National Quality Forum Adds to List of Serious Reportable Events

June 14, 2011 By Leave a Comment

The National Quality Forum has made four additions to its list of serious reportable events (SREs).  SREs represent largely preventable errors and events, such as wrong-site surgery, stage 3 or 4 pressure ulcers acquired post-admission, patient falls, or serious medication errors. The first NQF-endorsed® list of Serious Reportable Events in Healthcare was released in 2002.

25 events were updated from their earlier endorsement in 2006, and 4 new events were added to the list. The full list of events will be available for a 30-day public appeals process closing July 12, 2011.  NQF is a voluntary consensus standards-setting organization. Any party may request reconsideration of any of the 29 endorsed SREs by notifying NQF via email at appeals@qualityforum.org no later than Tuesday, July 12.

“Tens of thousands of lives are forever changed each year as a result of healthcare errors,” said Janet Corrigan, president and CEO of the National Quality Forum. “This newly expanded list of serious reportable events across multiple settings provides a critical opportunity to learn from mistakes and take swift action to improve patient safety.”

The four new serious reportable events include patient death or serious injury resulting from failure to communicate test results, and death or serious injury of a newborn baby associated with labor or delivery in a low-risk pregnancy.All of the measures were evaluated to ensure they were appropriate for public accountability and to verify that they could be used for hospitals, office-based practices, ambulatory surgery centers and skilled-nursing facilities, the NQF said.

“The updated list of Serious Reportable Events provides an essential accountability framework for ensuring our progress in improving patient safety,” said Gregg Meyer, MD, MSc, senior vice president for the Center for Quality and Safety at Massachusetts General Hospital and co-chair of the Serious Reportable Events in Healthcare Steering Committee. “It has evolved with the evidentiary base and represents an important complement to other NQF work in patient safety, such as the NQF-Endorsed Safe Practices.”

Click here to view the full National Quality Forum’s Announcement and Press Release on added Serious Reportable Events

This Announcement was released on June 13, 2011.

More information on the National Quality Forum can be found on here.

 

 

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Federal Appeals Court Orders VA To Overhaul Mental Health Care System

May 16, 2011 By Leave a Comment

A federal appeals court Tuesday May 11th, lambasted the Department of Veterans Affairs for failing to care for those suffering post-traumatic stress disorder and ordered a major overhaul of the behemoth agency.

Treatment delays for PTSD and other combat-related mental illnesses are so “egregious” that they violate veterans’ constitutional rights and contribute to the despair behind many of the 6,500 suicides among veterans each year, the U.S. 9th Circuit Court of Appeals said in its 2-1 ruling.

Noting that an average of 18 returning service members commit suicide each day, the court directed a district judge in San Francisco to order sweeping reform of the VA’s mental healthcare system.

The appeals court took nearly two years to issue its decision, in part because the court attempted to force the government to negotiate with the two veterans’ groups that sued over mental health care and benefits that had been delayed or denied.

Citing the court’s inability to order the government “to work faster,” Chief Judge Alex Kozinski had urged lawyers for the VA and the veterans groups to use the court’s mediation services to work out a plan for meeting the wounded veterans’ needs. The talks deadlocked and no settlement was reached.

“There comes a time when the political branches have so completely and chronically failed to respect the People’s constitutional rights that the courts must be willing to enforce them. We have reached that unfortunate point with respect to veterans who are suffering from the hidden, or not hidden, wounds of war,” said the ruling written by Judge Stephen Reinhardt and joined by Senior Judge Procter Hug Jr., both appointees of President Carter.

“The VA’s unchecked incompetence has gone on long enough; no more veterans should be compelled to agonize or perish while the government fails to perform its obligations,” the ruling said.

Kozinski dissented, saying that “much as the VA’s failure to meet the needs of veterans with PTSD might shock and outrage us, we may not step in and boss it around.”

He predicted that the majority’s directive would only prolong litigation and complicate the agency’s efforts to improve services.

“We would have preferred Congress or the President to have remedied the VA’s egregious problems without our intervention when evidence of the department’s harmful shortcomings and its failure to properly address the needs of our veterans first came to light years ago,” the majority said in heeding the chief judge’s concerns.

Veterans for Common Sense and Veterans United for Truth sued the VA four years ago, alleging systemic failures in the government’s processing of disability claims and appeals of denied coverage. U.S. District Judge Samuel Conti denied the groups’ claims on procedural grounds following a seven-day trial in 2008. The judge said he lacked the authority to order the VA to implement the Mental Health Strategic Plan it drafted in 2004 to overhaul its care system within five years.
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Hospitals Focus on Nurse-Doctor Teamwork to Reduce Errors

May 10, 2011 By Leave a Comment

An 18-year-old man with fever and chills is sent home from the emergency room with Tylenol and later dies of sepsis, a blood infection. A 42-year-old woman with chest pains is discharged, only to suffer a heart attack two hours later. A 9-year-old girl’s appendix ruptures after doctors rule she’s just got a bellyache.

Hospitals are drawing on lessons learned from these worst cases of missed or delayed diagnosis to overhaul emergency departments, where errors, oversights and a lack of teamwork between doctors and nurses can harm or kill patients. They are adopting new triage systems to ensure doctors and nurses jointly see at-risk patients soon after they arrive, requiring physicians and nurses to huddle to make sure no information is overlooked, and using time-outs at discharge to prevent patients with unresolved problems from leaving the ER.

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims. The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.

Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.

While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren’t available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University.
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It’s Patient Safety Awareness Week! March 6-12

March 10, 2011 By Leave a Comment

It's Patient Awareness Week!The National Patient Safety Foundation (NPSF) is celebrating Patient Safety Awareness Week on March 6-12; this annual event is designed to highlight improved patient-provider communication as a vital part of keeping patients safe.  This year, NPSF is also focusing on efforts to reduce medication errors and lower hospital readmission rates. As the nation’s leading voice for patient safety, NPSF’s goal for the campaign is to encourage improved patient care through better communication among providers, patients, families, and communities.

“Patient Safety Awareness Week underscores the needs addressed by national discussions on patient safety and emphasizes the value of collective effort and working together for making and keeping our health care system safe,” says Diane C. Pinakiewicz, president of NPSF.

According to a New England Journal of Medicine study analyzing close to 12 million fee-for-service Medicare beneficiaries, nearly 20 percent of those discharged from a hospital were re-admitted within 30 days; 34 percent were re-hospitalized within 90 days, and 54 percent, within a year.  Medication errors played a large, preventable role in these readmissions.

In support of Patient Safety Awareness Week this year, NPSF has made available a variety of online resources expressly designed to help patients understand what they can do and what they need to know to stay safe. Patients and families interested in learning more should visit www.npsf.org.

In addition, the Ask Me3TM program is again an integral component of Patient Safety Awareness Week.  This health literacy initiative is designed to assist with communication between patients and providers by way of three basic questions – “What is my main problem?”  “What do I need to do?” and “Why is it important for me to do this?”

Patient Safety Awareness Week, which NPSF has been leading since 2002, is intended to raise public awareness about the work being done to improve patient safety and the importance of effective partnering in these improvement efforts.  It is also an effort to directly involve patients and health care consumers in the process of ensuring that health care errors do not occur.

Health care organizations nationwide and around the world are displaying and distributing Patient Safety Awareness Week materials and resources, including posters, brochures, stickers, and lapel buttons to demonstrate their support and commitment.

Patient & Family Tools and Resources at NPSF

Press Release at NPSF.org

The Joint Commission also has a great select of Patient Safety Resources for your Healthcare Organization

 

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Nursing Leaders Convene to Share Strategies on Improving Patient Outcomes

February 7, 2011 By Leave a Comment

More than 1,000 nursing leaders from across the country will convened January in Miami to share strategies on how to use data on nursing performance to improve patient outcomes and the quality of America’s health care at an American Nurses Association (ANA) National Center for Nursing Quality® conference.

The 5th Annual National Database for Nursing Quality Indicators® (NDNQI®) Conference marked the launch of the American Nurses Association’s Nursing Quality Network, an Internet-based collaborative learning community providing an outlet for nurses from NDNQI-participating hospitals to share resources, experiences and strategies that have led to improvements in nursing care quality and patient outcomes.

The event also showcased the newest publication of the National Center for Nursing Quality ®, NDNQI Case Studies in Nursing Quality Improvement. The third in a series, the book provides a step by step guide on how to use NDNQI data to improve the quality of care. It includes 11 case studies describing how hospitals implemented new strategies and practices to achieve better patient outcomes, and how these successful methods can be applied to practice.

More than 1,700 hospitals participate in NDNQI – the nation’s most comprehensive resource of performance data collected at the hospital unit-level that is tied to nursing services. The number of NDNQI-participating hospitals grew by about 10 percent in 2010.
NDNQI allows hospitals to compare the performance of nursing units to others locally and nationwide, and use results from the reports to set benchmarks and make strategic improvements in nursing care, patient outcomes, patient safety and nurse satisfaction.

“It’s a step forward for health care and good for our patients whenever we can bring so many nursing experts together to share how they have used data to improve their performance,” said ANA President Karen Daley, PhD, MPH, RN, FAAN. “Transforming health care requires making evidence-based decisions that promote delivery of quality care and put the patient at its center. That’s what NDNQI and this conference are all about.”
The NDNQI Award for Outstanding Nursing Quality® will be presented January 27 to five hospitals that achieved overall excellence in nursing quality, based on data they report to NDNQI.

Read More about the NDNQI

Nursingworld.org

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Joint Commission: Facts & Roadmap for Hospitals – Advancing Effective Communication, Cultural Competence, & Patient and Family Centered Care

February 4, 2011 By Leave a Comment

Since 2007, The Joint Commission has been working toward improving access to care for all patients at our accredited organizations through better communication, cultural competence and patient- and family-centered care. In December 2009, the patient-centered communication standards were approved by The Joint Commission Board of Commissioners. The standards are published in the 2011 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Joint Commission surveyors will evaluate compliance with the patient-centered communication standards beginning January 1, 2011; however, findings will not affect the accreditation decision until January 1, 2012 at the earliest. The information collected by Joint Commission surveyors and staff during this implementation pilot phase will be used to prepare the field for common implementation questions and concerns.

There are a number of resources available on The Joint Commission website at http://www.jointcommission.org/Advancing_Effective_Communication/ to help health care organizations address communication, cultural competence and patient- and family-centered care.

Topic Details: JC PDF Document Advancing Effective Communication

Find more at Joint Commission Topic Library . . .

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Surgical Checklists Reduce Medical Errors — And Could Cut Malpractice Claims: Study

January 14, 2011 By Leave a Comment

Surgical checklists not only save lives by preventing medical errors, they could also make a big dent in medical malpractice claims, according to a study in the Netherlands.

Using data from the country’s largest medical liability insurer, a team led by Eefje de Vries of the Academic Medical Center in Amsterdam found that nearly a third of the malpractice claims arose from mistakes that likely would have been caught by a checklist.

For the study, published in the Annals of Surgery, the team identified the main reasons for errors in 294 successful insurance claims related to surgeries from 2004 to 2005. They then compared those to the items on a comprehensive surgical checklist called SURPASS, which is now used in several hospitals in the Netherlands.

The checklist includes things such as making sure the operating schedule is correct, checking that all equipment is available, and marking on which side of the patient the surgery is going to happen.

“While the checklist as a whole may seem a little intimidating, the separate parts for each stage of the surgical pathway take little time to complete,” de Vries wrote.

They found that 29 percent of the reasons for lawsuits could be linked to a step on the checklist, such as marking the patient or communication between hospital staff.

And in four of the 10 deaths in the claims database, at least one of the contributing factors was addressed in the checklist.

While there is no guarantee the checklist would have avoided those deaths if it had been used at the time, the researchers say it would likely have prevented “a considerable amount of damage, both physical and financial.”

The costs are significant.

Putting a price tag on the medical liability system is difficult, but one 2010 study estimated it costs the United States more than $55 billion annually, or 2.4 percent of the country’s healthcare spending.

In addition, experts say tens of thousands of Americans die each year due to medical errors.

Earlier studies have shown that when healthcare providers follow a checklist, they reduce those deaths dramatically and could save money by preventing complications that require further treatment.

“This kind of evidence indicates that surgeons who do not use one of these checklists are endangering patients,” said Atul Gawande at the Harvard School of Public Health, a surgeon who has written extensively on the topic.

Yet only about a fourth of U.S. hospitals use one of the three checklists that have been proven to work, he added.

“The message for hospitals is you want to adopt one of these checklists,” he said.

SOURCE From Lippincott Williams & Wilkins, Inc.: bit.ly/hmFN4M

Article via Reuters Life!

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2011 National Patient Safety Goals Now Available

December 23, 2010 By Leave a Comment

The Joint Commission 2011 National Patient Safety Goals are Now Available

The NPSGs are effective January 1, 2011. View Patient Safety Goals by Program.

Additional Update:

National Patient Safety Goal on Reconciling Medication Information – Effective July 1, 2011

The Joint Commission Board of Commissioners has approved revisions to the National Patient Safety Goal (NPSG) on reconciling medication information (was NPSG.08.01.01 but is now NPSG.03.06.01), effective July 1, 2011 for the ambulatory, behavioral health care, critical access hospital, home care, hospital, long term care, and office-based surgery accreditation programs.  The new, streamlined and focused version of the NPSG places a spotlight on critical risk points in the medication reconciliation process.  Read More . . .

Click Here to Read More on Joint Commission National Patient Safety Goals.

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Study: Many Patients Face Harm From Hospital Errors

November 30, 2010 By Leave a Comment

Despite nationwide efforts to improve patient safety in hospitals, nearly 20% of patients continue to be harmed by their care, according to a study published in the New England Journal of Medicine. Researchers analyzed 2,341 hospital admissions and identified 588 incidents of harm involving 423 patients. Two-thirds of the complications were considered preventable by hospital reviewers.

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