PA releases critical report in patient death

The Pennsylvania Department of Health cited the University of Pittsburgh Medical Center (UPMC) Montefiore for problems with patient assessment and building safety in the wake of the death of an 89-year-old patient in December, according to an article in the Pittsburgh Post-Gazette.

A maintenance worker found Rose Lee Diggs on the roof of UPMC Montefiore on December 3. The dementia patient died shortly afterward. State health investigators discovered numerous problems, including a failure to implement a plan of care. The facility was not penalized as a result of the findings.

Diggs had been transferred to the hospital from a nursing home on November 29, 2008. The nursing home notified the hospital that Diggs had been known to wander, according to the report. She reached the roof of the hospital through the door of a 13th floor mechanical room, which had a broken lock. Her body was found 13 hours after she was last seen in her 12th-floor room; she was wearing only a hospital gown and slippers on a night during which temperatures dipped into the 20s.

UPMC submitted an acceptable plan of correction on January 9 addressing the issues raised in the report, according to a Health Department spokesperson.

NJ bill would reveal hospital ‘never events’

A new bill working its way through the New Jersey legislature would reveal the identities of hospitals that commit medical errors including wrong site surgery and healthcare-associated infections, the Star-Ledger reports today.

Approved by a state Senate panel Monday, the legislation would expand the Patient Safety Act, which was enacted in 2005 and requires hospitals to report mistakes to the state Department of Health and Senior Services. The law currently protects hospital confidentiality because its sponsors believe it encourages disclosure.  The bill (S2471) provides broader disclosure under a compromise that a number of groups–including hospital groups, the AARP, unions, and state officials–supported in principle, the paper reports.

The bill now advances to the full state Senate.

The state would collect the information from billing records and publish it in the annual New Jersey Hospital Performance Report, which would be available online. In addition, the bill prevents the hospitals that made the mistakes and physicians who have admitted playing a role in the errors from seeking any payment for care associated with the errors. The bill would track the “never events” defined by CMS.

Resource for HAI prevention

Readers: As you have been reading in the posts below, hospitals are facing a great amount of pressure to get rid of  hospital-acquired infections (HAIs). I wanted to share news with you about a new audio conference coming up on March 23rd that will give expert advice on useful solutions to common HAI prevention pitfalls.

Pat Pejakovich and Connie Steed will be presenting. For more details, click here. It’s sure to be a great show.

HHS takes on HAIs in battle of acronyms

The fight against healthcare-associated infections (HAI) is a hot topic these days, and not just on the state level as we noted in our previous post. The federal government is getting in the act, too. The department of Health and Human Services (HHS) earlier this month unveiled a five-year plan for the prevention of HAIs.

The plan includes prevention targets for the elimination of six categories of HAIs: Central line-associated bloodstream infections, Clostridium difficile infections, catheter-associated urinary tract infections, Methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical site infections, and ventilator-associated pneumonia. The plan also outlines cross-agency efforts to save lives and reduce healthcare costs through expanded prevention efforts. It’s an ambitious effort and the plan’s introduction notes that the goal of eliminating all HAIs may not be attainable, but hey, at least they’re trying.

The value of nurses

I wanted to post an interesting article found on Nurses.com about a new study by the Lewin Group and sponsored by the American Nurses Association (ANA) and other nursing associations on the economic (and inherit) value of nurses.  By combining findings from 28 different studies, the ANA found that as nursing staffing increase, risk of compliacations for patients, as well as length of stay, decreases, thus improving patient safety and reducing costs. [more]

Quite the trend: States screening, tracking infection

Washington, Ohio, Pennsylvania, oh my! States are getting involved with hospitals more than ever these days, and one of the top areas they’re making a mark in seems to be infection control. Just this past month:

• Washington (WA), which has been in the spotlight since the Seattle Times wrote an in-depth piece on soaring MRSA rates, has proposed legislation in its House of Reps. that if passed, would require hospitals to screen “vulnerable” patients and isolate them in private rooms. The legislation would also subject hospitals to surprise inspections by the  Department of Health. Such requirements would make WA one of the most involved states in hospital policy.
• Business leaders and 24 hospitals in Ohio have launched “Solutions for Patient Safety,” a collaborative effort to reduce infections and medical errors. The group has received $1.5 million from Cardinal Health Inc. Those involved hope the initiative becomes a statewide effort as the Ohio prepares to publish hospital quality data online.
• Pennsylvania (PA), a well-known leader in patient safety efforts, has reported an 8% drop in infections from 2006 to 2007, according to a Pennsylvania Health Care Cost Containment Council report. This is the state’s third report on hospital-acquired infections, which included an impressive 1.6 million patients in 165 acute-care hospitals. The PA Safety Authority has also launched a new Web site design.

Readers: I know most of you are already facing intense pressure from the Joint Commission and the Centers for Medicare & Medicaid Services to reduce infection rates and make them public—what do you think about your state getting involved with surprise inspections, mandatory screening and reporting? Post your comments below.

Half of U.S. states use reporting systems

The PSM blog will be covering state regulations regarding patient safety extensively, so I thought this would be an interesting item to begin with:

The Agency for Healthcare Research and Quality (AHRQ) has released a December 2008  report by Department of Health and Human Services detailing the use of state reporting systems for adverse events occuring in hospitals. Here are some interesting key findings:

• As of January 2008, 26 states have adverse event reporting systems in place.
• Though three states use the National Quality Forum’s list of reportable events, the rest created their own lists.
• Twenty-three states reported using data to hold hospitals accountable; 18 states reported using data to promote learning and  prevent adverse events.

The report noted that states have no federal guidelines for these reporting systems, nor is there a national reporting system in place. This results in disparate reporting systems with results that cannot be combined in any suitable way to identify national trends. The report also noted, however, that state reporting systems help to assess a hospital’s response to an adverse event.

What do you think of your state’s reporting system? Do you have one? Do you need one? Leave your comment below!

How to get the most out of our PSM Blog

Welcome! As Jay posted below, this new Patient Safety Monitor Blog will cover those important patient safety regulation you need to know about. Here are some tips to better use the site so you’re always in the loop:

• It’s easy to share. Clicking on an individual post allows you to pass the entry along to  friends and colleagues through e-mail or by linking to another site.
• Use our  RSS feed. The orange icon in the upper right-hand corner of these posts will help you track PSM Blog news quickly, easily and efficiently.
• Get PSM Blog notifications sent to your email. In the right-hand column, you’ll find the option to subscribe to the blog to give you an update of the latest news and discussions.
• Know what the hot topics are. The “tag cloud” on the lower right will show you which topics are the most common topics being discussed.

If you have any questions about the new PSM Blog, or want to pass along any comments about our new setup, please e-mail me.

Welcome to PSM Blog

Hi, everyone. I’d like to officially welcome you to the Patient Safety Monitor Blog. We plan to use this venue to present information about patient safety regulations and requirements that affect hospitals, both on a federal and state level. We’ll also highlight new features and information added to the Patient Safety Monitor Crosswalk and site, as well as anything else we deem interesting or worthwhile. My colleague Tami Swartz and I will write the majority of the posts here, but when news breaks that requires additional analysis, we’ll turn to our prestigious PSM advisors for their tips and advice. The blog will be updated daily and occasionally more often than that if warranted, so please check regularly. And don’t be shy about leaving comments or asking questions.  Thanks for stopping by!

Contest Rules

The following are rules that will be used for any contests run through this blog.

1. No purchase necessary.
2. To enter, please include your name and facility with the entry.
3. You must be 18 years of age to enter.
4. To be eligible, entries must be completed and received by August 24. Incomplete entries will be disqualified. All entries become the property of HCPro, Inc. HCPro is not responsible for lost, misdirected, or delayed entries. Entries must be received by e-mail.
5. Potential winners will be notified by e-mail.
6. Decisions made by the judges are final.
7. By entering the contest, the entrant allows his/her name to be reprinted on the Patient Safety Monitor Blog without compensation. 
8. The prize is not redeemable in cash and must be accepted as awarded.
9. Winners must provide a valid mailing address to receive their award.
10. Employees (or immediate family members of employees) of HCPro, Inc., are not eligible to win.
11. HCPro, Inc. reserves the right to amend and change these rules as it deems necessary. Varying contests will have various rules.
12. One entry per person.
13. By entering this contest, you agree to accept and abide by these rules.