From the 8 March 2016 Imperial College London press release
Avoidable harm to patients is still too high in healthcare in the UK and across the globe.
Safety therefore must be a top healthcare priority for providers and policy makers alike.
These are the findings of two reports launched today by researchers from Imperial College London. Both reports, produced by NIHR Imperial Patient Safety Translational Research Centre (PSTRC), provide evidence on the current state of patient safety and how it could be improved the future. They urge healthcare providers to embrace a more open and transparent culture to encourage continuous learning and harm reduction.
The first report focuses on the current system used by NHS staff to report patient safety incidents, called the National Reporting and Learning System (NRLS). The report authors explain this system requires refinement and renovation, so as to take advantage of new technologies and recent behavioural insights. For example app-based technologies offer a simplified platform that engages staff in the incident reporting process. This will not only improve the ease of reporting, but also the accuracy of data reported.
In particular, the report reiterates problems around under-reporting of safety incidents, and reveals structural concerns within the NRLS, that have inhibited its usefulness as a tool to drive safety improvement.
The second report, Patient Safety 2030, suggests a ‘toolbox’ for patient safety. This would include: using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. Other points in the ‘toolbox’ include effective and high-quality education and training; strengthening measurement methods, including incident reporting, and exploring new digital solutions.
However, the authors warn that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and empower patients and staff to become more involved in preventing harm and improving care.
Ultimately, both reports issue a global call-to-action on patient safety: both for individual health systems to convert the evidence on how to improve patient safety into everyday practice, and for the global community of health systems to share learnings from each other’s successes and failures.
The publications: “NRLS Research and Development Final Report”, funded by NHS England, will be presented on March 8th at the Royal Society in London. The “Patient Safety 2030”, funded by a grant from the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK, will be presented on March 9th at the Patient Safety Global Action Summit 2016.
From the 14 February 2014 item at The Health Care Blog
“…. many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning.”
Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input.
In other words, just because it’s a “health” app doesn’t mean its necessarily so.
Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided
From the US Health and Human Services press release
Hospital-acquired conditions decline by 17 percent over a three-year period
A report released by the Department of Health and Human Services today shows an estimated 50,000 fewer patients died in hospitals and approximately $12 billion in health care costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer health care system occurred during a period of concerted attention by hospitals throughout the country to reduce adverse events. The efforts were due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. Preliminary estimates show that in total, hospital patients experienced 1.3 million fewer hospital-acquired conditions from 2010 to 2013. This translates to a 17 percent decline in hospital-acquired conditions over the three-year period.
“Today’s results are welcome news for patients and their families,” said HHS Secretary Sylvia M. Burwell. “These data represent significant progress in improving the quality of care that patients receive while spending our health care dollars more wisely. HHS will work with partners across the country to continue to build on this progress.”
Today’s data represent demonstrable progress over a three-year period to improve patient safety in the hospital setting, with the most significant gains occurring in 2012 and 2013. According to preliminary estimates, in 2013 alone, almost 35,000 fewer patients died in hospitals, and approximately 800,000 fewer incidents of harm occurred, saving approximately $8 billion.
Hospital-acquired conditions include adverse drug events, catheter-associated urinary tract infections, central line associated bloodstream infections, pressure ulcers, and surgical site infections, among others. HHS’ Agency for Healthcare Research and Quality (AHRQ) analyzed the incidence of a number of avoidable hospital-acquired conditions compared to 2010 rates and used as a baseline estimate of deaths and excess health care costs that were developed when the Partnership for Patients was launched. The results update the data showing improvement for 2012 that were released in May.
“Never before have we been able to bring so many hospitals, clinicians and experts together to share in a common goal – improving patient care,” said Rich Umbdenstock, president and CEO of the American Hospital Association. “We have built an ‘infrastructure of improvement’ that will aid hospitals and the health care field for years to come and has spurred the results you see today. We applaud HHS for having the vision to support these efforts and look forward to our continued partnership to keep patients safe and healthy.”
From the 21 December 2012 post at The Health Care Blog
…Julia Hallisy learned about patient safety the hard way. Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation…
…Hallisy decided to write a book that might help others. In 2008, I reviewed it on HealthBeat…
At the time I wrote: “Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.”
Recently, Hallisy emailed to tell me know that the book has now become a non-profit foundation: The Empowered Patient Coalition.
Go to their website and you will find fact sheets, checklists, and publications including, A Hospital Guide for Patients and Families that you can download at no charge. I found the Hospital Guide eye-opening. I have read and written a fair amount about patient safety in hospitals, but it told me many things that I did not know…
[Great outline of doctor/nursing hierarchy]
[Questions Patients and Advocates Should Ask]
[What To Look For In Your Medical Record]
As Elizabeth points out, it is important for patients and patient families to advocate for themselves.
Competent professional health care providers will welcome folks who are prepared and take an active role.
Dedicated hospital staff will not feel antagonized. They will work address concerns and questions for the patient’s benefit.
From the 2 February 2012 article at USA Today
Elizabeth Bailey learned what could go wrong in a hospital the hard way: by watching her elderly father endure a long in-patient nightmare.
It’s important to keep your medications organized because drug mix-ups are among the biggest risks you face in a hospital, experts say.
It’s important to keep your medications organized because drug mix-ups are among the biggest risks you face in a hospital, experts say.
Her dad got too much of one medicine, not enough of others and the wrong food (heavy sweets for a diabetic). One day, he went missing for six hours and, on another, he ended up in restraints on a psychiatric ward (he was suffering mental confusion from his mismanaged medications and poorly controlled blood sugar).
“There were mistakes all the time,” says Bailey, who at the time was a music video producer. “I felt like I was on a very poorly run film set.” She realized her family needed a system to handle the chaos.
Six years later, she has turned that system into a book:The Patient’s Checklist: 10 Simple Hospital Checklists to Keep You Safe, Sane & Organized. And she is no longer a video producer: Instead, at age 50, she is a graduate student in health advocacy and a patient representative at a New York City hospital.
Her mantra: “You want to go in hoping for the best, but you have to prepare — I don’t want to say for the worst — but you have to prepare for everything.”
Among her checklists:
•Before-you-go list. One tip: Organize a schedule for friends and family to be with you in the hospital. Especially crucial: having someone with you the night after a surgery (even if you must hire someone).
•What-to-bring list. Included: “economy-sized hand sanitizer.” You should plant that next to your bed so that you can frequently clean your hands — and not-so-subtly remind everyone else to do likewise. That may lower the risk that you will pick up a nasty infection.
•Daily medication log. She provides a chart to keep track of the name, timing and dosage of every drug you get. That’s because drug mix-ups are among the biggest risks you face in a hospital.
•Discharge plan. On that list: Make sure you know how to handle surgical sites, medical equipment and medications at home….
In her recent book, “The Patient’s Checklist: 10 Simple Hospital Checklists to Keep You Safe, Sane and Organized,” Elizabeth Bailey describes the simple steps patients can take to avoid some of the most common (and potentially deadly) medical mistakes in the hospital. The theme throughout: Pay attention, ask questions, and never assume that any hospital is error-free where your care is concerned.
Including these links
From a recent email from AHRQ (US Agency for Healthcare Research and Quality)
Teamwork and patient care tracking/follow-up are strengths for medical offices, but work pressure and pace are areas for improvement, according to new results from the AHRQ Medical Office Survey on Patient Safety Culture. Most (84 percent) medical office staff feel they have good teamwork among staff and providers and that the office follows up with patients appropriately (82 percent). But only 46 percent of staff rated the work pressure and pace in their office positively. The first edition of the Medical Office Survey on Patient Safety Culture: 2012 User Comparative Database Report provides results from 23,679 staff from 934 U.S. medical offices. The report helps medical offices compare their patient safety culture scores with other medical offices. It contains detailed comparative data on the survey by number of providers, specialty, ownership, region, and by staff position. Select to access the survey that can be used by medical offices, health systems and researchers to assess the opinions of medical office staff about patient safety issues and overall quality of care. It measures 10 areas of patient safety culture as well as overall ratings on quality and patient safety.
Am thinking that maybe the amount of “paperwork” would be factor in the ratings.
And that more providers could potentially affect ratings.
Maybe so..an excerpt from the summary
Number of Providers
- Medical offices with one or two providers had the highest average percent positive on all 10 patient safety culture composites.
- Percent positive scores (those responding “Excellent” or “Very Good”) for all five Overall Ratings on Quality were higher for medical offices with fewer providers.
- Medical offices with two providers had the highest (74 percent) percentage of respondents who gave their medical office an Average Overall Rating on Quality and Patient Safety of “Excellent” or “Very good.” Medical offices with 14 to 19 providers had the lowest (57 percent).
From the 15 March 2012 posting at The Health Care Blog
Far too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.
The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.
Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:
The posting goes on to include short checklists for use in hospitals, clinics, and doctor offices.
To help reduce harm, clinicians must partner with patients and families. Patients can use this checklist, as well as the information and tools listed below, to help keep them safe.
20 Tips to Help Prevent Medical Errors(Agency for Healthcare Research and Quality)
Don’t Become the Victim of a Surgical Error (CNN)
Medical Errors: Tips to Help Prevent Them (American Academy of Family Physicians)
My Health Notebook (Johns Hopkins Medicine)
Patient Handbook (Johns Hopkins Hospital)
Patient Safety Video (Johns Hopkins Hospital)
Patient Safety Checklists (Campaign Zero: Families for Patient Safety)
Taking Charge of Your Healthcare (Consumers Advancing Patient Safety)
From the 15 February 2012 Health Care Blog item
Patients, providers and the public have much to celebrate. This week, the Centers for Medicare and Medicaid Services’ Hospital Compare websiteadded central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.
Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences….
The US Agency for Healthcare Research and Quality is working to empower us through an ad campaign and online materials.
The ad campaign Questions are the Answers includes public service announcements (the videos may be viewed here)
The Questions are the Answers campaign also features these Web pages
From the 20th July Medical News Today article
Patient safety researchers are calling for the expanded use of electronic health records (EHRs) to address the disquieting number of medical errors in the healthcare system that can lead to readmissions and even death. Their commentary is in the July 6 issue of JAMA, The Journal of the American Medical Association.
“Leading healthcare organizations are using electronic health records to address patient safety issues,” said Dean Sittig, Ph.D., co-author and professor at The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics. “But, the use of EHRs to address patient safety issues hasn’t hit the mainstream yet and we think everyone should be doing this.”
One way to fast-track the use of EHRs to address patient safety issues would be to incorporate the annual patient safety goals of The Joint Commission, a healthcare accreditation organization, into the criteria for the certification of EHRs, said co-author Ryan Radecki, M.D., who is scheduled to join the UTHealth faculty Aug. 1….
Click here to read the rest of the news article