Deadly Deliveries Report

USA Today – Deadly Deliveries. Hospitals know how to protect mothers. They just aren’t doing it. -Alison Young

USA Today recently published an extremely sobering investigative report, on the topic of the maternal death rate in the United States. According to statistics, the US number of maternal deaths has increased between 1990 and 2015 while other developed countries have a decreased number of maternal deaths over the same time span. Having been a Neonatal ICU nurse, this article pulled on my heart strings, how could we be letting this happen? But then my inner fact checker came forth and I decided I had to verify these numbers. Maybe it was that the journalists had misinterpreted the reporting, or read some obscure report. Well, while I found other statistics they all pointed to the reality that the US is definitely lagging in the quality and safety of care being provided to pregnant mothers. It doesn’t matter what statistics you use, WHO, UNICEF, or those put forth by the Global Burden of Disease, the US has seen an increase over the past 25 years in the number of women who die while pregnant, during childbirth or within a brief period after having given birth. To highlight the extraordinary nature of this healthcare crisis, I looked at who else had an increasing maternal death rate over the same time period. It was even more sobering. Out of the 183 countries that had data reported, only 12 others also reported an increase in the rate of maternal deaths. The US is in a small subgroup that includes, North Korea, Guyana, Georgia, Serbia, Tonga, Zimbabwe, Venezuela, South Africa, Suriname, Saint Lucia, Jamaica and the Bahamas.

What’s even more alarming in this article titled, “Deadly Deliveries” is that many of these deaths are preventable through basic processes of monitoring and management. So why have we gotten away from simple tasks? This is what I don’t understand. Maybe it was the organization in which I worked, but when I was working in the NICU, there was an understanding, a philosophy, a culture that believed in being pro-active rather than re-active when it came to healthcare. Even if it meant being a bit aggressive in the treatment of these premature babies/critical ill infants, the belief was basically that an ounce of prevention was worth a pound of cure. We would rather anticipate an infant “crashing” so to speak and try to prevent than to wait for them to actually “crash” and then deal with all the repercussion that could result from that. Why isn’t this being followed in all areas of healthcare? I don’t understand.

Ever since the release of the IOM report in 1999-2000, there has been an increased focus on patient safety and quality of care. Reimbursement has been tied to certain safety and quality measures as enticement for utilizing patient safety principles and actively working to promote patient safety. My question is – I’m not certain that we need more quality measures to report so much as we need to be focusing on the patient and making certain that our care is individualized to each patient.

Thinking of Joining a Patient Safety Organization?

There are other factors that go along with identifying high risk patients, some which deal with access, other factors deal with understanding who the high risk populations are. Other’s maybe deal with the education of our healthcare providers, instructing them and providing simulation scenarios to utilize critical thinking skills. That is something that struck me as I read the article, what happened to the critical thinking skills? Healthcare isn’t just following checklists, though they definitely help! But healthcare is understanding the body and understanding the normal variations that each person may have and knowing what is normal for one person may not be normal for another. It’s treating each person individually, with respect and dignity, without judgment on their circumstances.

‘Deadly Deliveries:’ Quality Talk Podcast Examines Rising Maternal Death Rate

There isn’t just one answer to this crisis of decreasing our maternal mortality rate, but as healthcare providers we need to start remembering why we went into healthcare and becoming advocates once again for our patients. Participating in the AIM program and using their safety bundles will help, reaching out to counterparts in the UK, France, Finland and Germany to see what protocols, policies they put into practice to decrease their maternal death rate will also help. Education of our healthcare providers and simulation of potential high risk scenarios will provide experience and utilization of critical thinking skills. But first and foremost, we MUST start focusing on the patient and putting their needs as priority over and above any potential financial penalties. Care plans for the patient must be constantly evaluated and evolving. And my sister nurses need to be utilizing their critical thinking skills to advocate for the best care of the patient. Only then will we begin to see the care of our new mothers improve.

CPS Partners with Verge Health to Improve Patient Safety

Verge Manages Technology while CPS Provides Consultancy Services

On the heels of Patient Safety Awareness Week, Verge Health, a leader in healthcare risk management, has partnered with the Center for Patient Safety (CPS), a non-profit organization envisioning a healthcare environment safe for all patients and healthcare providers, in all processes all the time.

“The shift to value-based care, and the vast expansion of data sharing among and between health systems, presents both risk and opportunity,” says Mark Crockett, chief executive officer of Verge Health. “We are delighted to solidify our working relationship with CPS to help improve safety by leveraging technology to help protect patients.”

Under terms of the agreement, the two companies will partner to promote products, services, and events to their respective client bases promoting the shared vision of protecting patients and margins. The agreement formalizes a long-time relationship where Verge powers the CPS PSO, and CPS offers PSO services, consultation and education around patient safety culture.

“From conducting patient safety assessments to helping hospitals and other health care organizations improve patient safety, we generate a significant amount of data that must be kept secure while being accessible,” says Alex Christgen, Executive Director for the Center for Patient Safety. “We’ve been working with [Verge] for several years to support our Patient Safety Organization, and believe our patient safety vision fits well with the IT platforms that Verge provides.”

About Verge Health
Founded in 2001, Verge Health is a risk management software company. Verge Health’s software solutions enable healthcare organizations to proactively protect and defend patients, caregivers, and frontline staff, against errors, adverse events, and policy violations. With over 900 facilities and 500,000 active users, the company’s Converge Platform provides hospital organizations with a cross-functional, proactive surveillance tool enabling optimal quality and safety results. For more information, please visit https://www.vergehealth.com/

About Center for Patient Safety
The Center for Patient Safety, is a private, not-for-profit corporation dedicated to fostering change throughout the nation’s health care delivery systems and across the continuum of care. It provides patient safety services to more than 1000 health care facilities across the nation since its inception 12 years ago, which was in response to recommendations from the Missouri Governor’s Commission for Patient Safety. For more information, go to
https://www.centerforpatientsafety.org

Florida Supreme Court’s opinion in Charles vs. Southern Baptist

A note to CPS’ participants and friends:

The Florida Supreme Court has adopted a restrictive interpretation of the PSQIA as it relates to Florida’s risk management and discovery laws.   Charles vs. Southern Baptist analyzes the relationship between the Patient Safety and Quality Improvement Act (the Act) and Florida laws that govern the development and protection of patient safety and quality material.  The Court’s opinion is available here.

Providers in Florida need to get local legal advice about the extent of the state law impact on their safety and quality work, as this is the first step in applying Charles.   Though the decision has no direct impact in other jurisdiction, it will be part of the ongoing discussion about PSO protections, so it is important to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.   The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP.

 

The Court held that patient safety work and the related reports, when required by state law, could not be PSWP, using the same analysis put forth by AHRQ in its Guidance last year. (AHRQ Guidance document available here.) Because the Charles information was collected or maintained for a purpose other than submission to a PSO or for dual purposes, the Court held it is excluded from the definition of PSWP contained in the PSQIA and the final rule.

This finding (that the requested information was not protected PSWP) is important when examining the next issue, whether the PSQIA pre-empts Florida Amendment 7. That provision eliminates any protection for “any records made or received in the course of business by a health care facility or provider relating to any adverse medical incident.”  This discussion won’t delve into the detailed interaction of the PSQIA definitions and Amendment 7, though the relationship is complicated.  The important thing for PSOs and their participants in other states is the Florida Court’s somewhat gratuitous finding that the PSQIA could not supersede or pre-empt Amendment 7.

CPS doesn’t recommend that its PSO participants assume that Amendment 7 has pre-empted the PSQIA. There are several reasons why PSO participants should not view this as established doctrine (or in non-legal parlance, a “done deal”):

  • The Court’s pre-emption finding may well be dicta–an opinion stated by a court that is not necessary for its decision.  Dicta can be informative, but carries little true weight as precedent.  Viewed narrowly, this is just the Florida Supreme Court stating its opinion where it doesn’t really matter.
  • The Florida finding directly contravenes language in the PSQIA (Section 922): ‘‘(a) PRIVILEGE.—Notwithstanding any other provision of Federal, State, or local law, and subject to subsection (c), patient safety work product shall be privileged.”  This sets up a potential US Supreme Court appeal.  The US Supreme Court could either (1) accept the case and decide the pre-emption question or (2) find that the Florida Court’s statement was dicta and did not raise a real issue.

Applying Charles:

CPS has always advised its participants to divide their safety and quality work into 3 categories:

  1. Reports that have to be submitted under state or other federal law,
  2. Work that is required to be done and related documents that must be generated but not reported under state or other federal law, and
  3. Work that is not required by other law.

 

Under Charles, documents produced to meet an independent state law requirement (Category 1) are not eligible to be PSWP. Work product that results from other state-required activities (Category 2) is in a gray zone and the answer may depend on state law and how you have structured the work.  If you have questions, contact CPS.  Review your mandatory activities and reports (bullets one and two above) and design your PSES to include work that is done outside those categories. Your PSES can always consider non-PSWP; the deliberations and analysis within the PSES can be protected, but the non-PSWP work product cannot.

There remains an open issue of admissibility in court for any of this information.  That is another fight for another day.

CPS will keep you advised of new developments.

CPS will keep you advised of new developments.

 

Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit www.unitedforpatientsafety.org for more information and resources about #PSAW2017.

National EMS Safety Council

The Center for Patient Safety (CPS) acknowledges that patient and provider safety stretches across every aspect of healthcare delivery and it requires a collaborative approach among individuals and organizations with a vested interest in improving safety and reducing harm.  By participating with the National EMS Safety Council, CPS is supporting our organizational vision and mission. Read more on EMS World about this council.

 

 

Center Releases 2013 Annual Report

The Center for Patient Safety has recently released the 2013 Annual Report. In addition, the Center has provided a 2013 PSO Report that highlights and summarizes the data found in the Patient Safety Organization (PSO) database.

We hope you will see the value in the  work that is being done by the Center in collaboration with many healthcare providers across the  nation to improve the safety of healthcare delivery and the reduction of patient harm.

Click on a report to download:

2013 Annual Report     2013 PSO Report

Center Welcomes Dr. Michael Handler as Medical Director

Michael Handler, MD CPS Medical Director

A leading voice for patient safety will bring his expertise and insights to the Center for Patient Safety (CPS).

Michael Handler, MD, vice president of medical affairs and chief medical officer for SSM St. Joseph Hospital West in Lake Saint Louis, MO, is now serving as the Medical Director for the Center for Patient Safety. He has been serving as the chair of the Center Hospital Advisory Committee; now, in the capacity of Medical Director, Dr. Handler officially brings his expertise and advice to the Center’s initiatives and activities. Additionally, he will be a liaison between CPS and the physician community.

Dr. Handler said working as CPS Medical Director is natural extension of his clinical and administrative work in the area of patient safety.

“To me, there are few more important issues in healthcare today,” he said. “Saving lives and eliminating harm in healthcare settings must be a national priority. It adds up to better care and lower healthcare costs. I am excited to now work more closely with the Center to expand on and enhance its work with healthcare providers, professionals and the public.”

Read the full press release

Read Dr. Handler’s bio

Watch Dr. Handler’s video on YouTube

Center and Hospital HAI Reduction Efforts Recognized by Johns Hopkins

In appreciation for your dedication to the On the CUSP: Stop BSI Project and to advancing the science of patient safety. Your work saves lives.
Thank you,
The Armstrong Institute for Patient Safety and Quality  

The Center and On the CUSP: Stop BSI Project participating hospitals are recognized for reducing healthcare acquired infections (HAIs) and improving the safety culture!

Work in the Missouri and Kansas city metropolitan area has saved lives and healthcare costs by reducing central line associated blood stream infections by 69% and reducing catheter-associated urinary tract infections by 30% – both efforts are exceeding national goals.

The Center, on behalf of participating hospitals, recently accepted recognition of this work from national leaders in HAI prevention, the Johns Hopkin’s Armstrong Institute for Patient Safety and Quality.   View the press release

Two Missouri Hospitals Awarded Excellence in Safe Care Awards by MOCPS

CONTACT: Allison Collinger
[email protected]
314-680-1583

Jefferson City, MO — May 7, 2012 — Two Missouri hospitals have been recognized by Missouri Center for Patient Safety (MOCPS) with the fourth annual “Missouri Excellence in Safe Care” Award.

Becky Miller, Executive Director of MOCPS, announced Harry S. Truman Memorial Veterans Hospital in Columbia, MO and Golden Valley Memorial Hospital in Clinton, MO are being honored for their outstanding efforts to make a measurable difference in patient safety.

View Full Press Release (PDF Format) (Word Format)

April is Missouri Patient Safety Awareness Month
April is Missouri Patient Safety Awareness Month, sponsored by the Missouri Center for Patient Safety (MOCPS) to maintain a focus on the importance of error prevention in health care. In recognition of health care professionals’ efforts to provide safe care 24 hours a day, 7 days a week, 365 days a year, the MOCPS has developed provider and consumer resources to promote awareness of the importance of patient safety

Jefferson City, Missouri (PRWEB) April 02, 2012

Jefferson City, Missouri – April 2, 2012 — April is Patient Safety Awareness Month (PSAM) in Missouri and the Missouri Center for Patient Safety (MOCPS), is recognizing the importance of safe health care 24 hours a day, 7 days a week, 365 days a year, by making available resources on safe care for consumers, and a Safety Promotion Toolkit for healthcare providers and professionals to promote their continuous focus on safe care. https://www.centerforpatientsafety.org/april-2012-missouri-patient-safety-awareness-month

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PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.