Recent Safety Headlines – Posted January 2011

University of Missouri Health System Program Serves as Model for National Initiative

University of Missouri Health System Program Serves as Model for National Initiative

The Clinician Support Toolkit for Health Care was unveiled on December 7 at the IHI Conference by Susan Scott, RN, MSN, Patient Safety Coordinator at University of Missouri Health System, along with Linda Kenney of the Medically Induced Trauma Support Services.  The toolkit, developed by a group of national patient safety leaders, provides resources to support clinicians and staff following adverse events.

Comment on 2012 National Patient Safety Goals for Hospitals and Long Term Care Organizations through January 27

Comment on 2012 National Patient Safety Goals for Hospitals and Long Term Care Organizations through January 27

The Joint Commission is seeking comments on proposed 2012 National Patient Safety Goals addressing ventilator-associated pneumonia and catheter-associated urinary tract infections.

March of Dimes Releases Report - Improving Hospital Care for Moms-to-be

March of Dimes Releases Report - Improving Hospital Care for Moms-to-be

The March of Dimes has released ¡°Toward Improving the Outcome of Pregnancy III: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives¡± offering a vision for maternal care services, and providing moms with practical tips.

AHRQ Seeks Submissions from Nursing Home for the Nursing Home Survey on Patient Safety Culture Comparative Database through February 15

AHRQ Seeks Submissions from Nursing Home for the Nursing Home Survey on Patient Safety Culture Comparative Database through February 15

The Agency for Healthcare Research and Quality is seeking results of patient safety culture results from nursing homes that have administered the AHRQ  Nursing Home Survey on Patient Safety Culture.  Results will populate a national comparative database to enable AHRQ to develop comparative results that will assist in identifying strengths and opportunities for improvement in nursing home safety culture.

AHRQ Web M&M Updates

AHRQ Web M&M Updates

Recent Agency for Healthcare Research and Quality Morbidity & Mortality reports highlight topics of pressure ulcer development in an emergency department, medication error related to the use of multidose vials, and a case of kidney failure related to a failure to reevaluate a patient.  Another edition focuses on measuring patient safety, with spotlight cases on return to the emergency room due to faulty discharge instructions, mix up in breast feeding milk, and challenges of medication reconciliation.

Hand Hygiene Project Success Credited to Lean Six Sigma

Hand Hygiene Project Success Credited to Lean Six Sigma

The Joint Commission for Transforming Healthcare has released findings of its two-year hand hygiene project with 8 hospitals using Lean Six Sigma methodologies.  Compliance with hand hygiene requirements, identified to be as low as 50%, increased to 82%, in addition to decreases in healthcare-acquired infections.  Causes of failures to clean hands identified include non-accessible dispensers or sinks, failure to report compliance data, and a culture that does not stress hand hygiene.

Study Says CT Scan Use Rising in Emergency Rooms

Study Says CT Scan Use Rising in Emergency Rooms

A study presented at the annual meeting of the Radiological Society of North America reported a 16 percent increase in the use of CT scans in emergency rooms since 1995. Researchers express concern about the excessive use of expensive technology and the potential risks to patients from unnecessary radiation exposure. The study reports although CT scans were rarely used for chest pain in 2001, it is now the third most frequent reason for CT scan use, following abdominal pain and headaches.

New Research Highlights Benefits of Surgical Safety Checklists

New Research Highlights Benefits of Surgical Safety Checklists

In a study published in the New England Journal of Medicine, researchers in the Netherlands found that hospitals using a surgical checklist, modeled from the World Health Organization¡¯s Surgical Checklist, observed a more than 33 percent drop in surgical complications, and nearly a 50 percent decrease in deaths.  These findings are supported by   Stanford University researchers reporting a decrease in surgical mortality attributed to use of a checklist.

Joint Commission Updates Sentinel Event Statistics

Joint Commission Updates Sentinel Event Statistics

The Joint Commission has updated its statistics of sentinel events reported by accredited providers. A total of 7,147 events have been reported since January 1995, 66% resulting in patient death.  Most common events reported are wrong site surgery, suicide, operative/postoperative complications, delay in treatment, medication error and falls.

Business Roundtable Study Reveals US Making Improvement in Patient Safety

Business Roundtable Study Reveals US Making Improvement in Patient Safety

The recent 2010 Health System Value Comparability Study, while noting dramatic improvements in some critical areas, including patient safety, others have fallen further behind.  The study compares the value of the US health system compared to that of Canada, France, Germany, Japan and the UK, noting the US has increased 3.7 points, with a decrease in fatal hospital errors of 37%.

Study Shows Slow Progress in Medical Error Reduction

Study Shows Slow Progress in Medical Error Reduction

A study recently released of North Carolina hospitals shows no significant improvement in patient safety between 2002 and 2007.  The study published in the New England Journal of Medicine involved 2,341 patients in 10 hospitals, revealing, although few patients suffered long term complications from mistakes, 2.9% of the problems were permanent, 9.5% were life threatening and 2.5 were fatal.

Study Reveals Improvement in Unsafe Injection Practices

Study Reveals Improvement in Unsafe Injection Practices

In follow-up to previous outbreaks of hepatitis B and C in health care settings due to unsafe injection practices and lapses in infection control and aseptic technique, Premier has released results of a survey on the use of safe injection practices. The study revealed the majority of professionals are using safe practices, however, a 6% continue to reuse syringes and single-dose vials.

Report Reveals Impact of Human Factors on Home Care Quality and Safety

Report Reveals Impact of Human Factors on Home Care Quality and Safety

The National Academy of Sciences National Research Council has issued a report that includes seven commissioned papers on home care on topics matching care to people in their home care environment; the prevalence, characteristics, and care provision ability of informal caregivers; medical devices and information technology and systems in home care; impact of social, cultural, and community environments on home care; and the effects of policy, reimbursement, and regulation on home health care.

Video on Behavior Change ¨C Hand Hygiene

Video on Behavior Change ¨C Hand Hygiene

View this video on behavior change involving children, and how to effect behavior change.  A fun twist on a challenging aspect of health care.

OIG Estimates Adverse Events Affect One in Seven Hospitalized Medicare Patients

OIG Estimates Adverse Events Affect One in Seven Hospitalized Medicare Patients

The Department of Health and Human Services¡¯ Office of Inspector General has issued a report indicating that nearly one in seven hospitalized Medicare beneficiaries experience adverse events, at an estimated cost of $4.4 billion per year.

Safety Alert - Joint Commission Issues Sentinel Alert- Suicide Risk in ERs

Safety Alert - Joint Commission Issues Sentinel Alert- Suicide Risk in ERs

The Joint Commission has issued a Sentinel Event Alert warning of non-psychiatric patient risk of suicide in emergency departments and medical/surgical units. The alert calls for greater attention to the risk of suicide in these patients and recommends caregiver education and training.

Safety Alert - FDA Issues Safety Advisory - Pre-filled Glass Syringes

Safety Alert - FDA Issues Safety Advisory - Pre-filled Glass Syringes

The Food and Drug Administration has issued an alert regarding the potential for malfunction, breaking or clogging of needleless, pre-filled glass syringes when attempting to connect them to needleless intravenous access systems. Most of the reported problems involved syringes containing adenosine, a heart drug injected rapidly into the blood stream in emergencies. The FDA urges health professionals who purchase, stock or administer emergency or operating room medications to be alert to the problem, and consider stocking adenosine in vials or pre-filled plastic syringes.

Safety Alert - CHPSO Issues Alert on Re-Calibration of Air Mattresses

Safety Alert - CHPSO Issues Alert on Re-Calibration of Air Mattresses

The California Hospital PSO, has issued an alert in response to a hospital report identifying the failure to recalibrate air mattresses as a contributing factor in the development of pressure ulcers.  The hospital identified when the blower of the Sizewiseâ„¢ Pulsate low air loss mattress replacement system, adjusted by staff to accommodate individual patients, is turned off or unplugged, it defaults back to the standard inflation, resulting in over or under inflation.  The alert encourages staff to always check and re-calibrate air mattresses settings, as needed, to individual patients when re-connecting.

Safety Alert - Alcohol Prep Pads, Alcohol Swabs, and Alcohol Swabsticks Voluntary Recall by Triad Group - Potential

Safety Alert - Alcohol Prep Pads, Alcohol Swabs, and Alcohol Swabsticks Voluntary Recall by Triad Group - Potential

Triad Group has issued a voluntary recall of all lots of alcohol prep pads, alcohol swabs, and alcohol swabsticks. These products are also privately labeled for over the counter sales, and may use the names Cardinal Health, PSS Select, VersaPro, Boca/Ultilet, Moore Medical, Walgreens, CVS, or Conzellin. Details and instructions for returning the product are available on-line.

PREVIOUS NEWS - October-December 2010

The Joint Commission Center for Transforming Healthcare Issues Resources on Tackling Miscommunication Among Healthcare Workers

JAMA Article - Teamwork Improving Patient Safety in the OR Setting

AHRQ Resources on Human Factors Impact on Home Care Safety

Falls Prevention Missouri Net Interview with the Director of Missouri DHSS

The Joint Commission Asks for Hospital Innovative Practices

Health Affairs Study Says Patient Satisfaction on the Rise

Sorry Works! Launches New Web site

Elimination of Healthcare-associated Infections - White Paper

Sisters of Mercy Hosts Sorrel King-Family Tragedy Spurs Action to Prevent Errors

Parkland Health Center Teaches Infection Prevention Strategies to Nursing Students

Study Reveals Medical Errors Cost $20 Billion Annually

A Lesson from Mom - Don't be a Good Patient

IOM to Study Impact of Technology on Patient Safety

JAMA Article - Rapid Response Teams not Substitute for Wrong Bed Placement

Infection Prevention Strategies in Ambulatory Settings - HHS Seeking Comments

Health Affairs Article - Diagnostic Errors Need to Be Addressed

Survey Reveals Patients Concerned About Contracting Healthcare-associated Infections

Hospital Infection Data Reported to National Network

The Joint Commission Issues Targeted Solutions Toolâ„¢

Hospital Stays with Infections Due to Medical Care

Surgical Safety Checklist Saves Money & Improve Care

Health Affairs Study Reveals Annual Medical Liability Costs of $56 Billion - 2.4% of Healthcare Spending

Article Considers Disclosure Dilemma for Large-scale Events

Safety Alert - Use of POC Blood Testing Devices (MedWatch)

Josie King Foundation Offers Free Patient Journal App

Patients Less Likely to Sue When Doctors Apologize

FDA Alert on Needleless Connectors and Bloodstream Infections

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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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