VA Hospitals Implementing Airline Safety Tips

A study of over 108 Veterans Health Administration Hospitals showed an increased drop in patient deaths in facilities that implemented error prevention strategies created by airlines and NASA. Of the 108 facilities, the 74 that implemented the strategies had an 18 percent drop in deaths, compared to a 7 percent drop in facilities that did not implement them.

The Medical Team Training program was targeted at surgical teams, encouraging communication among members of the team, challenging each other to abide by safety practices, and encouraging the use of checklists in preoperative and postoperative briefings. Miscommunication among team members was identified by the aviation industry as a large factor contributing to errors.

The full study can be found in the October 20 Journal of the American Medical Association.


Source: Bloomberg Businessweek
http://www.businessweek.com/lifestyle/content/healthday/644661.html

Report Encourages Disclosure of Large-Scale Medical Mistakes

The Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) recommends that large-scale adverse events and medical mistakes should be reported by facilities, even though they do not result in patient harm. This recommendation was noted in a study titled, "The Disclosure Dilemma -- Large Scale Adverse Events," which was published in the New England Journal of Medicine.

The AHRQ encouraged facilities to personally contact all patients that may be affected by a large-scale error such as the use of improperly sterilized medical tools and equipment malfunctions, even if the patients suffered no effect. Facilities are concerned that reporting these events will cause psychological distress on patients that would have had no worries had the event gone undisclosed. They are also concerned that reporting events will place a burden of negative press on facilities.

The AHRQ recommends that facilities have a policy in place that sets a structure for reporting errors and reaching out to all affected patients with follow-up care and compensation.

To read the full study, click here: http://www.nejm.org/doi/full/10.1056/NEJMhle1003134


Source: BNA

Survey Shows Increase in Medical Errors Affected by Recession

A survey by the Institute for Safe Medication Practices shows that cutbacks due to the recession may be a contributing factor to medical errors.

The survey results show that many healthcare professionals are feeling short-staffed, and as a result, they are unable to participate in educational activities and feel too rushed to perform safety-focused activities such as double-checks on medication orders.

The increase in errors is also attributed to cutbacks in medication safety officer positions, where remaining staff cannot cover multiple units or facilities.

The full findings of the survey can be found here:
http://www.ismp.org/Newsletters/acutecare/articles/20100114.asp.


Source: Institute for Safe Medication Practices

OIG Report Evaluates State Adverse Event Reporting

A January 6 report by the Department of Health and Human Services Office of the Inspector General (OIG) reviewed 17 state adverse event reporting systems. In the report, the OIG found that seven states provided no public disclosures, three provided limited disclosures, and seven provided extensive public disclosures.

"Adverse events" are described as a situation where a patient is harmed in the course of receiving medical care, such as surgical site infections. The systems with "extensive reporting" disclosed the event and also provided the medical community with information and strategies on how to prevent future adverse events.

The report recommends that other systems follow the lead of the seven states with extensive reporting.

The following is a breakdown of the systems in the report:

• No Disclosures: Utah, Florida, Nevada, New York, South Carolina, South Dakota, Vermont
• Limited Disclosures: Colorado, Maine, Rhode Island
• Extensive Disclosures: Maryland, Massachusetts Board of Registration in Medicine, Massachusetts Department of Public Health, Minnesota, New Jersey, Oregon, Pennsylvania

The full report can be found here:
http://www.oig.hhs.gov/oei/reports/oei-06-09-00360.pdf.

Question of the Week: Should Facilities Use Surveillance to Ensure Compliance?

An article in today's American Medical News highlights how Maryland is using $100,000 in federal stimulus funds to train volunteers who will secretly monitor hand washing in 45 of the state's 47 acute care hospitals.

Maryland isn't the only state turning to surveillance methods. Rhode Island Hospital requires surgeons to participate in at least two video-recorded surgeries a year after five wrong-site surgeries were reported in the past two years. In 2007, the Massachusetts Legislature considered mandating video recorded surgeries.

There are those who support the use of surveillance and those who don't. Dr. Mark Chassin, president of The Joint Commission says that if surveillance helps hospitals determine what is affecting performance, then it can be an aid. However, Chassin cautions against the improper use of surveillance data as ammunition against individuals in their personnel files.

Dr. Mark E. Rupp, professor of infectious diseases at the University of Nebraska Medical Center and president of the Society for Healthcare Epidemiology of America believes that some providers will not like the "Big Brother" feeling that this system may impose.

What do you think? Is surveillance an effective way to boost compliance and help facilities identify practices that need improvement? Or do you think that this oversight method will cause more provider stress and anxiety?

Let us know what you think by taking this week's poll and providing your comments below.


Source: amednews.com
http://www.ama-assn.org/amednews/2009/11/30/prl21130.htm

One in Ten Surgeons Believe They Made a "Major Error" Recently

A study published in the Annals of Surgery shows that one in ten surgeons believe that they made a major medical error in the past three months.

The survey showed that surgeons experiencing burnout as a result of exhaustion, depersonalization, and personal career dissatisfaction were more likely to report an error. 40 percent of respondents said that they were experiencing "burnout," and 30 percent reported experiencing symptoms of depression. The study did conclude whether the burnout was a result of the errors, or if the errors were a result of the burnout.

The results reflect the feedback of 7,905 surgeons who completed a survey by the American College of Surgeons.

If it turns out that burnout is a link to medical error, then it looks like hospitals will have to figure out ways to boost physician morale as a way to maintain patient safety.


Source: Wall Street Journal Health Blog
http://blogs.wsj.com/health/2009/11/23/nine-percent-of-surgeons-have-made-major-errors-recently/

$54.2 Billion Spent on Medicare Fee-for-Service Errors in 2009

Peter Orszag, Director of the Office of Management and Budget, reported that Medicare and Medicaid spent $54.2 billion in improper payments in 2009. Orszag also reported that the rate of Medicare fee-for-service errors doubled in the past year.

Orszag attributes the doubled rate to a new system of counting errors, which counts incidents such as an illegible signature or submitting a claim without sufficient documentation as errors.

To address this problem, President Obama will issue an executive order requiring greater agency oversight, the creation of a website that allows the public to track and report improper payments, and penalties for those who do not return payments received in error.

This is another example of how billions of dollars are being spent with no contribution to improving healthcare. As healthcare reform continues to develop, let's hope that the government figures cost-effective ways to improve the administrative side of healthcare delivery and increase accountability for errors. $52.4 billion could go a long way toward patient-centered improvements.

Click here for the full article:
http://www.modernhealthcare.com/article/20091117/FREE/311179968.



Source: Modern Healthcare

Conn. Attorney General to Seek Legislation on Medical Mistake Disclosure

Connecticut Attorney General Richard Blumenthal has announced plans to seek legislation requiring hospitals to improve the disclosure of medical mistakes.

The legislation would also direct resources to the state Medical Examining Board and Department of Public Health to for the investigation of medical mistakes and complaints of errors.

Blumenthal believes that disclosure of medical mistakes will create transparency and increase hospital accountability for errors committed.

This is definitely a good strategy toward improving the delivery of health care services and preventing further medical mishaps. Better investigation of mistakes and complaints at all hospitals will be a huge undertaking for the state government, but may be an effective step toward preventing unnecessary patient harm. It will be interesting to see where the resources for this improved oversight will come from, whether or not this initiative is successful at improving care, and whether or not other states will seek similar legislation.

Source: BNA

Investment in Electronic Health Records Shows Improvements in Care

President Obama has pledged $19 billion to implement electronic health records (EHRs), aiming to reduce errors in care, while lowering costs.

The Los Angeles Times reports improvements at several hospitals where physicians are using EHRs to keep better track of their patients' medical histories. One hospital reported that an electronic prescribing system has virtually eliminated prescription errors.

Despite the advantages offered by EHRs, there are many facilities still weary of the transition. Implementing an EHR system will come at a cost of about $30,000 per physician. Furthermore, it is not guaranteed that one facility's system will be compatible with another facility's. There is also concern from patient groups about the security of their data and who should be granted access to it.

President Obama's health IT initiative in the stimulus package will offer funding to those facilities implementing EHRs. Meanwhile, the Department of Health and Human Services is set to work on standards regarding the use of EHRs.

Source: The Los Angeles Times
http://www.latimes.com/news/nationworld/nation/la-na-health-it15-2009mar15,0,3918496.story?page=2

AHRQ Announces Ten Patient Safety Organizations

The Agency for Healthcare Research and Quality (AHRQ) has announced the first 10 Patient Safety Organizations (PSOs) recognized by the Department of Health and Human Services (HHS). AHRQ is the main agency within HHS responsible for improving healthcare safety, quality, and cost-effectiveness.

The 10 newly listed PSOs will collect quality data voluntarily reported by providers and healthcare organizations. Using this confidential data, they will issue recommendations on how to improve patient safety and reduce medical errors.

Each PSO was approved by HHS and given certification that went into effect on November 5. AHRQ will announce new PSOs weekly as HHS certifies more organizations.

The 10 PSOs announced by AHRQ are:

• California Hospital Patient Safety Organization (CHPSO) in Sacramento, CA;
• Missouri Center for Patient Safety in Jefferson City, MO;
• ECRI Institute PSO in Plymouth Meeting, PA;
• Florida Patient Safety Corp. in Tallahassee, FL;
• Health Watch Inc. in Easton, MD;
• Human Performance Technology Group in Collierville, TN;
• Institute for Safe Medication Practices in Horsham, PA;
• Peminic Inc. in Fort Washington, PA;
• Sprixx in Santa Barbara, CA; and
• University Healthsystem Consortium in Oak Brook, IL.

Source: BNA

Survey Finds Patient Care May Be Harmed by Physician Handoff Errors

A survey showed that interruptions and distractions that occur during patient handoffs between residents may contribute to errors in patient care.

In 2006, 161 residents at Massachusetts General Hospital admitted that handoffs often did not take place in a quiet setting and were often interrupted, leading to misinformation or the incomplete communication of information.

An article in The Joint Commission Journal on Quality and Patient Safety urges physicians to compile complete information before meeting a colleague for a handoff in a quiet location with minimal distractions.

Source: The Boston Globe
http://www.boston.com/news/health/blog/2008/09/hazards_of_hand.html