Patient Safety Focus

AHRQ Updates Data Standards for Patient Safety Organizations

The Patient Safety and Quality Improvement Act of 2005 aims to improve the safety and quality of health care in the U.S. through voluntary reporting by clinicians and health care organizations of patient safety and quality information without fear of legal discovery.  The basic idea is that if every health care provider shares information about incidences in which patients were adversely affected, we can aggregate and analyze these experiences to gain more insight into how to improve care. 

The Act charged the Agency for Healthcare Research and Quality (AHRQ) with creating standards for data submitted to Patient Safety Organizations.  Without data standards, aggregating and analyzing the data will be as difficult as comparing the proverbial apple to an orange.

AHRQ initiated standards development process by issuing and working with Version 0.1 Beta, but now has announced in the Federal Register the release of Common Formats Version 1.0.  The Common Formats span definitions and reporting formats and relate to all patient safety concerns, including healthcare-associated infections, falls and pressure ulcers.  This is an important step forward in realizing the goals of the Act.

New Poll Suggests 18% of Americans Affected by Hospital Infections

Consumers Union conducted a poll during mid-March of more than 2,000 Americans to learn about their experiences with health care-associated infections, preventable medical errors and preventive care.  Almost one in five (18%) say they or an immediate family member have experienced a dangerous infection following a medical procedure. 

• Sixty nine percent of these respondents said they had to be admitted to a hospital or extend their stay because of these infections.

One-third of the Americans surveyed report that medical errors are common in everyday medical procedures.

• Thirteen percent have had their medical records lost or misplaced.
• Nine percent have been given the wrong medicine by a pharmacist when filling their doctor's prescriptions.

The results of the poll were released at a Congressional briefing on reforming the health care delivery system with the American Cancer Society, the American Diabetes Association, and the American Heart Association, who together also released a joint statement.

New AHRQ Study Finds Surgical Errors Cost Almost $1.5 Billion Each Year

A new study by William E. Encinosa, Ph.D. and Fred J. Hellinger, Ph.D. of the U.S. Agency for Healthcare Research and Quality (AHRQ) reveals that potentially preventable medical errors that occur during or after surgery may cost employers as much as $1.5 billion each year.

Published in the July 28, 2008 issue of Health Services Research, the researchers found that insurers pay additional costs for surgery patients who experienced the following conditions associated with medical errors compared to patients who did not:

• acute respiratory failure - $28,218 (52% more)
• Post-operative infections - $19,480 (48% more)
• errors related to nursing care, such as pressure ulcers and hip fractures -$12,196 (33% more)
• metabolic problems, including kidney failure or uncontrolled blood sugar - $11,797 (32% more)
• blood clots or other vascular or pulmonary problems - $7,838 (25% more)
• wound opening - $1,426 (6% more)

The study is based on a nationwide sample of more than 161,000 patients age 18-64 in employer-based plans who underwent surgery between 2001 and 2002, and used AHRQ's Patient Safety Indicators to identify medical errors. 

The authors conclude that studies focusing only on medical errors incurred during the initial hospital stay may underestimate the financial impact of patient safety events by as much as 30%.

Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance

As we continue our interview series with today’s thought leaders in patient safety, we spoke with Dr. Meghan Dierks, Assistant Professor, Harvard Medical School.

HVA (Hospital Video Auditing) is an innovative, non-intrusive, 24/7 auditing technology that significantly improves compliance with patient safety and hand washing practices and protocols

In structuring the HVA program at a surgery center in the southeastern United States, Dr. Dierks has witnessed compliance scores soar from 35% to 90%+... and even more striking, she's seen compliance rates remain there.

In what ways, and to meet which specific goals, is the healthcare facility using HVA?

"We applied the technology to tackle a refractory problem in the healthcare compliance arena--the very basic safety protocol revolving around hand-hygiene and getting physicians to modify their safety behavior. The technology was two-fold: first, it would provide us the ability to collect highly reliable data and we hadn't been able to in the past. And, second, by nature of collecting high-quality data and instilling a feedback loop to relay that data to physicians practicing in that environment we could achieve a behavioral change.

We had two goals, both of which were achieved through the use of HVA. First, we needed to be able to collect highly reliable data over a sustained period of time on hand hygiene behaviors--something that has been difficult to achieve using other strategies. Second, in order to achieve a behavioral change, we needed to be able to use this data to provide continuous performance feedback to the healthcare workers practicing in that environment."

What significant points of success and improvements have you witnessed from the surgery center using the technology?

"Prior published studies have demonstrated that other efforts and interventions--such as employing human observers or posting educational signage--achieve short term, but not sustainable improvements in compliance. HVA is a highly reliable data-collection technique that enabled us to continuously measure performance over a long period of time in the surgery center, and document positive movement toward an established goal.

We are now reaching our sixth month of continuous measurement and feedback. Using HVA, we identified a relatively low baseline compliance rate of 38%. We provided weekly feedback, and over the next several weeks, saw dramatic improvements in compliance. This relatively high compliance rate has now been sustained in the 88%-98% range for six months. While the fact that we achieved 98% compliance within four weeks is remarkable, equally striking is the sustainability of the behavior change."

HAIs on the rise in NY State

According to KaiserNework.org, the rate of hospital-acquired infections (HAIs) has increased in New York State. What isn't clear is whether the rise is due to an actual increase in HAIs or the ability of the state to better track a larger number of them. According to Kaiser's report:

"The report found that about 3,200 of 1.45 million hospitalizations resulted in a hospital-acquired infection in the state, an increase from about 2,900 out of 1.48 million hospitalizations a year earlier. Coalition President Bruce Boissonnault said that the number represents "a small fraction of the infections. For example, many people do not show symptoms of an infection until they're discharged, and those patients would not be in that sample (used in the study)." This is the first year a health trend has worsened since the coalition began conducting the study six years ago, the AP/Times Union reports."

The report also cites that the overall likelihood of dying from a hospital procedure decreased from 8.5% for eight inpatient procedures in 2002 to 7.4% in 2006. State Health Department spokesperson Jeffrey Hammond said, "While it may be possible that infection rates are getting worse, it may also be true that hospitals are more vigilant at reporting infections, and that's good news for patients".

Transparency in reporting is a good and necessary first step in acknowledging the problem but we need to understand the full range of infections we need to be reporting against--and the practices and technologies that all hospitals should be implementing in order to eradicate them. Then the numbers will serve us in not only tracking the breadth of HAIs and their main causes, but the successes of hospitals that have initiated better protocols, tests and auditing systems.

Summary of report located here. 2008 New York State Hospital Report Card is available online.

CDC Data Flawed, Regulations Too Lax?

In taking a strong stance with the CDC through an April 15th Commentary in The Washington Times before her testimony to Congress, Betsy McCaughey, Chairman of The Committee to Reduce Infection Deaths (RID), writes:

"Tomorrow Congress will hold hearings on whether the federal government is doing enough to prevent deadly hospital infection. The answer is 'no.' The biggest culprit is the CDC. The CDC claims 1.7 million people contract infections in U.S. hospitals each year. The truth is several times that number."

MCaughey then discusses the growing numbers of MRSA and how that alone skews the CDC's numbers:

One of the fastest growing infections is "Mersa" or MRSA, which stands for methicillin-resistant Staphylococcus aureus, a superbug that doesn't respond to most antibiotics. In 1993, there were fewer than 2,000 MRSA infections in U.S. hospitals. By 2005, the figure had shot up to 368,000 according to the Agency for Healthcare Research and Quality. By June, 2007, 2.4 percent of all patients had MRSA hospital infections, according to the largest-ever study, published in the American Journal of Infection Control. That would mean 880,000 victims a year.

That's from one superbug. Imagine the number of infections from bacteria of all kinds, including such killers as VRE (vancomycin-resistant Enterococcus) and C. diff (Clostridium difficile). Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, recently told Congress that MRSA accounts for only 8 percent of hospital infections.

These new facts discredit the CDC's official 1.7 million estimate. CDC spokeswoman Nicole Coffin admits "the number isn't perfect." In fact, it is an irresponsible guesstimate based on a sliver of 6-year-old (2002) data. The CDC researchers who came up with it complained that not having actual data 'complicated the problem.'

Numbers matter. Health conditions that affect the largest number of people generally command more research dollars and public attention."

McCaughey's column is compelling and points a very strong finger at the CDC to (1) provide up-to-date, accurate data on this (preventable!) epidemic and (2) increase the protocols to be in line with those of other countries who have eradicated the problem (as Europe has with MRSA screening). She also draws correlations to other government regulators, noting:

"It is common for government regulators to become soft on the industry they are supposed to regulate. A coziness develops. Federal Aviation Administration inspectors failed to insist on timely electrical systems inspections, say news reports. The same may be true at the CDC, where government administrators spend too much time listening to hospital executives and not enough time with grieving families."

The current statistics on hospital-acquired infections (HAIs) are already mind-numbing...but to think that there are far higher, and far more that we could be doing makes McCaughey's voice one of the most important in the fight on preventable medical errors.

 Full piece located here. A transcript of McCaughey's address to Congress can be downloaded here (PDF).

Health Grades' Report Cites 238,000+ Preventable Deaths, $8+ Billion In Preventable Costs

In their fifth annual Patient Safety in American Hospitals Study, Health Grades Inc., cites that errors in treatment resulted in 238,337 potentially preventable deaths of Medicare patients in the US, costing $8.8 billion.

HealthGrades Inc. analyzed over 41 million patient records for the study and found that approximately 3 percent of all Medicare patients suffered from some medical error-- which equates to about 1.1 million Patient Safety Incidents (PSIs) from 2004-2006. In the report, Health Grades describes medical errors as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim…[including] problems in practice, products, procedures, and systems."

There were 270,491 actual in hospital deaths that occurred among patients who developed one or more of 16 PSIs and the report states, "Using previous research, we calculated that 238,337 were attributable to patient safety incidents and potentially preventable."

In a prepared statement, HealthGrades' chief medical officer and primary author of the study, Dr. Samantha Collier, said "While many U.S. hospitals have taken extensive action to prevent medical errors, the prevalence of likely preventable patient safety incidents is taking a costly toll on our health care systems -- in both lives and dollars", she continues, "HealthGrades has documented in numerous studies the significant and largely unchanging gap between top-performing and poor-performing hospitals. It is imperative that hospitals recognize the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost."

Starting October 1st, the federal Centers for Medicare and Medicaid Services will stop reimbursing hospitals for the treatment of eight major preventable errors, including objects left in the body after surgery and certain kinds of post-surgical infections. As we covered recently, many insurance agencies have already stopped reimbursing for such errors.

Full report by Health Grades is located here (PDF).

Month in "Focus": March Review

March was a busy month that brought us the official launch of PatientSafetyFocus.com, our support for the first Patient Safety Awareness Week, key findings across several states, and some excellent recommendations for the industry.

And, once again, March was a month that delivered too many statistics that are nowhere near where they should be--as those numbers represent lives hurt and lives lost, all due to preventable medical errors.

Here's a wrap-up of what we've been covering over the past month:

Medicare's plan under fire before it begins: Interesting feedback in the Ann Arbor News article titled "Medicare Plan May Backfire in its results, Penalizing of hospitals is overly punitive". According to the piece: "Come October, Medicare will stop paying hospitals for certain medical mistakes." If you recall, they're not the only ones, as major insurers have just started saying no-pay to "never events" (events that never should have happened in the first place). More here.

AARP releases stifling statistics: Key findings from AARP's (American Association of Retired Persons) New Jersey chapter's recent "Does it Make You Sick?" survey shine even more light on the striking issue of preventable medical errors. According to The Record: More than a third of New Jersey residents surveyed say they or a family member have been a victim of a medical error. Read on here.

HRH works to improve trust: In efforts to not only increase patient safety but to maintain trust, Hendricks Regional Health (HRH) in Avon, Indiana formed a Patient Safety Committee in 2006 consisting of 25 members from all levels and buildings of the medical group. Learn about the interesting initiative here.

Celebrity as influencer for patient safety: An unlikely, but altogether welcome Patient Safety Advocate, 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).The result is two-fold: first, it brings attention to the startling statistics now standing at "1 error per patient per day" which adds up to 100,000 deaths per year in the U.S. alone. But, second, it has brought an unlikely patient safety advocate to the fore in Dennis Quaid (view video here).

Oregon announces increase in deaths from preventable medical errors

Oregon's commission that collects voluntary reports of medical errors has reported that 24 patients died of preventable errors in 2007, compared with 21 in 2006. In 2007, 54 of Oregon's 57 acute care hospitals participated--with those 54 hospitals providing 99 percent of the hospital care provided in Oregon.

Further, Oregon is the only state in the country with a completely operational voluntary reporting program.

According to The Portland Business Journal article, "Issues related to 'communication' were the most often cited fundamental cause. For those events that resulted in death, organizational factors and patient factors become very important as well."

Over the last two years, five types of adverse medical events have accounted for nearly 60 percent of the reports, specifically:

• 18.9 percent of reports were of foreign objects retained inside the body following an invasive procedure.
• Wrong site procedures comprised 10 percent of reports.
• Medication errors accounted for 10.1 percent of reports.
• 9.5 percent of events were related to falls.
• Infections were responsible for 8.8 percent of errors."

In 2003, the state Legislature passed the bill which created the patient safety commission that same year and is supported by fees collected from participating health care organizations. The reports that are collected by the commission span errors including medication mix-ups and hospital-acquired infections...as well as "near-misses" and "lessons learned." Information about these errors is  shared with members to guard against future errors.

Full article can be accessed here.

Celebrities bring needed attention to preventable medical errors

Last November, actor 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 has concluded that it was due to failure of the staff at Cedars-Sinai to follow their own procedures. The report rules the overdoses as "preventable medication errors."

The result is two-fold: first, it brings attention to the startling statistics now standing at "1 error per patient per day" which adds up to 100,000 deaths per year in the U.S. alone. But, second, it has brought an unlikely patient safety advocate to the fore in Dennis Quaid (see video below).

While insurers are taking aggressive steps to decrease preventable medical errors and patient safety advocacy groups are working to increase awareness through various programs, celebrity advocates can be pivotal in getting this issue to the front pages of our media and into the hearts and minds of people...and, hopefully, continue to place pressure on hospital administrators (and drug manufacturers) to instill every possible precaution and process in place to prevent further errors.

With 1 error per patient per day now the average (see that CNN video here), this issue is bigger than AIDS and breast cancer--but completely preventable. All told, we simply cannot wait any longer to amplify awareness of this issue. While we feel for the trauma that has been placed on the Quaid's, we are thankful that he is using his experience and his celebrity as a platform to advocate for much-needed change. And we hope that the media continues to dedicate coverage to this issue, especially given better processes and solutions that thwart against human error have already been created.

Part of the 60 Minutes featuring Dennis Quaid and wife is below--RSS and email subscribers, click through to the blog to view. A listing of current statistics is located here.