Too many avoidable errors in patient care, says report [Press release]

From the 8 March 2016 Imperial College London press release

Excerpts

by Kate Wighton

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.

[Reblog] Could mHealth Apps Be a Reprise of the EHR? The Need For Clinician Input

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.

Related articles

• Patient Safety Movement Continues Its March Toward Eliminating Preventable Patient Deaths
• Debate heats up over safety of electronic health records
• Could mHealth Apps Be a Reprise of the EHR? The Need for Clinician Input

[Press Release] Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided

#172216716 / gettyimages.com

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.”

…

Additional Information

• Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013
• May 2014 patient safety results report
• Partnership for Patients Preliminary Evaluation Report

The Empowered Patient Strikes Back (Book and Web site)

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]

Related articles

• Oops! US Doctors Screw Up Surprisingly Often: Study (livescience.com)
• Patients as customers: surfing for hospital emergency departments with shorter wait times (blogs.vancouversun.com)
• My experience as an empowered patient (worldofdtcmarketing.com)
• How to Make Your Hospital Stay Safer and Cheaper: A Checklist (pbs.org)
• Hospitals Are Killing Us (lewrockwell.com)

 

Book offers 10 checklists for hospital patients / Links to related resources

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….

Related Resources

• [4 minute video]How to make your hospital safer and cheaper (PBS, October 22, 2012)

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.

• A safety checklist for patients (Points From Pronovost – Johns Hopkins)

Including these links

• 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)
• Getting Safer Care (AHRQ)

Related articles

• How to Make Your Hospital Stay Safer and Cheaper: A Checklist (pbs.org)
• What the U.S. Could Buy With Wasted Health Care Money (pbs.org)
• Reducing Healthcare Associated Infections And Improving Patient Safety Conference, 22 November 2012, London (medicalnewstoday.com)
• Computerized Checklist Offers Best Preventive Strategy For Deadly Blood Clots (medicalnewstoday.com)
• Seven Factors Driving Up Your Health Care Costs (pbs.org)
• How to Stop Hospitals From Killing Us (listahit.wordpress.com)
• 10 shocking medical mistakes (cnn.com)
• Electronic Checklists Help Prevent Medical Errors (informationweek.com)
• Waste in U.S. Health Care: Your First-Hand Accounts (pbs.org)

New AHRQ Report Finds Teamwork and Follow-Up as Strengths of Medical Offices but Work Pressure and Pace are Problemat

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).

A safety checklist for patients

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)

Related articles

• The Patient’s Checklist by Elizabeth Bailey (asourparentsage.net)
• Survive your hospital stay with patient checklist (msnbc.msn.com)
• Patient Safety Week 2012: How Do We Make A Difference? (hcfama.org)
• Patient Safety Awareness Week (medicineandtechnology.com)

To Gauge Hospital Quality, Patients Deserve More Outcome Measures One Comment

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….

Related Resources

• Hospital Quality Compare (Centers for Medicare & Medicaid Services)- compares quality of care for certain medical conditions at more than 4,200 hospitals. The site also includes a checklist to help you choose a hospital

• Leapfrog Hospital Ratings – information on this site is derived from hospitals’ voluntary submissions of The Leapfrog Hospital Survey. More about the Leapfrog Group at their About Page
  
• AHRQ (US Agency for Health Care Research and Quality
  • Consumer Page includes
    • Choosing Quality Health Care
    • Getting Safer Care
    • Comparing Medical Treatments
  • Clinical page includes
    • Outcomes and Effectiveness
    • Effective Health Care
      
• Medicare.gov includes
  • Home Health Compare
  • Nursing Home Compare

 

 

Related articles

• Doctor Rating Web Site Health Grades is a Time Magazine “Best 50″ – How Trustworthy Is the Content?? (jflahiff.wordpress.com)
• Georgia hospitals rated on infections (ajc.com)
• Hospital Reviews Reflect Data On Hospital Outcomes (medicalnewstoday.com)
• The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality (bespacific.com)
• Surgical Outcomes-Based Measures Developed: Approval Marks Latest Step In Path To National Implementation (medicalnewstoday.com)
• The Leapfrog Group names Children’s Memorial a top children’s hospital for patient safety (prweb.com)
• The Leapfrog Group Names Virginia Mason Top Hospital of the Decade (prweb.com)
• Roswell Park Named to Leapfrog Group’s Annual Top Hospitals List (prweb.com)
• How patient satisfaction can kill (kevinmd.com)
• American Health Care System Gets Positive Prognosis In “U.S. Health Care: The Good News” February 16, 2012 At 9 P.M. Est On PBS With Correspondent T.R. Reid (prweb.com)
• National Quality Forum endorses 2 American College of Surgeons NSQIP measures (eurekalert.org)
• Skeptical Scalpel: Patient satisfaction and reality (gruntdoc.com)
• Nurse Navigators Providing Patient Satisfaction at Medical Center (prweb.com)
• Hospital Caregivers use MagnaSnap Paper Clamps at Bedside to Improve Patient Satisfaction Scores (prweb.com)
• Requiring doctors to give orders on patients they have not seen (kevinmd.com)

Health IT and Patient Safety: Building Safer Systems for Better Care

Health IT and Patient Safety: Building Safer Systems for Better Care

From the report…

If implemented appropriately, health IT can help improve health care providers’ performance, better communication between patients and providers, and enhance patient safety, which ultimately may lead to better care for Americans. Health IT is designed to help improve the performance of health professionals, reduce costs, and enhance patient safety. For example, the number of patients who receive the correct medication in hospitals increases when these hospitals implement well-planned, robust computerized prescribing mechanisms and use barcoding systems. However, poorly designed health IT can create new hazards in the already complex delivery of care.

In the wake of more widespread use of health IT, the Department of Health and Human Services asked the IOM to evaluate health IT safety concerns and to recommend ways that both government and the private sector can make patient care safer using health IT. The IOM finds that safe use of health IT relies on several factors, clinicians and patients among them. Safety analyses should not look for a single cause of problems but should consider the system as a whole when looking for ways to make a safer system. Vendors, users, government, and the private sector all have roles to play. The IOM’s recommendations include improving transparency in the reporting of health IT safety incidents and enhancing monitoring of health IT products.

Government agency working to empower patients and others to improve health care quality

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

• Reducing Medical Mistakes with questions to ask your health care provider, how to prevent medical errors, and more
• Talking with Your Clinician with tips on how to give and get information, get quality care and more
• Planning for Surgery with questions to ask and tips
• Getting a Prescription with tips on keeping track of meds, how to take medicine safely, and more
• Links to Additional Patient Safety Resources

Related articles

• Your Health Priorities Tool (AHRQ) (jflahiff.wordpress.com)
• I’m happy that patients use the internet  (ScienceRoll)
• IOM Report: Government Should Consider Public Health Implications Of All Major Legislation (jflahiff.wordpress.com)
• Question Authority (centerforhealthmediapolicy.com)

E-health Records Should Play Bigger Role In Patient Safety Initiatives, Researchers Advocate

http://diseasemanagementcareblog.blogspot.com/2011/07/more-on-electronic-health-record.html

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

Related articles

• Make Patient Safety Goals Part Of Meaningful Use (informationweek.com)
• Electronic health records software poses security concerns (medcitynews.com)
• Wayne Memorial Hospital Selects Electronic Forms Software from Access to Seamlessly Integrate e-Forms and Clinical Data into EHRs via Meditech (prweb.com)
• More On Electronic Health Record Prescribing Errors (diseasemanagementcareblog.blogspot.com)