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May 2008

Want to submit content to PatientSafetyFocus.com?

We've had several people ask about submitting content to PatientSafetyFocus.com, and we thank you for your inquiries. It's our pleasure to share content contributions with our readers. If you're interested in contributing content, please contact us via email.

For new readers, and those interested in this opportunity, this blog serves as a resource to increase and "focus" awareness on patient safety information, programs, developments and solutions.

We're very interested in content that covers new patient safety studies, developments, practices and solutions. Patient Safety is a big area and can cover many areas, such as: preventable medical errors, hospital-acquired infections, infection control, hand hygiene compliance and patient safety incidents.

The content should be targeted to our audiences which span hospital administrators and caregivers who are looking for new ways to improve their patient safety practices, press professionals seeking current information in the patient safety arena, patient safety advocates who are also working for change, and consumers interested in patient safety statistics and developments.

Each submission will be reviewed to ensure its in-line for our readers and all submissions will feature your name, your organization's name and URL. Please contact us at this email. Thank you!

Apologies pave the way to more transparency

"The willingness of doctors at several major medical centers to apologize to patients for harmful errors is a promising step toward improving the quality of a medical system that kills tens of thousands of patients a year inadvertently."

An interesting NYT editorial discusses the recent move by a handful of prominent academic centers in adopting a new policy that promptly discloses errors--offering earnest apologies and fair compensation instead of tight lips fearing litigation and increased liability.

"For years, experts have lamented that medical malpractice litigation is an inefficient way to deter lethal or damaging medical errors. Most victims of malpractice never sue, and there is some evidence that many patients who do sue were not harmed by a physician’s error but instead suffered an adverse medical outcome that could not have been prevented. The details of what went wrong are often kept secret as part of a settlement agreement.

Now, a handful of prominent academic medical centers have adopted a new policy of promptly disclosing errors, offering earnest apologies and providing fair compensation. It appears to satisfy many patients, reduce legal costs and the litigation burden and, in some instances, helps reduce malpractice premiums."

So far the response to more transparency and honesty from those that have suffered has been encouraging. At the University of Illinois, out of 37 cases where the hospital acknowledged and apologized over preventable medical errors, only one patient filed suit. At the University of Michigan Health System, existing claims and lawsuits fell dramatically from 263 in August 2001 to 83 in August 2007--with legal costs falling by two-thirds.

As the writer astutely hits on, "Admitting errors is only the first step toward reforming the health care system so that far fewer mistakes are made. But reforms can be more effective if doctors are candid about how they went astray."

Patients have always deserved honesty; and indeed transparency is a step in the right direction. But it's not the solution. What transparency does is to pave the way to openly acknowledging that there are real problems that have led to a full-on epidemic of preventable medical errors.

Now it's up to hospitals, patient safety organizations, federal agencies and innovative companies to work together in developing and implementing the practices, protocols and technologies that will move the standard of care to new heights while moving the numbers of mistakes--and needed apologies--way down.

Full article located here.

New York proposes landmark legislation for patient safety

New York Governor David Paterson (pictured left) has announced legislation that works to dramatically improve patient safety and better facilitate the prevention and response of infectious disease transmissions (as well as prevent future infection control violations).

All told, the Governor's Program Bill increases the authority of the Department of Health (DOH) in epidemiological investigations while providing consumers with access to more information about physicians--particularly those charged with misconduct.

According to Governor Paterson, “It is critical that our system of disciplining physicians be as strong as possible to ensure that cases of misconduct are uncovered, reported and acted upon – even as we remain mindful that persons charged with misconduct have a due process right to challenge such charges. The improved access to information will also lead to better health care for the entire State of New York.”

The legislation is focused on illuminating misconduct by physicians, malpractice claims and legal actions, so as to better inform the public of potential threats. And among its myriad points, the bill also includes that course work or training in infection control practices, already required for physicians, physician assistants and specialist assistants, must also be completed by every medical student, medical resident and physician assistant student--along with documentation of such training.

In his comment, New York State Health Commissioner Richard F. Daines, M.D. said: “This bill strengthens patient safety by updating current law to the way medicine is practiced today. Thanks to Governor Paterson's support, the State Health Department will have clearer authority and access to more information to assist in medical conduct investigations. Patients also benefit from access to more information about the physicians who provide their care.”

The bill appears to advance much of medical reporting to where it should already be; so it is a positive step forward. But what we encourage and implore--in addition to these measures--are systems that prevent human error in the first place (not just reporting them after the fact so as to prevent additional ones). After all, systems, like HVA, that continuously monitor on a 24-7 basis for many of the issues leading to hospital-acquired infections, and immediately alert hospital staff to potential issues, have already shown to improve compliance rates from 38% to 98+% and kept them there.

Full article on Governor Paterson's legislation is located here.

RID's 3rd Edition of "Unnecessary Deaths"

Last month we covered the tremendous work that RID (the committee to Reduce Infection Deaths) is performing in the fight against hospital-acquired infections (HAIs). In her April 15th Commentary in The Washington Times, Betsy McCaughey--the organization's founder and chairman--outlined the growing threats and costs of this preventable epidemic and her concern over the government's role, particularly the CDC's lax regulation within this arena.

With superbugs (e.g. MRSA, VRE, C.diff) on the rise, RID is calling for tighter regulations, corrected statistics on the true scope and size of the problem, better hygiene and improved protocols in teaching physicians how to do no harm. RID's work is important, well-informed and saves lives and so we call your attention to the third edition of RID's "Unnecessary Deaths: The Human and Financial Costs of Hospital Infections," a compendium of articles, facts and figures regarding this epidemic and steps for eradicating it.

The articles range from how MRSA screening is essential and how cleansing prevents C. diff to how infection prevention makes hospitals more profitable and how hospital infection is the "next asbestos". Also included is a look at how medical students should be taught hygiene, not just medical best practices, and a bill on how hospitals should submit infection report cards. RID's website has plenty of free information as well.

Again, you can access the third edition of "Unnecessary Deaths" by clicking here.

Patient Safety "Checklist" Doctor Lands Top Spot in Time's 100 Most Influential People

Peter Pronovost, the Johns Hopkins Doctor who has amassed acclaim for his successful "checklist approach" in decreasing preventable medical errors has landed a much-coveted spot among Time's 100 Most Influential People.

We covered Pronovost's work back in December (post located here) and it's both exciting and rewarding to see a patient safety advocate--working for change from within the walls of the healthcare institution--be recognized in such company as the Dalai Lama, Oprah Winfrey and Steve Jobs.

According to the article: "In science you learn that the simplest answer is often the best. That's a principle sometimes lost in a world of high-tech medicine—but not on Dr. Peter Pronovost. A critical-care researcher at Johns Hopkins University, Pronovost may have saved more lives than any laboratory scientist in the past decade by relying on a wonderfully simple tool: a checklist.

In the U.S., hospital-acquired infections affect 1 in 10 patients, killing 90,000 of them and costing as much as $11 billion each year. Pronovost, 43, began investigating this alarming trend at Johns Hopkins' hospital in 2001 and concluded that arming physicians with a chart reminding them of each step in routine procedures drastically reduces the medical errors that lead to such infections. After he published his results in several prominent journals, the medical community started listening. Michigan hospitals began implementing Pronovost's checklists in ICUs in 2003. Within three months, hospital-acquired infections at typical ICUs in the state dropped from 2.7 per 1,000 patients to zero. More than 1,500 lives were saved in the first 18 months."

With our own technology and 24-7 monitoring service, Hospital Video Auditing (HVA), we, too, employ a checklist approach across a wide range of clinical and non-clinical processes including hand hygiene protocols and central line insertion policies. Indeed, the simple acts of double-checking as Pronovost advocates...and implementing support systems that guard against human error with HVA...lead to incredible results. And those results directly equate to lives saved, increased trust and billions of dollars that can be invested on finding cures instead of fighting lawsuits that could have been altogether prevented.

More on HVA here
Time article located here
Post on the New Yorker article located here
Image above courtesy of Time

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