who continue to provide the level of support and expertise that our customers expect. Along the way, we’ve worked with some of the most talented hospital clients that can be found anywhere. By listening closely to them and collaborating with them, together we’ve helped to radically improve patient care. They truly have been partners, and together we are changing healthcare.”

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

HIMSS Response to New IOM Report on IT and Patient Safety

HIMSS Has a Focus On Patient Safety

The Institute of Medicine Report on Patient Safety and Health IT is a notable contribution to the dialogue on how to make the American healthcare delivery system safer. Its recognition that "Continuing to use paper records can place patients at unnecessary risk for harm and substantially constrains the country’s ability to reform health care" is a strong endorsement for the path healthcare is on. HIMSS also agrees with the IOM that we should not be complacent; there are ways to make health information technology even safer and better for healthcare providers and the patients they serve.

HIMSS notes that the scope of the IOM’s Patient Safety & Health IT report was limited, focusing on making health IT safer. While the deficits of the paper-based system have been well-addressed by IOM in its past publications “To Err is Human” and “Crossing the Quality Chasm”, those deficits still should be noted. The paper-based health system, still in use in many clinical practices and hospitals across our nation, has profound deficiencies in failing to portray a full and up-to-the-minute picture of patients' conditions and care. The paper-based health system kills.

to read the full release from HIMSS please visit http://www.himss.org/ASP/ContentRedirector.asp?type=HIMSSNewsItem&ContentId=78785&utm_medium=twitter&utm_source=twitterfeed

Baxter Completes Acqusition of Baxa

Baxter International Inc.announced the completion of  its acquisition of Baxa Corporation, for a cash consideration of $380 million. Baxa develops pharmacy technology that enhances the efficiency and  patient safety of oral and IV dose preparation and delivery.

"The acquisition of Baxa demonstrates Baxter's long-term commitment to nutrition and patient safety and it allows us to offer a broader range of solutions for the safe preparation and delivery of IV medications," said Robert M. Davis, president of Baxter's Medical Products business. "We believe Baxa's expertise in safely preparing IV and oral liquid medications, and their shared commitment toward improving patient care through innovative drug preparation and delivery technology will benefit patients around the world."

To read more about Patient Safety please visit Patient Safety & Quality Healthcare

Getting a Feel for Better Infection Control

Nurse Training Important to Reduce Hospital Acquired Infections

For every one hundred patients admitted to hospitals for the year 2002, 4.5 patients developed a  hospital-acquired infection (HAI) (Graves & McGowan, 2008), and many experts believe the percentage has risen in recent years. Under new CMS guidelines, providers may risk partial or full denial of reimbursement for procedures where staff medical errors such as infections arise from a lack of training. With an IV catheter infection estimated to cost $100,000 in hospital care, clinical directors understand the need to improve nurse training and proficiency as an HAI risk-management activity and as a critical element of quality care and meeting patient safety goals.

As a result, healthcare organizations are exploring new options for training as part of their efforts to address the problem of infection control. One of the new options for training nurses includes advanced computer-based simulation—an approach previously used mainly in training surgical residents on specialized procedures or devices.


Practice Vs. Reality with “Dummies”
 
The market for medical simulation is estimated to reach $1.5 billion by 2012 (Quinn, 2010), with the dominant share of the market currently comprised of mannequin-based training for nurses and medics, along with specialized training developers. Training with mannequins at simulation centers has become a routine and valuable part of healthcare provider efforts to address patient safety both for training nurses new to a specific procedure as well as providing continuing education for experienced nurses. This is particularly true as so-called “dummies” have become increasingly high-tech with electronic displays, sensors, and readouts.
Yet mannequins have limits in their ability to address the full instructional experience of procedures. They cannot provide a learning experience that includes what a procedure “feels like” when performed on the internal organs of a patient. Achieving such experiential muscle memory is paramount to achieving proficiency in the specific procedure, as well as deeply learning every step in the process—from the first step of correctly cleansing the area to be treated, to the last step of properly applying the dressing and disposing of any waste. 


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

To Improve Patient Safety, Health Information Technology Needs Better Oversight, Accountability

IOM Report addresses Patient Safety

To protect Americans from potential medical errors associated with the use of information technology in patient safety, a new report by the Institute of Medicine calls for greater oversight by the public and private sectors.  The report examines a broad range of health information technologies, including electronic health records, secure patient portals, and health information exchanges, but not software for medical devices.

The secretary of the U.S. Department of Health and Human Services should publish a plan within 12 months to minimize patient safety risks associated with health IT and report annually on the progress being made, the report says.  The plan should include a schedule for working with the private sector to assess the impact of health IT on patient safety.  However, if the secretary determines that progress toward improving patient safety is insufficient within a year, the U.S. Food and Drug Administration should exercise its authority to regulate these technologies.  Concurrently, FDA should begin planning the framework needed for potential regulation so that the agency is ready to act if necessary.

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

AHRQ Announces New Grants to Fight Hospital Acquired Infections

AHRQ announced that it has awarded $34 million in fiscal year 2011 for grants and contracts to hospitals, academic medical institutions, and  research organizations to expand the fight against healthcare-associated infections . These projects funded by the agency help to attain the goals of HHS' Partnership for Patients initiative, a nationwide public-private partnership that aims to improve patient safety  and reduce unnecessary return visits to the hospital while making care less costly.

"Infections are not an inevitable consequence of health care; they are preventable," said AHRQ Director Carolyn Clancy, M.D.  "With this investment, we are building on proven strategies to give doctors and health care teams the help they need to ensure that patients are safe from infections."

These awards include projects to develop, test and spread the use of new modules of the Comprehensive Unit-based Safety Program (CUSP), a proven method to prevent and reduce HAIs.The new modules target three additional infections that are also areas of focus for the Partnership for Patients:

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

For more informaiton on Patient Safety and healthcare acquired infections please visit Patient Safety & Quality Healthcare

Standard Register Introduces New Patient Identification Product

Standard Register, a recognized leader in managing critical information and communications for healthcare, announced the introduction of InterimID™, a stand-alone solution for producing patient ID bands and labels with both barcodes and patient demographics during system or network downtime.

“As healthcare organizations increasingly rely on automated workflows, network and HIS downtimes pose serious challenges for patient registration and care,” said JP Parmley, director of patient identification programs for Standard Register Healthcare. “Hospitals need a ‘plan B’ that assures both patients and documentation are properly identified and barcoded, so care can proceed with a measure of accuracy and confidence.”

Standard Register’s InterimID is a stand-alone solution that resides on the desktop where it is readily accessible to staff when the health information system (HIS) or network goes down. Configured to enterprise and departmental needs, the simple interface allows the registrar or clinician to efficiently enter patient information. The application provides a unique barcode for positive identification of the patient and clinical documents, and easy reconciliation with the medical record once the system is back online.

“Our goal was to provide a simple, cost-effective solution that would allow hospitals to manage registration in a disciplined way and mitigate some of the problems associated with manual processes downstream,” said Parmley. “Barcoding adds that discipline and provides support to vital automated processes, such as medication administration.”

Standard Register Healthcare also provides downtime applications through SMARTworks® Clinical Enterprise, a technology platform that manages both automated and manual workflows for patient registration, identification, care and discharge.

Adverse Events Launches New Website

Published on www.psqh.com

AdverseEvents, Inc. (AEI) Co-founder and President, Brian Overstreet, announced the launch of the AdverseEvents website—a first-of-its-kind online resource that delivers accurate, real-time information on adverse drug events. Users will now have the ability to quantify and fully understand the scope of patient safety issues based on accurate rates of side effects by using AEI’s easy-to-use, fully searchable database. AEI’s proprietary data set has applications for both healthcare professionals and patients.

There has been limited access to reliable drug side effect information. The U.S. Food and Drug Administration’s (FDA’s) Adverse Event Reporting System (AERS) is the only current database of adverse event information but it is inaccessible, incomplete, filled with misspellings and misclassifications, and often out-of-date. Patients have been left to rely solely on drug labels, which can list hundreds of potential side effects with no insight into the real-world incidence or outcome rates. This lack of information has left patients and healthcare professionals confused, and often misinformed about real-world drug safety risks.

To solve this major healthcare challenge, AEI has developed RxFilter™, a proprietary 17-step data refinement process that standardizes and normalizes the FDA’s AERS into an accessible, comparative database of all FDA approved medications. It is the only resource that utilizes the RxFilter process to combine all the varied designations for a medication found in AERS into a single report, and standardizes the AERS data for improved accuracy of adverse drug event information. This dramatically improves the search and alert functionality for side effect information, data analysis and outcomes data, and provides the only comparison views of a drug and its side effects. AEI’s data will increase transparency throughout the healthcare and pharmaceutical industries.

to read the full article please visit Patient Safety & Quality Healthcare

AHE Announces New Partnership with Kimberly Clark Professional

The Association for the Healthcare Environment (AHE), of the American Hospital Association (AHA),  announced a partnership with Kimberly-Clark Professional to launch “The Heart of Healthcare”: a new, educational campaign designed to recognize and elevate the critical role that healthcare environmental services (ES) departments play in supporting patient safety initiatives and reducing healthcare-associated infection (HAI) rates.

“The Heart of Healthcare” campaign will elevate these pivotal contributions to patient safety through print and online advertising that spotlight the ways in which ES professionals help to improve patient outcomes. The campaign will encourage and support peer-to-peer learning, provide advice from experts in the field and offer support and tools for those new to the field.

“We are proud to salute our members and all ES professionals with this well-deserved recognition. It honors the important contribution they make to enhance care safety and their commitment to patients and residents,” said Patti Costello, executive director, AHE. “We appreciative that Kimberly-Clark Professional is partnering with us to recognize ES professionals with the “The Heart of Healthcare” award. This is an exciting time and we are pleased that the important role of ES professionals is being recognized.”

“The Heart of Healthcare” award will recognize outstanding ES professionals who are on the frontlines making a difference for patients and residents. A panel of AHE members will select one first place winner and three “outstanding” honorable mentions. The first place winner will receive a one-year complimentary AHE membership, a framed certificate of recognition, an engraved, crystal award and the opportunity to be featured in a “Heart of Healthcare” advertisement.

“Kimberly-Clark Professional is excited to partner with AHE on this campaign to recognize the highly meaningful, yet often less publicly visible impact that ES professionals have on patient safety and the quality of healthcare,” said Laura Ball, marketing manager, healthcare, Kimberly-Clark Professional. “We have always recognized that ES professionals are on the frontlines continually making a difference in the lives and safety of patients and residents.”

For more information on the campaign, and how to nominate an ES professional for “The Heart of Healthcare” award, please visit ahe.org.

About AHE

AHE (ahe.org) represents, defines, and advances the professionals responsible for care of the patient environment to ensure quality patient outcomes and healthy communities. A professional membership group of the American Hospital Association, AHE serves more than 2,400 members. AHE provides education, networking and recognition for personal and professional achievements as well as collaboration with the AHA on public policy and advocacy issues related to the healthcare environment.

About Kimberly-Clark Professional

Kimberly-Clark Professional (kcprofessional.com) is dedicated to providing essential solutions for a healthier, safer and more productive workplace. These include a unique portfolio of innovative, cost-effective and sustainable offerings for office buildings and lodging properties, healthcare facilities, manufacturing environments, laboratories and cleanrooms, educational facilities, food preparation and processing operations, and home professionals. Kimberly-Clark Professional offers a comprehensive array of hand hygiene and contamination control solutions to break the germ transmission chain and help create a healthier workplace as well as wiping and safety solutions that minimize risk and drive productivity. Its trusted global brands include Kleenex, Scott, Jackson Safety, Wypall and Kimtech. Located in Roswell, Ga., Kimberly-Clark Professional is one of Kimberly-Clark Corporation’s four business sectors.

AHRG Releases Guide to Unintended Consequences of Electronic Health Records

AHRQ has released the Guide to Reducing Unintended Consequences of Electronic Health Records (EHRs). The Guide addresses problems that may occur during implementation and ongoing use of EHRs. Prepared for AHRQ by the RAND Corporation, the Guide is based on research and interviews with organizations that have recently implemented EHRs. The authors include Spencer S. Jones, Ross Koppel, M. Susan Ridgely, Ted E. Palen, Shinyi Wu, and Michael I. Harrison. The guide is available for free download from AHRQ.

For more information on Patient Safety and Electronic Health Records please visit www.psqh.com

ISMP Promotes Use of Story Telling to Improve Patient Safety

In the ISMP Medication Safety Alert!, the Institute for Safe Medication Practices  promotes the use of true stories to improve patient safety by drawing attention to medication errors and inspiring and sustaining cultural change."Telling true stories is an ISMP Hallmark; Here's why you should tell stories, too…" describes the power of stories, reviews legal and public disclosure concerns, and offers advice for crafting and sharing stories effectively.
The ISMP Medication Safety Alert! is available on ISMP's website.

For more information on patient safety success stories please visit Patient Safety & Quality Healthcare

Standard Register and Poken Launch Touch-Enabled Products and Services for Healthcare

pokenHEALTH will transform events and build stronger connections for healthcare organizations.

Standard Register, a recognized leader in managing critical information and communications for healthcare, and Poken, a Swiss-based technology company, announced today they have joined forces to launch a new product and service platform, pokenHEALTH™, which Standard Register will market exclusively to healthcare in North America.

“This exclusive relationship brings together Poken’s market leadership in real-world, social media with our healthcare expertise to offer clients an unprecedented way to transform events, build stronger connections with their stakeholders and truly differentiate their brand,” said Scott Wallace vice president of strategic development for Standard Register Healthcare, a business unit of Standard Register that serves 62 percent of U.S. hospitals.

“Together, we have the opportunity to transform events and help hospitals create connections with people that are fun and memorable,” said Stéphane Doutriaux, founder & CEO of Poken. “Our platform caters to these needs, while providing a secure and confidential platform for continued interaction.”

pokenHEALTH provides healthcare marketers with a leading-edge suite of interactive, touch-based marketing tools to manage community and professional events. Using Swiss watch-industry microelectronic knowledge, pokenHEALTH runs on a unique, near-field communication (NFC)-enabled ecosystem of Poken devices, smart phone apps and tags that allow meeting participants to interact with each other and the sponsor. Users can collect and share contact information, event materials and other resources. Data is wirelessly and instantly sent from one device to the other based on the proximity of their keychain devices or smart phones.

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

Standard Register To Launch Celebrate Healthcare Program

Standard Register will unveil its innovative Celebrate Health program at the Society of Healthcare Strategy and Marketing Development's (SHSMD) 2011 Annual Conference in Phoenix, Arizona September 14-17. Designed to help hospital marketers save time and elevate their effectiveness in promoting national healthcare observances, Celebrate Health provides ready-to-use kits of marketing materials – posters, brochures, mailers and promotional items – that can be easily branded and produced in a matter of days.

There are more than 275 national healthcare observances that raise awareness for specific health topics and recognize the healthcare professionals that contribute to the quality of care. Observances give hospitals the opportunity to showcase their services and people through related health fairs and events.

"Today's hospital marketers are being asked to play a broader, more strategic role in advancing relationships with patients, physicians, staff, benefactors and the community. Yet, rarely is there sufficient time or money to support their efforts. They're expected to do more with less," said Tom Gutman, director of marketing solutions for Standard Register Healthcare, a business unit of Standard Register.

"Celebrate Health gives them a cost-effective, turn-key solution that simplifies planning for key observances. It shortcuts the design and production processes providing professional marketing materials within days instead of weeks or months," he explained.

Robert F Higgins Elected to Advanced Practice Strategies Board of Drectors

Advanced Practice Strategies a provider of continuing medical education solutions for risk management and patient safety, today announced that Robert F. Higgins, founding partner of Highland Capital Partners and Senior Lecturer at Harvard Business School, has been elected to APS' Board of Directors.

"Bob has a remarkable track record working with early-stage healthcare companies," said Dennis Ferrill, chief executive officer of APS. "His expertise in the healthcare industry will enable him to make significant contributions to the APS board. I look forward to working with him as APS undergoes a period of rapid growth and expansion as we advance outdated continuing medical education practices and dramatically improve patient safety."

"APS represents an outstanding opportunity to expand the knowledge base of our nation's medical professionals," said Higgins. "Medical error is a massive and growing problem. APS is building the next generation of learning tools for physicians, nurses, and other medical professionals. I look forward to working with the Dennis and the team to improve the performance of clinical professionals and enhance patient outcomes."

For more information on patient safety and risk management please visit Patient Safety & Quality Healthcare

RF Surgical Systems Closed 12 Million Dollar Financing

RF Surgical Systems, Inc., announced the closing of a $12 million round of fundraising led by new investor Split Rock Partners, a venture capital firm focused on emerging healthcare, software and Internet services companies. Previous investors Menlo Ventures, Stanford University and two of the company founders also participated in the round.

“This new infusion of financing will help drive our continued growth by enabling us to scale operations and continue to evolve to meet the needs of our customers in providing the utmost in patient safety.”
Since the release of the RF Assure Detection System in November 2010, the company has added more than 70 new hospitals and surgical centers to its extensive customer base. Because of the rapid acceptance of the technology in the market place, RF Surgical will use this funding to drive customer growth and product innovation. The company will focus on several strategic initiatives to accelerate market capture including the expansion of the company’s sales and field support team. This funding will also allow the company to intensify key R&D programs such as the development of a market-leading solution to tag surgical instruments and other patient safety-related products.

“We are thrilled with the growing number of new hospital systems, across the country, deploying RF Surgical’s Detection System to mitigate the highly preventable medical error of RSI,” said Dr. Jeffrey Port, co-founder and chairman of RF Surgical. “This new infusion of financing will help drive our continued growth by enabling us to scale operations and continue to evolve to meet the needs of our customers in providing the utmost in patient safety.”

Minnesota Hospitals Win Patient Safety Awards

Twelve Hospitals Win Patient Safety Awards

Twelve Minnesota hospitals each won a Minnesota Hospital Association Patient Safety Excellence Award this month.

The initiative recognizes organizations' efforts to prevent pressure ulcers, (under the association's SAFE SKIN campaign); falls (under the SAFE from FALLS program); wrong-site surgical or other invasive procedures (under the SAFE SITE program); and foreign objects unintentionally left behind following surgery (under the SAFE ACCOUNT campaign) and during labor and delivery (under the SAFE COUNT initiative).

Awards are bestowed quarterly in the program that is more than three years old. Most Minnesota hospitals have already won some, if not all, of the five types of awards available. Hospitals must re-qualify for awards each round.

The association's safety campaigns are based on national and state best practices. They also incorporate lessons learned from hospitals that experienced adverse health events.

Awardees must implement at least 90 percent of each campaign's required measures. One such measure, for instance, requires hospitals to reposition immobile patients every two hours if such patients are at risk for developing pressure ulcers.

To learn more, visit MHA's Web site at www.mnhospitals.org.

To learn more about hospital patient safety programs please visit www.psqh.com.

WellPoint and IBM use Watson Technology for Healthcare Analytics Applications

WellPoint, Inc. and IBM announced that they are working together on the first commercial applications of the IBM Watson technology. WellPoint will develop and launch Watson-based solutions to help improve patient care through the delivery of up-to-date, evidence-based health care for millions of Americans. IBM will develop the base Watson healthcare technology on which WellPoint's solution will run.


Watson is a computing system built by a team of IBM scientists who set out to accomplish a grand challenge - build a computing system that rivals a human's ability to answer questions posed in natural language with speed, accuracy and confidence. Earlier this year, Watson competed and won against two of the most celebrated players ever to appear on Jeopardy! Watson's ability to analyze the meaning and context of human language, and quickly process vast amounts of information to suggest options targeted to a patient's circumstances, can assist decision makers, such as physicians and nurses, in identifying the most likely diagnosis and treatment options for their patients.

In recent years, few areas have advanced as rapidly as health care. For physicians, incorporating hundreds of thousands of articles into practice and applying them to patient care is a significant challenge. Watson can sift through an equivalent of about 1 million books or roughly 200 million pages of data, and analyze this information and provide precise responses in less than three seconds. Using this extraordinary capability WellPoint is expected to enable Watson to allow physicians to easily coordinate medical data programmed into Watson with specified patient factors, to help identify the most likely diagnosis and treatment options in complex cases. Watson is expected to serve as a powerful tool in the physician's decision making process.


"There are breathtaking advances in medical science and clinical knowledge, however; this clinical information is not always used in the care of patients. Imagine having the ability to take in all the information around a patient's medical care -- symptoms, findings, patient interviews and diagnostic studies. Then, imagine using Watson analytic capabilities to consider all of the prior cases, the state-of-the-art clinical knowledge in the medical literature and clinical best practices to help a physician advance a diagnosis and guide a course of treatment," said Sam Nussbaum, M.D., WellPoint's Chief Medical Officer. "We believe this will be an invaluable resource for our partnering physicians and will dramatically enhance the quality and effectiveness of medical care they deliver to our members."

Watson may help physicians identify treatment options that balance the interactions of various drugs and narrow among a large group of treatment choices, enabling physicians to quickly select the more effective treatment plans for their patients. It is also expected to streamline communication between a patient's physician and their health plan, helping to improve efficiency in clinical review of complex cases. It could even be used to direct patients to the physician in their area with the best success in treating a particular illness.
"With medical information doubling every five years and health care costs increasing, Watson has tremendous potential for applications that improve the efficiency of care and reduce wait times for diagnosis and treatment by enabling clinicians with access to the best clinical data the moment they need it," said Manoj Saxena, general manager, Watson Solutions, IBM Software Group. "WellPoint's commitment to innovation and their work to improve how care is delivered and benefits administered make them an ideal partner for IBM's software and services to pioneer new efficiencies in health care."

Depending on the progress of the development efforts, WellPoint anticipates employing Watson technology in early 2012, working with select physician groups in clinical pilots.
"The implications for health care are extraordinary," said Lori Beer, WellPoint's executive vice president of Enterprise Business Services. "As one of the nation's largest health insurers, we have an important role to play in helping to improve health care quality. We believe new solutions built on the IBM Watson technology will be valuable for our provider partners, and more importantly, give us new tools to help ensure our members are receiving the best possible care."

Healthcare Spending Higher for Hospital Employees

Healthcare spending is 10 percent higher for hospital employees than it is for the general employee population, according to a study by the healthcare business of Thomson Reuters. The gap is wider when employees' dependents are factored in. The cost of healthcare for hospital workers and family members covered by their health insurance is 13 percent higher than average.

In addition to using more healthcare services, hospital employees and their dependents also were found to be less healthy. They had an 8.6 percent greater illness burden than the U.S. workforce at large and were more likely to be diagnosed with chronic medical conditions including asthma, diabetes, congestive heart failure, HIV, hypertension and mental illness.
The research also found that hospital workers and their families had fewer physician office visits, yet were 22 percent more likely to visit the emergency room.

"Ideally, the healthcare workforce would be a model for healthy behaviors and the appropriate use of medical resources," said Raymond Fabius, MD, chief medical officer for the Healthcare business of Thomson Reuters. "Unfortunately, our data suggests that the opposite is true today. Hospitals that tackle this issue can strengthen their business performance and community service."

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

Patient Safety Checklists Help Michigan Hospitals ROI

Published on American Medical News Website

Michigan hospitals that implemented checklists to prevent central line-associated bloodstream infections in their intensive care units saw an average tenfold return on their investment in patient safety, said a study published in the September/October issue of the American Journal of Medical Quality(www.ncbi.nlm.nih.gov/pubmed/21856956).

Each catheter-related bloodstream infection costs a Michigan hospital $36,500 to treat, on average, but implementing the checklist program costs only about $3,375 per infection avoided. More than 100 Michigan ICUs were able to cut bloodstream infections by an average of two-thirds, with many hospitals eliminating the infections entirely. On average, each hospital saved about $1.1 million a year by implementing the patient safety program, the study said. The patient safety "bundle" now being spread to hospitals nationwide costs each hospital an average of $161,000 to put into place, mostly for staff time.

For more information on reducing Hospital Acquired Infections please visit Patient Safety & Quality Healthcare 

Apollo Data Technologies Health Changes Name to Metodcare, Inc.

Apollo Data Technologies Health, Inc. announces today that the company has changed its name to MethodCare, Inc. MethodCare provides hospital predictive analytics software for the revenue cycle using proven data mining technology to identify greater revenue, savings, and staff performance. MethodCare's real-time advanced analytics arm hospital administrators with the critical intelligence to make strategic, data-driven business decisions and proactive improvements to address the growing demands of financial and regulatory pressures. 

"The name MethodCare better personifies our mission--to provide hospitals with a new method of leveraging their data to increase financial health and quality of patient care," said Jeff Kaplan, chief executive officer, MethodCare. "We look forward to our rapid expansion and continuing to provide our valued customers with the latest data mining and analytics to help them operate more efficiently and profitably." 

MethodCare's suite of software includes, AR Management, CDM Management, Charge Recovery, Contract Management, Credit Balance Automation, Denial Management, Patient Safety, and Payment Validation. Hospitals and health systems across the U.S., such as Northwestern Memorial Hospital, have realized significant savings from MethodCare's software. 

10 Things to Know about Retained Surgical Sponges

By Jim Sweeney
Senior VP of Sales & Marketing
ClearCount Medical Solutions

published on Becker's ASC Review


Retained surgical sponges are one of the oldest surgical complications documented in clinical literature and remain today an enduring risk to operating room facilities, personnel and the public they serve. Today there is hope that with the addition of new technology, the incidence of retained sponges can be dramatically reduced or even eliminated. Here are 10 things you should know about this persistent problem.

1. Retained surgical items (RSIs) are the most frequent and most costly surgical "never event," according to data from CMS.[1] In Oct. 2008, Medicare implemented policy to no longer reimburse hospitals for consequential surgical procedures and charges associated with this hospital-acquired error. Most private insurers subsequently followed this reimbursement policy.

2. In 2010, RSIs became the #1 sentinel event reported in the United States among all adverse events that can lead to patient injury.[2] Sentinel events are defined and tracked by The Joint Commission, which accredits hospitals as a condition of licensure and the receipt of Medicaid reimbursement.


3. Surgical sponges represent over two-thirds of all RSIs due to their prevalence and function in surgery, and are typically regarded as the most dangerous retained item due to complications of serious infection and adherence to critical tissue and organ structures. It is also estimated that each retained surgical sponge incident costs providers more than $250,000 per incident.[3]

4. According to a New England Journal of Medicine article, approximately one in every 1,500 chest or abdominal surgeries results in a sponge or other item being accidentally left inside the patient.[4] Estimates of annual incidence translate to 40-60 cases of retained incidents per week throughout the United States.


5. The underlying cause of RSIs is predominantly due to falsely reconciled sponge counts. In 88 percent of the cases where a retained item is discovered, retrospective review of the surgical record indicates the surgical staff believed they had accounted for all items used in the surgical case.[5]

to read the full article please visit Becker's ASC Review

To read about Patient Safety programs and case studies please visit www.psqh.com

Mass. Governor Patrick Touts MetroWest Medical Center Use of EarlySense

Technology aimed at alerting doctors when the condition of their patients deteriorates is at the center of MetroWest Medical Center’s new patient safety and quality care initiative, which Gov. Deval Patrick will help tout this afternoon in Framingham.

The hospital initiative, using technology developed by EarlySense Ltd., will be the focus of a product demonstration, followed by a symposium on advances in patient safety at acute care hospitals and long-term care facilities. Organizers say there have been 50 cases documented in the past year in which alerts provided by the EarlySense system helped nurses and doctors save the lives of their patients. EarlySense recently announced its decision to locate its headquarters in Massachusetts.

Read more: http://www.metrowestdailynews.com/archive/x1413012551/Patrick-in-Framingham-to-tout-life-saving-patient-alert-technology#ixzz1XCmcSvF3

Excela Health Selects RF Surgical to Reduce Retained Surgical Errors

RF Assure Detection System Helps Hospitals Improve Patient Safety

By Bob Stiles
Pittsburgh Tribune Review

By waving an instrument that resembles a big soap bubble wand, Excela Health medical staff can tell if a sponge has been mistakenly left inside a patient during surgery. They began using the RF Assure Detection System in its three hospitals in Westmoreland County and the Norwin Medical Commons.

The surgical team either passes the wand over the patient or places a mat under the patient to locate a forgotten sponge. The instruments activate microchips -- the size of a pea -- that have been inserted into the sponges. A beep or sustained tone sounds if the devices detect a sponge. "We're the first health system in the area to use it," said Jesse Hixson, Excela perioperative nurse manager. The process takes about six seconds, and the sponges add a $15 cost to a surgery, Hixson said.


A left-behind sponge, which looks like gauze, can cause discomfort, infection or even death.
"We're trying to do things for patient safety," said Dr. Marc Costa, chairman of Excela's department of surgery. "We want to make sure leaving behind a sponge doesn't happen."
Sponges are used in surgery when a cavity is opened, such as a chest or abdomen. Typically, surgeons will use about 15 sponges; the number jumps to 100 during an open-heart operation, Hixson said.

A sponge is left behind once in every 1,500 cases, according to RF Surgical Systems Inc., the Bellevue, Wash., company that makes the detection system. Some studies put the number at one in 5,000 cases.Before an operation, a circulatory nurse and a scrub technician count sponges and medical instruments, and the count is repeated when the surgery is finished, Costa said.

According to RF Surgical, its system is used in hospitals in Cincinnati, Los Angeles and Philadelphia, among others. There is no cost for the devices but hospitals must purchase the special sponges from the company. The detection instruments are used at different times during the operation, and records of the checks are kept on file."(The detection system) is used to supplement our count, not replace the counting process," Hixson said. "There's no excuse for (sponge errors) to happen."

"And we don't want it to happen," said Marci Cook, Excela vice president of perioperative service.

Read more: Excela Health takes high-tech step forward in patient safety - Pittsburgh Tribune-Review http://www.pittsburghlive.com/x/pittsburghtrib/news/westmoreland/s_755222.html#ixzz1XBMawT8k

New Report Indicates Hospitals With More Procedures Have Better Patient Safety

Hospitals with larger volumes of procedures have better patient safety. A new study in the journal Health Services Research found that hospital volume is inversely related to preventable adverse events."That means that the more procedures these hospitals were performing, the lower rates they would have of adverse events," said lead author Tina Hernandez-Boussard in a Health Behavior News Service article.

Researchers from Stanford University School of Medicine examined the rates of nine different adverse events in hospitalized patients after three surgical procedures. In almost every case, hospitals with higher surgical volume--more than 28 procedures per year for abdominal aortic aneurysm, more than 245 for heart bypass surgery, and more than 89 for gastric bypass surgery--had fewer adverse events than hospitals with low volumes of surgery.
The findings suggest that hospitals below a certain surgical volume shouldn't be doing the procedure, Dr. David Bates, executive director of the Center for Patient Safety Research and Practice and chief of general internal medicine at Brigham and Women's Hospital, told Health Behavior News.

Read more: More hospital procedures mean better patient safety - FierceHealthcare http://www.fiercehealthcare.com/story/more-procedures-mean-better-safety/2011-09-01#ixzz1Wnj2Bbc6

ConversePoint Developing New Communications Platform for Hospitals

ConversePoint, has announced its plans to develop and commercialize a communications platform for the healthcare industry that will significantly save clinicians time, hospitals millions in productivity costs and improve accountability measurements for critical events per the Joint Commission's National Patient Safety Goals along with the license of key Qualcomm technology.

The ConversePoint platform will integrate asynchronous communication technology developed by Qualcomm Incorporated, the world leader in 3G and next-generation mobile technologies, with proprietary ConversePoint technologies to create a new solution that will work seamlessly with multiple mobile communication standards, mobile carriers, or mobile devices.

"ConversePoint will greatly improve how hospitals function," said Shawn Evans, Chief of Staff and Attending Emergency Physician for Scripps Memorial La Jolla Hospital based in San Diego, CA. "Until now, there has been no solution that truly understands the needs of clinicians and effectively solves them. It allows us much greater efficiencies, which translates into better patient care."

Don Jones, VP of Wireless Health Global Strategy and Market Development for Qualcomm Labs and a member of ConversePoint's advisory team, states, "Qualcomm selected ConversePoint because of the team's extensive expertise in building complex, high-value, telecom-grade mobile and software technologies that fuel game-changing businesses. ConversePoint will change the notoriously hectic nature of communications in today's healthcare environment."

The founders of ConversePoint, Marisa Bryce, CEO, and Randall Menna, CTO, have a long collaboration with Qualcomm, having developed core transactional and communication solutions for Qualcomm over the past 10 years that have been used, purchased and adopted by millions of users over multiple carriers and industries, including healthcare, transportation, consumer products and financial services.

ACR Responds to The Joint Commission Sentinel Event Alert

The Joint Commission (TJC) issued a Sentinel Event Alert titled “Radiation Risks of Diagnostic Imaging.” Such alerts are issued periodically by TJC to describe underlying causes of these sentinel events and to suggest steps to prevent occurrences in the future.
This alert indicates general agreement that “care should be taken to weigh the medical necessity of a given level of radiation exposure against the risks, and that steps should be taken to eliminate avoidable exposure to radiation.” This message concurs with the message that the ACR has been sending to its members, patients and the general public for several years.

However, the alert indicates that the CMS January 2012 requirement for accreditation of CT, MRI, and PET was promulgated “as a result of the potential dangers associated with ionizing radiation.” The ACR, a sponsor of the legislation requiring this accreditation, considers this statement inaccurate, first because the legislation is aimed primarily at ensuring a high level of quality for these modalities, including inspection and evaluation of image quality and, second because MRI, a component of the accreditation requirement, produces no ionizing radiation.

A second inaccuracy is the statement that the ACR launched its National Radiology Data Registry (NRDR) in May. In fact, NRDR has been in existence since 2008. In May 2011, the ACR launched its Dose Index Registry (DIR), a national registry that permits facilities to monitor dose from each CT scanner and compare those doses to national benchmarks. The TJC Alert unfortunately makes no specific mention of the existence of the DIR.
We are pleased TJC acknowledges that “experts disagree on the extent of the risks of cancer from diagnostic imaging” but we are concerned with the recommendation for “awareness of the potential dangers from diagnostic radiation among organizational leadership, hospital staff and patients” considering that there is significant scientific disagreement on the magnitude of those dangers.

In general, the ACR applauds TJC’s alert for its comprehensiveness and strong recommendations regarding selection of the right procedure and the right dose, creating effective processes, ensuring safe technology and promoting a safety culture. The College is particularly pleased to have already addressed, through its DIR, recommendation 19 which endorses the creation of a national registry to track radiation doses.

To read more about patient safetyhe Joint Commission (TJC) issued a Sentinel Event Alert titled “Radiation Risks of Diagnostic Imaging.” Such alerts are issued periodically by TJC to describe underlying causes of these sentinel events and to suggest steps to prevent occurrences in the future.
This alert indicates general agreement that “care should be taken to weigh the medical necessity of a given level of radiation exposure against the risks, and that steps should be taken to eliminate avoidable exposure to radiation.” This message concurs with the message that the ACR has been sending to its members, patients and the general public for several years.

However, the alert indicates that the CMS January 2012 requirement for accreditation of CT, MRI, and PET was promulgated “as a result of the potential dangers associated with ionizing radiation.” The ACR, a sponsor of the legislation requiring this accreditation, considers this statement inaccurate, first because the legislation is aimed primarily at ensuring a high level of quality for these modalities, including inspection and evaluation of image quality and, second because MRI, a component of the accreditation requirement, produces no ionizing radiation.

A second inaccuracy is the statement that the ACR launched its National Radiology Data Registry (NRDR) in May. In fact, NRDR has been in existence since 2008. In May 2011, the ACR launched its Dose Index Registry (DIR), a national registry that permits facilities to monitor dose from each CT scanner and compare those doses to national benchmarks. The TJC Alert unfortunately makes no specific mention of the existence of the DIR.
We are pleased TJC acknowledges that “experts disagree on the extent of the risks of cancer from diagnostic imaging” but we are concerned with the recommendation for “awareness of the potential dangers from diagnostic radiation among organizational leadership, hospital staff and patients” considering that there is significant scientific disagreement on the magnitude of those dangers.

In general, the ACR applauds TJC’s alert for its comprehensiveness and strong recommendations regarding selection of the right procedure and the right dose, creating effective processes, ensuring safe technology and promoting a safety culture. The College is particularly pleased to have already addressed, through its DIR, recommendation 19 which endorses the creation of a national registry to track radiation doses.

Please visit Patient Safety & Quality Healthcare

AED Failures Connected to Deaths From Cardiac Arrest

More than one thousand cardiac arrest deaths over 15 years are connectedautomated external defibrillators (AEDs) failure; battery failure accounted for almost one-quarter of the failures. The study was published in Annals of Emergency Medicine (“Analysis of Automated External Defibrillator Device Failures Reported to the Food and Drug Administration” http://bit.ly/ox6YYr).


“Survival from cardiac arrest depends on the reliable operation of AEDs,” said lead study author Lawrence DeLuca, MD, of the University of Arizona Department of Emergency Medicine in Tucson. “AEDs can truly be lifesavers but only if they are in good working order and people are willing to use them.”

Researchers analyzed reports to the Food and Drug Administration (FDA) about all adverse events connected to use of an AED between January 1993 and October 2008. Of the 40,787 AED-related events reported to the FDA, 1,150 adverse events connected to fatalities were reported. Almost half (45 percent) of failures occurred during the attempt to charge and deliver a recommended shock to the person in cardiac arrest. Problems with pads and connectors accounted for 23.7 percent of the failures, and battery power problems accounted for 23.2 percent of the failures.

Sudden cardiac arrest is a leading cause of death in North America and Europe. Odds of survival decline by 7 to 10 percent per minute of delay in defibrillation. Even as AEDs have proliferated in public places such as airports and offices, bystanders are reluctant to use them. An Annals of Emergency Medicine study published earlier this year found that less than half of people in public places reported being willing to use an AED and more than half were unable to recognize one.

for more information on adverse medical events and patient safety please visit Patient Safety & Quality Healthcare

Ardent Health Services Expand Use of Surgical Information Systems to Include Patient Tracking

 Ardent Health Services of Nashville, Tenn. will expand its system-wide use of the Surgical Information Systems Solution to include anesthesia automation, analytics and patient tracking on a single perioperative record.  In preparation for upcoming meaningful-use criteria, Ardent will partner with SIS to be interoperable with McKesson systems in its hospitals in Albuquerque, N.M. and Tulsa, Okla. in order to improve patient safety, ease of use and functionality.

"The SIS Solution will allow us to improve our care to patients," said Steve Landgarten, M.D., chief medical officer and chief quality officer of Ardent Health Services.  "With these modules, caregivers in our hospitals can view important patient information in real-time such as which medications have been administered, when they were administered and what impact those medications have over time.  It's a much improved patient tracking, documentation and analytics process."

SIS Anesthesia is the only specialty anesthesia system featuring a shared database with a perioperative system.  This shared database enables continuity of care as any change to the perioperative record that impacts the anesthesia record is automatically reflected in the anesthesia record, optimizing the automation of the care process.  A single perioperative record is efficient, easy-to-use, cost effective and provides for consistent documentation across the perioperative continuum – supporting a higher quality of patient care.

For more information on patient safety and pharmacy automation please visit Patient Safety & Quality Healthcare

The Joint Commission Issues Sentinel Alert on Radiation Risks

The Joint Commission (TJC) issued a Sentinel Event Alert titled “Radiation Risks of Diagnostic Imaging.” Such alerts are issued periodically by TJC to describe underlying causes of these sentinel events and to suggest steps to prevent occurrences in the future. This alert indicates general agreement that “care should be taken to weigh the medical necessity of a given level of radiation exposure against the risks, and that steps should be taken to eliminate avoidable exposure to radiation.” This message concurs with the message that the ACR has been sending to its members, patients and the general public for several years.

However, the alert indicates that the CMS January 2012 requirement for accreditation of CT, MRI, and PET was promulgated “as a result of the potential dangers associated with ionizing radiation.” The ACR, a sponsor of the legislation requiring this accreditation, considers this statement inaccurate, first because the legislation is aimed primarily at ensuring a high level of quality for these modalities, including inspection and evaluation of image quality and, second because MRI, a component of the accreditation requirement, produces no ionizing radiation.

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Philips Releases Remote Patient Monitor

Royal Philips Electronics announced the global release of IntelliVue MX40, a wearable patient monitor that can be used for the monitoring of ambulatory patients and during patient transport. The MX40 combines the benefits of the IntelliVue X2 and Philips telemetry into a single, compact wearable monitor. MX40 helps clinicians to better manage patient alerts and is designed with infection control in mind.

Many patients can benefit from mobile monitoring in the hospital, including those who can be monitored in a progressive care area or during supervised recovery from an acute event or surgical procedure. Mobile monitors also help clinicians spend more time with patients: one hospital estimates that its nursing staff saves an average of 40 minutes every day by using the MX40 display to check patients’ ECG rhythms, instead of calling a technician at the central station monitor.MX40 can help clinicians to better and more systematically manage patient alerts both at the patient and at the hospital’s central monitoring station.

"The MX40 is helpful in streamlining patient monitoring at the bedside. The mobile monitoring function helps us ensure patient safety during transfers and while infusing medication drips,” Alycia Kielty, RN, Surgical Cardiovascular unit, Sanford USD Medical Center in Sioux Falls, South Dakota said. “For us, these added product benefits have increased communication efficiency, and decreased the need for extra bulky equipment."

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