Archive for February, 2009
Joint Commission releases top sentinel events
In its March issue of Perspectives, The Joint Commission published an update of its top 10 most reported sentinel events. At the top is wrong-site surgery, with 741 cases reported. Out of these reported events, 69% of patients died. The top five events are:
- Wrong-site surgery
- Suicide
- Op/post-op complication
- Medication Error
- Delay in treatment
In the same issue, The Joint Commission listed its top compliance issues for hospitals. At the top is EC.5.20 (ensuring environment complies with the Life Safety Code©). Second is National Patient Safety Goal 2C, (referred to now as NPSG.02.03.01) on the reporting of critical test results. The rest of the top noncompliance standards focus mainly on information management, medication management and environment of care.
AHRQ announces states involved in CLABSI prevention project
The Agency for Healthcare Research and Quality (AHRQ) has decided which states will participate in its $3 million grant for preventing central line-associated bloodstream infections (CLABSI) in intensive care units (ICU). This press release from the AHRQ caught my eye because I wrote a story for Briefings on Patient Safetywhen this program was announced. The program will model similar prevention efforts after the Johns Hopkins University and the Michigan Hospital Association’s project that reduced these types of infections in 100 Michigan ICUs. The states announced to be involved in the study are California, Colorado, Florida, Massachusetts, Nebraska, North Carolina, Ohio, Pennsylvania, Texas, and Washington.
The goal for these states is to reduce CLABSI by 80%. Currently, the rates of infection nationally are five per every 1,000 patient days. The Michigan program set the bar high, and is the reason for replication on a broader scale. Within three months there, infection rates in more than half or participating ICUs dropped to 0%.
It seems that there was so much interest in participating in the study that the AHRQ had to turn interested states away. However, it says that the Johns Hopkins Quality and Safety Research Group has received some additional private funding to involve some of those states.
Simple solutions for patient safety
The HealthLeaders Media Industry Survey 2009, released earlier this week, shows that many healthcare leaders think that while technology is an important part of patient care, driving home the fundamentals of patient safety is actually more important. For example the notion that handwashing is far more effective at preventing HAIs than implementing some sort of technology that monitors infection rates. In fact, only 12% of who answered the survey said that their electronic medical records played a large part in improving quality and patient safety.
The cause analysis: What’s your diagnosis?
As part of the Peminic-Greeley PSO’s services, organizations recieve a comprehensive cause analysis to determine the underlying reasons why errors occur (or don’t occur). We really focus on offering a personal solution based on your specific details. Below is a snippet from an interview I had with Heather Comak, managing editor of Briefings on Patient Safety, a publication of HCPro, Inc. In this part of the interview, we were discussing what makes the Peminic-Greeley PSO different from others.
Trying to decide if joining a PSO is right for you?
If you’re part of an organization that is not sure if joining a Patient Safety Organization is right at this time, here are some suggestions on what you can focus on to gain internal buy in:
- cost of learning savings
- benefits of identification of approaches to eliminate “No-Pay Events”
- benefits of aggregation services
- benefit of protections (if applicable)
This first bullet point, about the cost of learning savings associated with a PSO will be a big reason why hospitals decide to join. Shared knowledge is a powerful tool and in an industry like healthcare it can not only save lots of money, but save the lives of patients.