Patient Safety Focus

NQF Releases Updated Safe Practices with Help of Dennis Quaid

Yesterday, at the National Press Club in Washington D.C., the National Quality Forum released an updated manual on Safe Practices for Better Healthcare.  Dennis Quaid, the well-known Hollywood actor, participated in the release by sharing his personal story of a medication error experienced by his newborn twins in 2007.  He cited his partnership with the Texas Medical Institute for Technology, a key contributor to the report, and underscored leadership, safe practices and technology as the most important pillars of improvement.

The updated report, replete with tools to improve safety, draws on new evidence published since the last report was issued in 2009.

More Research Needed on Patient Handoffs

According to a study released today in the American Journal of Nursing, more research is needed to create an evidence base of how best to handle handoffs of patients between nurses as they come and go with shift changes. 

Two-thirds of sentinel events in hospitals are thought to happen because of poor communication (Joint Commission), and inadequate nursing handoffs are widely believed to increase the chances of negative consequences for patients.  However, this systematic review of nursing handoff literature from the 1987-2008 discovered that little research has been done to determine best practices.  The Joint Commission now wants hospitals to standardize this process, but there is little evidence to support one approach over another.

Physicians Not Optimistic About Quality Trends

Yesterday, Sermo, Inc. and athenahealth released a joint survey of 1,000 physicians called the Physician Sentiment Index.  The first survey of its kind, it suggests that physicians are pessimistic about the future of health care.  In fact,

• 64% say that the health care environment is detrimental to their delivery of quality care
• 59% believe the quality of medicine will decline in America over the next five years

Despite the medical advances that enter into the health care delivery system on an ongoing basis, only 18% believe that the quality of medicine will improve over the next five years.  However, seven in ten physicians believe that electronic health records can help reduce medical errors and improve physician compliance with clinical guidelines and feel that the benefits justify the costs of installing such systems.

Medical Schools Falling Short in Equipping Future Doctors to Provide Safe Care

According to a report issued last week by the National Patient Safety Foundation, medical schools are not doing enough to train future doctors to provide safe care.  The Lucian Leape Institute convened 40 leading experts in medical education, patient safety, and health care improvement.  They found:

• Medical schools do not teach safety science and do not equip doctors in training with needed interpersonal skills
• Medical schools and teaching hospitals need to create learning cultures that emphasize patient safety, transparency, and collaborative behavior
• Medical Schools and teaching hospitals need to begin intensive patient safety training for faculty so that they can serve as adequate models for their students

The report also suggests that the accrediting bodies for medical schools (the Liaison Committee on Medical Education) and residency programs (the Accreditation Council for Graduate Medical Education) revise their accreditation standards to promote a more significant focus on patient safety.

Experts Argue for Partnership to Reduce Harm to Patients from Devices

Modeled after the Commercial Aviation Safety Team, a new partnership in health care could greatly reduce errors that harm patients, say leading experts in patient safety.  Citing growing awareness of the dangers of radiation therapies, such as reported in the New York Times and elsewhere, Peter Pronovost and colleagues suggest that to reduce the risk of harm to patients from medical devices, health care needs a private-public partnership to supplement the professional, regulatory and financial incentives in place today.  Clearly, the mounting data on patients harmed from mistakes in radiation therapy provide one strong case example on the need for such a partnership. 

To achieve a successful partnership modeled after the Commercial Aviation Safety Team, which has contributed to the ongoing decline in deaths due to aviation, Dr. Pronovost and his colleagues cite the need for leadership, financing and active participation by relevant government agencies, provider groups and health care delivery systems.

Leapfrog Group Issues List of Top 2009 Hospitals

  On December 3, 2009, The Leapfrog Group issued its annual list of "Top Hospitals."  For the first time, The Leapfrog Group added efficiency measures into the equation.  Across three categories including urban, rural and children's, Leapfrog recognized 34 hospitals, among the 1206 who participated in the voluntary Leapfrog Hospital Survey, as hitting high marks on quality, patient safety and efficiency.

Arrowsight Referenced in NEJM Sounding Board Article on Accountability -- by Suzanne Delbanco, Ph.D.

In this week's New England Journal of Medicine, nationally-recognized patient safety experts Peter Pronovost, MD, Ph.D. and Robert Wachter, MD argue that the "no blame" approach to improving patient safety needs to be balanced with accountability.  While refraining from blaming individual health care workers for making preventable medical mistakes makes them feel more comfortable to report mistakes, it may not be enough to propel forward efforts to improve care that are stalled.

Citing poor hand hygiene practices as an example, the authors review the structural changes and information campaigns that hospitals have implemented and conclude that they have not done enough to bring hand hygiene compliance to an acceptable level.  What's left to do? Hold health care workers accountable when they fail to adhere to patient safety practices known to protect patients from adverse outcomes.

There are certainly different ways to assess how well workers comply with critical protocols as well as myriad ways to hold them accountable.  But the authors highlight, in the case of hand hygiene, that one prerequisite is to have in place a fair and transparent auditing system of which clinicians are made well aware.  By way of footnote, Arrowsight is referenced as providing one methodology - video - that can be used both to measure and to provide feedback to clinicians.  Pronovost and Wachter cite the fact that meatpacking plants use remote video to hold workers accountable for performance (also Arrowsight's work) -- isn't it time we offer the same protection to patients?

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

HHS Allocating $25 Million to Address Patient Safety and Medical Liability

The U.S. Department of Health and Human Services has announced that it is allocating $25 million to address patient safety and medical liability.  Through the Agency for Healthcare Research and Quality(AHRQ), HHS will provide grants of up to $3 million each to states and health care systems wanting to implement or evaluate demonstration projects aimed at improving patient safety while fixing the problems with the liability system.  There will also be smaller planning grants available for up to $300,000.  AHRQ will also conduct a "review of what works," to be done by December 2009, of initiatives to improve quality and reduce medical liability to help guide HHS' work and investments in this area.

The Funding Opportunity Announcement will be available on www.grants.gov by October 17, 2009.

Leapfrog Hospital Survey Results Released

The results of the 2008 Leapfrog Hospital Survey, released this week, suggest that hospitals still have tremendous work to do to be safe for patients. 

For example, sixty-five percent yet to put in place all of the recommended policies to prevent hospital-acquired infections (though this is an improvement from 87% in 2007).  Similarly, seventy-five percent do not fully meet the standards for thirteen critical safety practices from hand washing to the competency of the nursing staff.  Just 30% of hospitals are fully meeting the standards for preventing hospital-acquired pressure ulcers and only 25% are meeting standards for preventing certain injuries in the hospitals. 

The Leapfrog Group's Survey included 1,276 hospitals in 37 major metropolitan areas.

2009 Safe Practices Released by National Quality Forum

The National Quality Forum has released the 2009 Safe Practices for Better Healthcare.  These 34 evidence-based practices build on six years of development, and represent practices that should be implemented in every hospital.

The 2009 report adds new practices in areas such as pediatric imaging, glycemic control, organ donation, catheter-associated urinary tract infection, and multi-drug resistant organisms. The report updates other previously endorsed practices based on new evidence, including the pharmacist’s role in medication management and pressure ulcers, and an entire chapter on healthcare-associated infections.  Some of the Safe Practices remain the same, such as hand hygiene and management of patients in ICUs by doctors with special training in critical care.

The Texas Medical Institute of Technology funded the project.  The National Quality Forum will be holding webinars throughout the year to review implementation strategies for the Practices.