Patient Safety Focus

More Hospitals Agree to Take Key Steps When "Never Events" Occur

More hospitals than before have agreed to take key steps when a “never event” occurs during the course of care in their facilities.  Never events – serious reportable adverse events that should never happen during course of care – include surgery on the wrong body part, certain surgical site infections, and leaving a foreign object inside a patient’s body during surgery. 

 

These findings come from the 2008 Leapfrog Hospital Survey, which just announced that 63% of hospitals participating the Survey have agreed to:

• Apologize to the patient or family affected by the never event;

• Report the event to at least one of the following agencies: the Joint Commission, a state reporting program for medical errors, or a Patient Safety Organization;

• Perform a root cause analysis consistent with the instructions from the chosen reporting agency; and,

• Waive all costs directly related to the serious reportable adverse event.

This is an increase over last year, when 52% agreed to the policy.

 

For a recent interview we did with Leapfrog Group CEO Leah Binder, go here.

Medicare Encouraging Patient Safety through Financial Disincentives -- by Lisa Hayden Espenschade

On October 1, 2008, Medicare placed new financial responsibilities on hospitals for certain “reasonably preventable” hospital acquired conditions.  In addition to Medicare’s new policy, covered here in more detail previously, private insurers are following suit.

 

Catheter insertion is associated with two conditions on the list: vascular and urinary tract infections. Medicare is also targeting surgical site infections after coronary artery bypass and some other orthopedic and bariatric procedures.

 

These three types of infections accounted for 42,096 cases in fiscal year 2007, according to the Centers for Medicare and Medicaid Services. Vascular catheter-associated infections are the worst offender on Medicare’s list--affecting 29,536 patients in 2007. Bladder catheterization is linked to another 12,185 infections.

 

Economic incentives, such as no longer elevating payments to cover the costs of preventable complications are likely to motivate improvement, but to improve, hospitals need effective systems designed to prevent the medical errors in the first place.

 

Many prevention principles – particularly hand hygiene – apply to both these types of catheter-related bloodstream infection (CR-BSI).  This is where Hospital Video Auditing (HVA) can help:  it gives 24/7/365 monitoring for adherence to safety practices and protocols and encourages health care workers to both improve and sustain their performance. 

 

Previous posts on CR-BSIs include:

Hygiene. A study at Huguley Memorial Medical Center in Fort Worth, TX, looked at simple measures for limiting infection: practicing hand hygiene, avoiding femoral lines because of proximity to the groin, using gloves and other physical barriers, and monitoring the appearance of lines.

Checklists. Atul Gawande’s December 10, 2007, article in The New Yorker detailed infection prevention research from Peter Pronovost, a critical-care specialist at Johns Hopkins Hospital. Pronovost found providers often skipped crucial steps during line insertion. Our post excerpting Gawande’s article includes information on hospital culture and successes using checklists.

Studies, Statistics & Safety. Robin Walters, RN, BSN, notes studies about costs of CR-BSIs plus strategies and guidelines for prevention. Among them: the Central Line Bundle from the Institute for Healthcare Improvement and participation in infection prevention collaboratives like the 5 Million Lives Campaign and the National Healthcare Safety Network.

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.

 

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Medicare and Medicaid increasing incentives to reduce "never events"

The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2008 that it is taking several additional actions to improve the quality of care in hospitals and reduce the number of "never events" -- preventable medical errors that result in serious consequences for the patient.

For the Medicare program, CMS has provided additional incentives for hospitals to improve the quality of care provided to people with Medicare, including payment provisions to reduce never events that occur in hospitals.  In addition, CMS sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. Almost 20 states either have already eliminated or are considering eliminating payment for some never events.

Last year, CMS listed eight preventable conditions for which it would not make additional payments.  This year it is adding three:

• Surgical site infections following certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity
• Certain manifestations of poor control of blood sugar levels
• Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Many private insurance companies have now implemented similar policies as covered by Patient Safety Focus earlier.

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.

"No Pay" Policies Now Mainstream

Along with Aetna and Wellpoint, Anthem Blue Cross and Blue Shield and Medicare and Medicaid, now CIGNA insurance will no longer reimburse hospitals for preventable medical errors (PMEs). These reimbursements currently pertain to "never events"--which are errors in patient care that can and should be prevented, like operating on the wrong area and administering the wrong blood type (learn more about "never events" here).

The policy will become effective as of October 1, 2008 and, according to CIGNA, “CIGNA is committed to improving quality for our members throughout the health care system,”  said Jeff Kang, MD, chief medical officer for CIGNA HealthCare. “Our policy on never events and avoidable hospital conditions is designed to put patient safety first and to encourage hospitals to improve quality  every day, one patient at a time.”    

Helen Darling, president of the National Business Group on Health, remarked “Hospitals, health care professionals and health plans must all work together to ensure that ‘never events’ never happen, avoidable conditions are always avoided, and every patient receives quality treatment in a safe and caring environment.”    

There's now little doubt that "No Pay" policies have hit mainstream...the question now is how long it will take to progress from never events to cover more PMEs.

Full news release located here.

More Insurers Say "No Pay" to PMEs

A few months back we asked if the tides were turning. Now it appears those waves are gaining momentum.  No longer isolated to Insurance Companies' Aetna and Wellpoint, Anthem Blue Cross and Blue Shield in New Hampshire announced Thursday that it will no longer pay for Preventable Medical Errors (PMEs).

According to the article: "Anthem called the move an initiative aimed at working toward eliminating preventable major adverse medical events in order to lower health care costs.

From the standpoint of Donna Fitts, the vice president of Quality and Risk Systems at Portsmouth Regional Hospital, this decision by a major insurance carrier will have a positive impact on hospitals across the state, including her own. 'It will force us, in a very busy medical environment, to stop and take stock of the things we do,' Fitts said. 'It is crystal clear that many of these things are errors that should never occur in a hospital."

According to Anthem: "The primary focus of these efforts will be to ensure that physicians and hospitals are using appropriate processes, technologies and strategies to address 'never events' and, ultimately, to enhance the quality of care delivered to hospitalized patients," said Richard Lafleur, M.D., medical director, Anthem Blue Cross and Blue Shield in New Hampshire. 'We continue to work collaboratively with physicians and hospitals to analyze why and how these events occur, and to proactively find ways to improve patient safety and clinical care.'

In addition to improving patient safety and quality outcomes, Lafleur added that the initiative will help protect Anthem's members from additional costs resulting from medical errors. 'As a strong advocate for patient safety, we have a responsibility to our members to work with our hospital partners to put processes in place that focus on preventing these events,' said Lafleur."

Full article here.

Turning the Tide? Insurers say "No Pay" to Preventable Medical Errors.

In what could be the turning point for the hospitals getting dramatically more diligent on preventing medical errors, Aetna and WellPoint have taken a bold, and needed, stance: no more paying for preventable medical errors.

According to an article in The Wall Street Journal:

"The companies are following the lead of the federal Medicare program, which announced last summer that starting this October, it will no longer pay the extra cost of treating bed sores, falls and six other preventable injuries and infections that occur while a patient is in a hospital. The following year, it will add to the list hospital-acquired blood infections, blood clots in legs and lungs, and pneumonia contracted from a ventilator.

Private insurers are looking first at banning reimbursements for only the gravest mistakes. But health-insurance executives say it is only a matter of time before the industry also stops paying for some of the more common and less clear-cut problems that Medicare is tackling, such as hospital-acquired catheter infections or blood poisoning. "I'd rather have the cudgel in place first than push the list too far," says Aetna President Mark Bertolini.

Some hospitals and others are concerned that the new strategy could drive up medical costs in other ways as hospitals absorb or pass on the expense of introducing the safety and screening procedures needed to help avoid mistakes.

Ultimately, insurers say, the efforts will trigger safety improvements and savings for patients."

But the policy is not to save the insurers money, it's to save lives. According to, Thomas Granatir, director of policy and research at Humana, Inc.--which is working on a policy similar to Medicare's, "It's not a matter of not paying for them. It's about getting them not to happen in the first place."