Patient Safety Resources

Missouri Purges Data From Infection Records

An article by Jim Doyle exposes the fact that the State of Missouri has deleted hospital infection data from their records citing that it is too costly to maintain and too sensitive for the public to review for more than a year. 

Doyle writes:  "Without access to infection data from previous years, consumers won't be able to adequately assess a hospital's performance in preventing infections, consumer advocates say. Specifically, the policy of the Department of Health and Senior Services makes it difficult to review how hospitals have performed over time and whether they perform consistently above or below the national average."

This decision to purge data has stirred a heated political, legal and social debate regarding public health records. 

Rep. Rob Schaaf, R-St. Joseph, a family-practice physician who pushed the infection bill in the Legislature is quoted as saying, "It's pretty sad to me that the (health) department can't give you a trend to show that a hospital is getting better or worse. It shows that the department doesn't really care,"

Senator Sarah Steelman, one of the original bill's sponsors, said "I'm surprised at the agency. The job of the health department is to protect people. It makes no sense at all to eliminate data after one year."

Ken Bunting, executive director of the National Freedom of Information Coalition, weighed in on the topic by stating, "It sounds like they're violating the spirit if not the letter of the law, If it's being posted online, they don't need to take it down."

To read Doyle's entire article please visit "Missouri Purges Data From Infection Records".

New Resources on Adverse Events in Hospitals

OIG report The U.S. Department of Health and Human Services Office of the Inspector General(OIG) has just released two new reports on adverse events in hospitals.  These are the start of a series of reports that the OIG will be issuing to Congress to comply with the Tax Relief and Health Care Act of 2006.   The Act mandates that OIG keep Congress up to date on the incidence of adverse events among Medicare beneficiaries, the payments associated with care related to the adverse events, and the processes for identifying and denying payments for such events.

The first, entitled Adverse Events in Hospitals: Overview of Key issues, identifies seven areas of importance for understanding the "landscape" of these events.  In addition, the report identifies strategies for reducing the incidence of adverse events.  The findings are based on interviews with a vast array of stakeholders.

The second, Adverse Events in Hospitals: State Reporting Systems, outlines the existing State programs and how the States use the data they collect.  As of January 2008, 26 States had implemented reporting systems and another one was in the works.  Twenty three of the States use their systems to hold hospitals accountable, while 18 use the data to promote learning and prevent adverse events.

Survey Targets Key Elements of a Culture of Safety -- by Robin Walters, R.N., B.S.N.

As part of our guest contributor program, we thank Robin Walters R.N., B.S.N, for her article below that explores progress among hospitals toward building a culture of safety. Be sure to also read Robin's other contributions on bloodstream infections and hand washing compliance.

Studies link a "culture of safety" with reducing hospital-acquired infections and harmful medical errors.  But what qualities define a culture of safety and how do hospitals measure up?

In a culture of safety, an atmosphere of trust exists in which people are free to report mistakes (and close calls) without fear of retribution.  Knowing that errors will occur, the focus is on the system which allowed the error, not the person making the error.  In an institution with a strong culture of safety, personnel learn from their mistakes and seek solutions.  Teamwork is a hallmark ingredient.

Hospitals can both evaluate and learn how to strengthen their safety scores by using the Hospital Survey on Patient Safety Culture.  Funded by the Agency for Healthcare Research and Quality (AHRQ), this confidential survey takes about 10 minutes to complete and is designed to assess staff attitudes and actions in 12 aspects of patient safety culture.

To give hospital administrators a reference for their results, AHRQ sponsored a database. The first Comparative Database Report was released in 2007.  For the 2008 Report, 98 of the 519 hospitals submitting results did so for the second time, allowing the Report to identify trends.  The following are highlights from this latest Report:

  • A strength among hospitals is "Teamwork Within Units" -- staff work together and support each other in an atmosphere of respect.
  • An area for growth is "Nonpunitive Response to Error," as it appears staff do not have faith that event reports will not be used against them and mistakes will not stay in their personnel file.  But those hospitals that improved in this area did tend to show an increase in the number of events reported.
  • Smaller hospitals had the highest average positive scores and improved more between reports.
  • Comparing work units, Rehabilitation scored the highest while ICU and Medicine scored the lowest in "Overall Perceptions of Patient Safety."  Pediatrics and Pharmacy made the most patient safety progress.
  • Hospital Administration/Management viewed conditions more positively than other staff in 11 of the 12 areas measured.
  • Of the trending hospitals, 27% showed a 5% or more decrease in the area of "Staffing," which indicates a decline in confidence that workloads and hours are appropriate.

About the author: Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural.

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Joint Commission releases its 2009 National Patient Safety Goals

The Joint Commission has released its 2009 National Patient Safety Goals for each of its accreditation programs.  The Goals are meant to help health care organizations use proven approaches to reducing ongoing failures in patient safety.  Separate, but overlapping goals have been issued for nine different health care settings:  ambulatory care, behavioral health care, critical access hospitals; disease-specific care; home care; hospitals; laboratories; long-term care; and, office-based surgery. 

New in 2009 are there hospital requirements for preventing lethal health care-associated infections from multiple drug-resistant organisms (MDROs), central line-associated bloodstream infections and surgical site infections.  These build on prior Goals in an effort to combat the increasing rate at which patients today are acquiring preventable infections in hospitals.  The new requirements for central line-associated bloodstream infections also apply to ambulatory care and office-based surgery, home care and long-term care.  Prevention of surgical site infections will be a new requirement for ambulatory care facilities and office-based surgery practices.  Health care organizations have a one-year phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.

IHI's 2008 Progress Report Proposes "New Rules" for Quality Care, Safety

If you've not yet had the chance to review the Institute for Healthcare Improvement's (IHI) 2008 Progress Report, it's worth your while. The report--titled "Quality Rules!"--is extremely thoughtful in setting out 10 "new rules" (as compared to the old rules).

New rules include more continuity, collaboration, control and safety as a system priority (vs. an individual responsibility), transparency as necessary (vs. secrecy), along with giving providers better tools and more efficient systems.

Speaking of IHI, on the left-hand sidebar, we feature several other helpful Patient Safety resources provides by the organization including practices for improving hand hygiene, a hand hygiene improvement report and their central line bundle.

Download the Progress Report (PDF) here. Full IHI website here.

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