Patient Safety Focus

IOM Vision for Reducing Medical Errors Not Yet Realized

Has the U.S. made any progress on patient safety since the Institute of Medicine (IOM) released To Err is Human in 1999?  According to Consumers Union, few of the IOM’s recommendations have been implemented.  In a recently released report, Consumers Union's Safe Patient Project highlight’s the following areas as falling short of the IOM’s recommendations for tackling preventable medical mistakes:

 

Prevention of medication errors:  Only a minority of hospitals has implemented computer physician order entry systems, the Food and Drug Administration has not reviewed and changed enough confusing and sound alike drug names, and there is not yet a system for reporting medication errors by facility.

Transparency:  There are still 24 states that do not require public disclosure of infections or other quality and safety data.

 

Measurement: the Agency for Healthcare Research and Quality estimates that patient safety has actually declined year after year, but still has too little data to make accurate assessments.

 

Standards for Competency: Efforts to boost the competency of health care providers have been scattered and criticized.

Leapfrog Group 2008 Top Hospitals Announced

Today, The Leapfrog Group announced its 2008 Top Hospitals, with 26 adult and 7 children’s hospitals making the cut.  To make this list, hospitals must demonstrate high performance on a variety of quality and safety measures that are part of the Leapfrog Hospital Survey.  Meant to provide national recognition for the hospitals on the list, Leapfrog has released the list for the last several years.  The requirements for making the list have gotten more stringent each year, with this year’s criteria requiring:

• Fully meeting Leapfrog standards for computer physician order entry(CPOE) systems, as well as testing CPOE systems with Leapfrog’s CPOE evaluation tool;
• Fully meetings standards for a complex, high-risk procedure on Leapfrog’s list for evidence-based hospital referral;
• Fully meeting the standard for physician staffing in the ICU; and, 
• Fully meeting or demonstrating significant progress on 13 other patient safety practices, including hand hygiene practices.

More details on the methodology and the complete list of the 2008 Leapfrog Top Hospitals is available on The Leapfrog Group web site.

Leapfrog Group Launches Updated Hosptial Ratings Web Site

On August 1st, The Leapfrog Group launced an updated web site with new safety and quality information on hospitals nationwide.  To date, 1,169 hospitals have submitted responses to important questions about quality that consumers can use to compare hosptials.  Many more hospitals are expected to participate in the Leapfrog Hospital Survey over the coming months.  The web site shows individual hospital results, which are freely available and updated monthly. 

Along with questions about whether hospitals have implemented patient safety practices endorsed by the National Quality Forum, for the first time ever, the Leapfrog Survey queries hospitals about their use of resources and efficiency in performing certain procedures.  It also asks for rates of "hospital acquired conditions" such as bed sores, falls and burns.  And based on data submitted by participating hospitals, it also estimates the odds of dying at those hospitals as a result of undergoing certain high-risk surgeries.  For more about what's new in the 2008 Leapfrog Survey, visit: https://leapfrog.medstat.com/pdf/whatsnew.pdf. 

Quaid Professes He'd "Never Allow A Loved One in A Hospital Alone"

“In my line of work if I make a mistake, we have take two,” actor Dennis Quaid told reporters at the annual meeting of the Association of Health Care Journalists. “If you’re a healthcare professional and make a mistake you could kill somebody.”(full WSJ article here)

As we posted on last month, five months ago, Dennis Quaid's newborn twin babies were given almost fatal overdoses of an injectable anticoagulant in LA's Cedars-Sinai hospital. The babies were given nearly 1,000 times the normal 10-unit does of the drug Heparin. While the twins have fortunately recovered, California regulators have fined the hospital $25,000 for giving overdoses of the blood-thinning drug to three children (two of which were Quaid's twins), with the California Department of Public Health concluding that it was due to failure of the staff at Cedars-Sinai to follow their own procedures.

Since that time, in order to take action, Quaid and his wife started The Quaid Foundation, along with suing Baxter International--maker of the blood thinner involved--over its labeling and packaging of heparin. In a segment in March, Baxter told CBS’ 60 Minutes that "The error in the Quaid case rests with the hospital and its staff “because the product was safe and effective, and the errors, as the hospital has acknowledged, were preventable and due to failures in their system.”

Quaid is no doubt a highly significant and influential patient safety advocate for us all. After all, his celebrity status provides a unique and very public platform to bring the issue front and center to the public discourse. Just as we stated when we began this blog, "To improve patient safety practices--and significantly decrease preventable medical errors--necessitates communication as much as it does innovation."

For Quaid the near-death experience has been all too sobering with him professing, “I’d never allow a friend or a family member ever to be in a hospital alone."

All told, what Quaid can do in communicating the current problems and pitfalls, businesses can do in innovating protocols and solutions. Moreover, through our innovation of always-on, 24/7 auditing technology, HVA provides constant monitoring of many patient safety protocols and processes. The result? Neither Quaid's loved ones, nor any member of the public, needs ever be in a hospital "alone."

(HVA results cited here. Process that HVA monitors located here. More information located here.)

Photo Credit: Wall Street Journal Health Blog

Leading Patient Advocate Argues "Quality control is Cost Control"

In an article that takes on the patient safety issue from a cost argument, Jamie Stevenson, vice president of the Consumer Health Quality Council, writes: "Our health care needs to become safer. The good news is we all can take a role in improving the system. Quality improvement and cost control cannot be separated. Medical errors cost the nation $17 to $29 billion each year.

Quality control is the best form of cost control."

Among the sobering statistics (many located here), according to the Institute of Medicine, medical errors injure nearly one million Americans each year during their hospital stay, and among those injured, nearly 100,000 patients die as a result.

In Massachusetts alone, the New England Healthcare Institute estimates one in every 10 Massachusetts patients suffers an avoidable medication mistake. And according to the Centers for Disease Control and Prevention, one in five inpatient hospital admissions results in a hospital-acquired infection.

 Further advocating for more transparency, Stevenson implores:

"The public has a right to know whether a hospital is struggling with a problem such as infections. Armed with the necessary information, patients and families can make truly informed decisions and participate in improvement efforts. Healthcare transparency is about creating openness, honesty and truth-telling in healthcare."

Full article located here.

Patient Safety Awareness Week: a tremendous cause, a terrific opportunity to launch our own!

We are proud to launch PatientSafetyFocus.com right in time for, and as an avid supporter of of, Patient Safety Awareness Week (occurring March 2nd - March 8th, 2008).

What is Patient Safety Awareness Week (PSAW)? It is a national education and awareness-building campaign, developed by the National Patient Safety Foundation, for improving patient safety at the local level. Hospitals and healthcare organizations across the country are encouraged to plan events to promote patient safety within their own organizations. Educational activities are centered on educating patients on how to become involved in their own health care, as well as working with hospitals to build partnerships with their patient community. More information is available here.

How does this blog support the objectives of the program? We are dedicated to focusing on patient safety information, programs and solutions. In aggregating relevant, recent content on programs, protocols, developments, reports, resources, advocacy efforts and studies, our hope is that PatientSafetyFocus.com provides a platform to increase awareness of the critical issue of preventable medical errors--and through raising awareness, we significantly raise the bar.

How are we pushing for change? To improve patient safety practices and significantly decrease preventable medical errors necessitates communication as much as it does innovation. We hope the blog format also works to build conversation among patient safety advocates, media professionals, hospital administrators, insurers and those persons who have either themselves been affected by preventable medical errors or have loved ones that have.

Join the National Patient Safety Foundation and PatientSafetyFocus.com in increasing awareness of this important issue...after all, be you doctor, patient, insurer or advocate, it's in everyone's best interest to improve patient safety!