Archive for November, 2009
It’s been 10 Years since “To Err is Human”; has patient safety improved?
November 2009 marks the ten year anniversary since the Institute of Medicine (IOM) released its groundbreaking ‘To Err is Human’ report, bringing to light the staggering number of medical errors and resulting preventable deaths that occur in U.S. hospitals each year (that report put the number at 98,000). Since then, entire organizations have been formed, laws passed, and new ways of thinking incorporated into healthcare in an effort to reduce this number. There has been much positive change.
My colleague Cheryl Clark at HealthLeaders Media published this article today that spells out some of the areas in which the healthcare industry has improved patient safety, as well as some of the areas that could still use attention. Some of the bright spots: Certain states have taken the lead on creating tough reporting laws and mandating detailed incident reports. The Institute for Healthcare Improvement has helped thousands of hospitals collaborate with each other and use best practices to reduce patient harm with its various campaigns. Healthcare providers have joined together to decide on common medication labeling practices to reduce the number of medication errors. The CMS will no longer reimburse hospitals for specific adverse events. There’s been a detailed look at how the culture of an organization can drive the performance of its staff members. I’d also add to this list that the AHRQ has played a huge role in funding patient safety research and spurring projects in the name of healthcare quality.
However, many adverse events continue to occur, despite the efforts of many within healthcare. The article names surgical safety, infection control, and medication safety as three areas to which more attention needs to be paid if we want to take a 20-year look back and find that even more progress has been made. I think that along with these issues is the topic of how technology will come to effect them as well. How will EMRs/ CPOE effect infection control and monitoring?
Do you think that the industry has shown significant progress since the IOM report was issued 10 years ago?
How much money is HIT really saving? Not much, according to a new study
As the government continues to focus on promoting the implementation of health information technology at U.S. hospitals, a new study finds that increased computerization has not reduced costs or increased efficiency thus far, reports HealthLeaders Media.
The study, Hospital computing and the costs and quality of care: A national study, was published in the November 20, 2009 American Journal of Medicine. One positive finding in conjunction with increased computerization was a slight bump in quality scores.
The study analyzed the approximately 4,000 annual responses to the Healthcare Information and Management Systems Society (HIMSS) Analytics survey of hospitals’ computerization for the years 2003-2007, as well as data from Medicare cost reports and cost/quality analysis developed by the 2008 Dartmouth Health Atlas.
The researchers found that overall, hospitals increased their use of information technology from 2003 to 2007. The average hospital included in the HIMSS survey had implemented 64% of the 24 computer applications asked about in the survey. However, during this time hospital administrative costs increased, although the increases were small (24.4% to 24.9%). Further, those facilities that have ramped up their use of HIT have not seen a related reduction in costs or increase in efficiency.
The study was met with protest from hospital leaders who insist that use of health information technology at their facilities has benefited the staff members and patients in the form of increased quality. It may be too soon to assess cost reductions associated with HIT.
HealthLeaders Media spoke to a few leaders in the industry who felt that forms of HIT, such as electronic medical records (EMR) and practitioner order entry, are worth their initial investment because of the effect they are having on quality and patient safety. You can read their views here. Most feel that the true value of HIT will not be realized until the many forms in use at hospitals and health systems are interconnected.
What has the discussion about HIT centered around at your facility? Are there more proponents than opponents, or vice versa? Have there been new processes rolled out with switches to EMRs or CPOE?
AORN and 3M team up for hand hygiene initiative
The latest initiative to be announced in the name of preventing healthcare-acquired infections (HAI) comes from the Association of PeriOperative Registered Nurses (AORN) and 3M. The two groups are partnering on the “It’s In Your Hands” campaign to bring to light the best hand hygiene practices for the according to AORN’s recently revised “Recommended Practices for Hand Hygiene in the Perioperative Setting.”
The campaign also seeks to involve nurses around the country by inviting them to share their creativity through a YouTube video contest. Nurses can enter videos via YouTube from December 1, 2009 through January 18, 2010. The short videos should address proper hand hygiene techniques for the operative setting that comply with the revised AORN practices, as well as address the topic from both an educational and fun standpoint.
During the week of February 1, the final three videos, as chosen by a panel of AORN Recommended Practices Committee members, will be displayed on the AORN Web site. Visitors to the Web site will be able to vote on their favorite video until February 22. The nurses behind the video voted to be number one will receive up to three free registrations to the AORN Annual Congress, paid for by a 3M grant. More information about the contest will be posted at www.aorn.org after December 1.
The human side of patient safety
An article appearing in the New York Times earlier this week addresses an interesting view on the world on patient safety: with so much focus on preventing adverse events, treating patients as human beings has fallen by the wayside. The author contends that in an attempt to fill out the right forms, ensure the correct tests have been ordered, and make sure all regulations have been complied with to get patients back on their feet, healthcare workers are more interested in “satisfying the system” than treating patients.
I wonder if this idea is true and if so, is there anything that can be done to both provide care in a manner that is ‘by the book’ and take the time to get to know patients, and in doing so, help them heal? I think there is some truth to the opinion but I also think that patients are better off today (patient safety-wise) than they were ten or 15 years ago. Although patients may not know personally their physicians as well as they have in the past, they can be sure that measures are in place at their hospitals to help prevent them from acquiring certain infections, or encourage proper medication labeling.
What are your thoughts on the topic?
Press Ganey report: Patient satisfaction increasing across the country
Patient satisfaction is on the rise, according to Press Ganey’s annual Hospital Pulse Report. The report surveyed nearly 3 million patients about their experiences at more than 2,000 hospitals nationwide during 2008. Overall, patient satisfaction has steadily increased since 2003, with 85% of those surveyed reporting satisfaction with care in October 2008. Additionally, Press Ganey found that more patients than ever before (a 1.96 % increase) were likely to recommend the facility where they had received care to a friend. The area that most affects how patients rate their care corresponds to communication—how staff members communicate with patients, especially when patients express concerns or complaints during their stays.
The report identifies as a catalyst for quality improvement that hospitals began publicly reporting their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data in March 2008, and in turn increased patient satisfaction scores. The scores are available on www.hospitalcompare.hhs.gov. Some members of the public are turning to the site to find information for comparing inpatient care in their area. However, according to the report, the larger effect has been that providers are aware of their own and their competitors’ scores, and are putting more effort into delivering patient-centered care as a result.
Have you seen a change in how services are offered, or how your day-to-day shifts occur due to some of the focus areas on the HCAHPS survey?
Another case of hospitals behaving badly
St. Francis Hospital and Medical Center in Hartford CT is the latest facility to make headlines for violating state regulations concerning patient care. The hospital was placed on probation by the Connecticut Department of Health, according to the Hartford Courant. One of the more recent instances involved a heart surgery patient who sustained a brain injury during a May18 surgery. The patient later died on June 18, and on July 2, the hospital stopped offering non emergent cardiac surgeries.
The major problem in this case stemmed from a pump failure with the pump used for cardiopulmonary bypass, according to the Courant. The hospital did not address the pump failure adequately. Specifically, the hospital didn’t report the pump failure to the Food and Drug Administration or the manufacturer or communicate the failure to hospital leaders and other members of the medical staff. Additionally some of those providers involved in the surgery did not participate in a cause analysis, and what I think constitutes the worst offense, the hospital put the pump that failed back into use just three or four days after the incident.
The hospital has issued a statement saying that it has made administrative changes, updated OR procedures, and revised equipment and maintenance protocols. You can find the full article here.
I wrote this post last week about a Rhode Island hospital that was fined by the state’s Department of Health. I know that these two cases are gaining media attention, so that’s not to say that other facilities in their area are not committing similar errors. But in reading the descriptions of how the situations were handled, it seems to me that neither facility really placed much emphasis on learning from their mistakes, which I think is what is most startling.
Joint Commission and HHS publish new video to improve patient-provider communication, reduce disparities in care
The Joint Commission and Health and Human Services released yesterday a 30-minute series of videos titled Improving Patient-Provider Communication: Joint Commission Standards and Federal Laws. The videos, which can be found on YouTube, were created out of recognition that there are a lack of resources out there that touch on methods for improving communication between patients and their providers for non English speaking patients, and patients who are hard of hearing. Additionally, the are many current regulations surrounding those topics, and The Joint Commission is developing a set of standards surrounding cultural competence, patient-centered care, and effective communication.
The project runs through January 2010. It will attempt to address how better to incorporate health literacy, culture, and diversity into Joint Commission standards. You can read more about the project here.
Diagnosis errors: No easy fix
Physicians are responsible forone of the most complicated and important decisions in medicine: the diagnosis. Any further treatment plan rides on this diagnosis, and it may not be surprising that diagnosis error is now being looked at as a significant percentage of all medical errors. A report published in the November 9 Archives of Internal Medicine showed that anonymously, 310 physicians revealed 583 diagnosis errors, of which 44% were related to lab and radiology testing errors, including test ordering, test performance, and clinician processing.
But why do physicians make diagnosis errors? The answer lies in both cognitive processes and they systemic factors that influence the way in which a medical decision is made.
I co-wrote an article for HealthLeaders Media today about diagnosis error. The idea came from listening to one of theInstitute for Healthcare Improvement’s recent WIHI programs on the topic, which, if you haven’t listened in to yet this year, are truly worth catching. There is a great dialogue between the expert speakers and the audience because they address many of the questions that listeners bring up while virtually “chatting” with one another. Anyway, the WIHI featured Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston and Pat Croskerry, MD, PhD, professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia. Both of these men are leaders in the field of diagnosis error and recently helped plan the second annual conference on the topic. Schiff is an author on the aforementioned Archives of Internal Medicine report.
Both men discussed that diagnosis errors occur more often than they are reported, and they have not been given as much attention to errors like medication errors, falls, and other tangible errors. This is because of the underreporting and also because it is harder to make the case that someone’s thinking was the cause of an error. In fact, diagnosis errors are partially the result of a cognitive impairment and partially the result of systemic failures—meaning the hospital system sets physicians up for failure.
I find the topic fascinating, what are your thoughts? The idea that people create certain thinking biases, often without even knowing it, and that that bias can factor into a decision that may determine the course of a patient’s treatment, even if it is the wrong treatment—it is a scary thought, but interesting nonetheless.
I suggest checking out the HealthLeaders article, please let me know of any feedback!
Announcing Patient Safety Monitor!
HCPro is launching its newest product today: Patient Safety Monitor, an online resource for your patient safety needs. The product features the monthly newsletter Briefings on Patient Safety, a tools library, access to our popular “Patient Safety Talk” listserv, and weekly news alert. The main features is the Crosswalk, which organizes many patient safety-related regulations by what is required by The Joint Commission, CMS, and all 50 states.
This blog is actually a part of the larger Patient Safety Monitor product, and you’ll now notice a link back to the home page in the “links” section in the righthand column of the blog. If you’re already a subscriber of Briefings on Patient Safety, you now have access to Patient Safety Monitor as part of your subscription.
If you’re interested in finding out more about Patient Safety Monitor, be sure to check out the demo. You can also sign up for a free 7-day trial.
I don’t often publicize lots of our HCPro products using this blog simply because I know that most readers aren’t coming here for that. But I do think that readers of this blog might be interested in what this product has to offer. I hope you check it out!
RI hospital commits fifth wrong-site surgery since January 2007
Staff members at Rhode Island Hospital in Providence, have committed the facility’s fifth wrong-site surgery since January 2007, resulting in a $150,000 fine levied by the state’s Department of Health (DOH), reports The Providence Journal. This is only the second time that the hospital has been fined, the first being after the hospital’s third incorrect neurosurgery occurred in 2007. The latest wrong-site surgery involved a procedure done on a patient’s incorrect finger. In addition, the DOH is requiring that the hospital
- install video and audio monitors in each operating room
- allow a licensed clinical professional who isn’t part of the surgical team to observe every surgery for a year
- adopt the statewide procedure for using safety checklists and marking the surgical site
- summarize each wrong-site surgery since 2005 to send to accrediting and government agencies
- conduct mandatory training sessions for all staff members who work in the operating room to review procedures
Readers, I’m wondering what you, as people who work in hospitals each day, make of this? This hospital, which should have been by all accounts been following the Universal Protocol as well as the state’s guidelines for preventing wrong-site surgery, did not. However, many readers of this blog may know and understand the culture necessary to ensure that the correct steps are taken to prevent a wrong-site surgery. Do you think the requirements made by the Health Department will prove to help this facility sort out its patient safety issues? Do you have any general thought about this instance?
In a related note, the president and CEO of Rhode Island Hospital, Timothy Babineau, MD, has offered to answer questions on the hospital’s Web site through November 9 (not specifically related to this event, but you could get any questions on this topic to him if you so desire).
Please see the Providence Journal article, it does a good job of explaining the story.
