All Entries Tagged With: "error reporting"
How does your hospital’s patient safety culture compare?
The Agency for Healthcare Research and Quality (AHRQ) has released Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. You can compare your hospital’s culture to 1,032 others in the U.S.
The survey was developed in 2004 to help hospitals assess their patient safety culture in 2004. The first benchmarking database was released in 2007 and included data from 382 hospitals.
Out of 472,397 staff working in these hospitals, teamwork within units had the most positive response (80%). Most also rated their hospital well in regard to managers listening to input from staff about patient safety and praising staff for following patient safety protocol (75%).
Staff did not rate their hospitals as well when it came to creating a nonpunitive response to error (44%), or implementing safe handoffs and transitions (45%).
Interestingly, 54% of respondents, on average, reported no adverse events in their hospital over the past year, an indication of possible underreporting.
The survey results urge me to do a bit of promoting of two books I truly think readers might have interest in:
First is Creating a Just Culture: A Nurse Leader’s Guide. The authors go into detail about what it actually takes to create a nonpunitive culture (hint: it’s not easy, but in time it can be done!). It’s an easy read that provides sample incident reporting policies, a sample just culture principles document, case scenarios, advice on disclosure, and more.
Second is Occurrence Reporting: Building a Robust Problem Identification and Resolution Process. What’s to love about this book? It takes the overwhelming process of event reporting and whittles it down, giving advice on which events to collect, which events to focus on, how to implement a system that staff actually use, how to make sure actual, quality improvement actions come out of all the work, etc.
Okay, I’ve said my piece. Now say yours: Does this report surprise you? Does your hospital leadership let you know where you stand, comparatively? What’s holding up nonpunitive culture and event reporting? Share your thoughts below.
New California law prompts healthcare facilities to report radiation overdoses
California hospitals have less than a year to adhere to a new law requiring the state Department of Public Health to be notified any time a patient is given a radiation dose in an imaging scan exceeding 20% of what was intended, reports HealthLeaders Media.
The new bill signed by Arnold Schwarzenegger won’t go into effect until July 1, 2012.
Recent overdoses of radiation in the state have prompted the new bill. Cedars-Sinai Medical Center in Los Angeles admitted to accidently giving 206 stroke victims eight times the dose of a normal radiation procedure, according to an article in The New York Times.
A two-year-old boy in a California hospital was administered an overdose of radiation which allegedly burned parts of his face, according to CW13.
The new law requires hospitals and clinics to record every radiation dose done on CT systems. The recorded doses then must be verified by a medical physicist. Healthcare facilities have five days to inform the Department of Health if anything goes wrong.
Read the rest of this article on California’s new law at HealthLeaders Media.
What do you think of the new law passed by California? Share your comments with us!
Hospital Culture report shows gains, areas for improvement
In more news from the Agency for Healthcare Research and Quality (AHRQ) this week, a snapshot of the nation’s culture of safety at hospitals shows some positive strides as well as room for improvement. The Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report was released yesterday, providing interested parties the chance to compare their own hospital’s culture with facilities around the nation who administer the Hospital Survey on Patient Safety Culture. This survey poses a series of questions to staff about their perceptions of the culture at their institution around the following domains:
- Communication openness
- Feedback and communication about error
- Frequency of events reported
- Handoffs and transitions
- Management support for patient safety
- Nonpunitive response to error
- Organizational learning–continuous improvement
- Overall perceptions of patient safety
- Staffing
- Supervisor/manager expectations and actions promoting safety
- Teamwork across units
- Teamwork within units
The 2010 report pulls together survey responses from 885 hospitals, representing 338,607 respondents. Of the 885 hospitals, 321 have already submitted data in previous years, and can observe their own trends within the report. The report has been released annually since 2007. The actual survey was created in 2004 to help hospitals measure their own cultures of safety and attitudes about patient safety.
The three most positively rated areas included in the report are teamwork within units, supervisor/manager expectations and actions promoting patient safety, and the overall patient safety grade of the unit or hospital (mostly As and Bs). The three areas with the largest potential for improvement nonpunitive response to error, handoffs and transitions, and number of events reported (most staff said they did not report any events).
You can find a link to the full report here. It breaks out many different characteristics of survey respondents, like facility size, location, teaching status, and even by specific work units within hospitals.
Does your hospital use the AHRQ Hospital Survey on Patient Safety Culture to assess perceptions surrounding patient safety at your facility? Do you use another tool? No tool at all? I think this report is a helpful snapshot, but it using this information for improvement is really in the hands of hospitals themselves. There is a “recommendations” section at the end of the report for analyzing survey results, which could help guide hospitals.
Joint Commission posts updated Sentinel Event data
The Joint Commission has posted its latest sentinel event statistical brief. Not much has changed as far as the top most reported events from 1995-2009:
- Wrong-site surgery: 13.5%
- Suicide: 11.9%
- Op/Post op complication: 10.9%
- Delay in treatment: 8.4
- Medication error: 8.1
- Patient fall: 6.4
- Unintended retention of foreign body: 5% (only reflects from 2005-2009 because it was added as a sentinel event in 2005)
In 2009, 153 more events were reported (be it self reported, or non-self reported) to The Joint Commission than in 2008. The thinking here is usually that more reports does not necessarily mean worse care–it means that healthcare providers are becoming more comfortable with reporting adverse events.
Does this data help you? Have you found that occurrence reports have been growing at your own facility? Have you struggled to create a culture of reporting? It’s certainly one of the most difficult things to get across to staff, who often feel like they’ll be penalized for reporting.
GAO says not enough information yet about PSO system to assess progress
The Government Accountability Office (GAO) was required by the Patient Safety and Quality Improvement Act of 2005 to assess the effectiveness of the law by February 1, 2010. In its report released on January 29, the GAO found that although the Agency for Healthcare Research and Quality (AHRQ), under the direction of the Department of Health and Human Service (HHS), has taken action to carry out the intent of the Patient Safety Act. However, because much of the action took place within the last year (final regulations became effective on January 19, 2009), the GAO is unable to evaluate at this time if the intent of the Patient Safety Act is being carried out.
The Patient Safety Act required a few things:
- The establishment of Patient Safety Organizations (PSO) to work with hospitals in collecting patient safety data
- A set of “common formats” in which data should be collected
- The creation of a Network of Patient Safety Databases (NPSD), to which PSOs would submit de-identified patient safety data. The data would eventually be analyzed and used to improve nationwide patient safety practices.
After consulting with administrators at the AHRQ, HHS, and 17 out of the 65 registered PSOs, the GAO found that although solid groundwork has been laid for carrying out the intent of the law, it is too early to tell if the law is being effective, as many of the requirements are in the midst of being completed. However, the GAO cautions, because it is voluntary for hospitals to contract with a PSO in the first place, the full value of the law may never be realized even when all of the work of listing PSOs, establishing the NPSD, and analyzing data is finished.
You can find the full report from the GAO here.
I’m curious about what you make of this report. It was required by law to be undertaken, but it seems to me like it would have been more logical to assess that there’s not been enough action taken yet to fully report on the effectiveness of the Patient Safety Act, and to shelve the report for a year or two. That being said, one of the striking things that did come out of the report seems to be the overall lack of hospital engagement with existing PSOs. Of the PSOs interviewed, only three had already collected data from contracted hospitals. What’s more, only four PSOs reported having contracts to work with hospitals to collect data for the NPSD.
Has your hospital elected to work with a PSO? Do you know why or why not?
OIG says adverse event reporting systems vary by state, many are limited
The Office of Inspector General released a memorandum last week saying that there is no standardized method of collecting adverse event information nationally, and that state systems vary on how they define and manage this information. The memorandum, mandated by the Tax Relief and Health Care Act of 2006, outlined the results of an examination of adverse event reporting systems in 17 states, as well as eight Patient Safety Organizations, and CMS’ “never events.”
Of the states it looked at, seven states made more information public than others. These were Maryland, Massachusetts (which has two systems), Minnesota, New Jersey, Oregon, and Pennsylvania. There were three states that disclosed less than the first seven, including Colorado, Maine, and Rhode Island, and seven other states had no public disclosure included with their adverse event reporting systems. These were Utah, Florida, Nevada, New York, South Carolina, South Dakota, and Vermont.
Overall, even with the inclusion of Patient Safety Organizations (which were launched a year ago as the byproduct of the Patient Safety Act of 2005), there is a lack of one central database to which all hospitals can submit adverse event data. PSOs have created the Network of Patient Safety Databases, as well as a list of common formats for which adverse event data can be in, but that is just for PSOs and not for the state adverse event reporting systems. Additionally, the data coming from the NPSD will not be available for analysis until early 2011.
Do you live in a state that collects adverse event reporting data and if so, is that data made available to the public? Do you think the government needs to take on a larger role in creating a standardized set of adverse events around which data should be collected at each hospital?
You can read more analysis about the memorandum in this HealthLeaders Media article.
“Big Brother” may be keeping watch on patient safety practices
Maryland is using some of its funds from the American Recovery and Reinvestment Act to pay for “secret shoppers” to evaluate whether hospital staff members are washing their hands. A Rhode Island hospital is being forced to install video cameras by the state’s department of health to monitor its operating rooms because several wrong-site surgeries have occurred there in the past few years. These examples may be part of a new trend of hospitals using surveillance as a technique to improve patient safety, reports American Medical News.
The data from the Maryland project will not be made public, but will be shared with all participating hospitals. Hospitals will be able to compare the rates of compliance among groups of staff members, such as physicians and nurses.
The use of surveillance to improve patient safety can be effective, as long as it is used as a helpful aid, Mark Chassin, MD, MPH, president of The Joint Commission told American Medical News. However, he said, secret shoppers, video cameras, and other types of technology can only be successful if they are not also undermining the culture of an organization.
This balance is certainly a difficult one to strike. Has your organization employed any type of surveillance in an effort to improve patient safety? The use of hand washing monitors is probably the most common form of surveillance that I’ve heard of, and usually these are done in conjunction with some other sort of “fun” patient safety or infection control initiative a hospital. This type of surveillance mentioned in the American Medical News article takes the idea to a new level, and it will be interesting to see if it has a larger effect on patient safety than other tactics.
AHRQ spearheads effort to bring patient voice into error reporting
The Agency for Healthcare Research and Quality (AHRQ) is leading an effort to give patients a voice in error reporting. I wrote this article for HealthLeaders Media last week, and a longer version will be appearing in the September Briefings on Patient Safety. It discusses how the AHRQ is working with a couple of groups to design a consumer reporting system. 2009 brought us Patient Safety Organizations, formalized reporting opportunities for healthcare professionals, but often missing from the discussion about how medical errors occur is that of the patient. However, patients offer a viewpoint that is unique–one that observes the entire continuum of care. Healthcare providers are at the disadvantage of only knowing what happens when a patient is under his or her care, and not once that patient has moved on.
I spoke with Sue Sheridan, of Consumers Advancing Patient Safety, about her involvement with the project. Sheridan, a woman who has had two major medical errors occur to family members, has been a great voice in helping to design what a consumer reporting system might look like. She, along with 17 other experts that are part of a technical expert panel, are helping to advise and mold a possible consumer reporting system. The project also involves extensively interviewing patients and family members who have been victims of medical errors.
You can read the article by clicking here. What are your thoughts about standardizing a method for collecting consumers’ error reports?
