Hyman D, Neiman J, Rannie M, et al. Pediatrics. 2017;139.
The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.
Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2017;26:423-428.
A recent article asserted that medical error is the third leading cause of death in the United States. This perspective questions the accuracy of this estimate. The authors note that this estimate was generated by simply combining medical error rates from prior studies, without adhering to guidelines for quantitative synthesis or accounting statistically for the uncertainty associated with the extrapolation of these studies. There are also inherent limitations in the original data, which used trigger tools to identify adverse events. The studies from which the error rates were calculated could not clearly determine whether the adverse events detected actually contributed to the patient's death. Patients who are critically ill tend to have more adverse events because they experience more medical interventions. However, their deaths may be due to the underlying illness rather than the medical care they received. The authors argue that an inaccurately high estimate for medical error–related mortality draws attention away from other crucial patient harms, such as pressure ulcers and medication safety, both of which rarely contribute to mortality but are of high priority to patients.
Ward MA, Schweizer ML, Polgreen PM, et al. Am J Infect Control. 2014;42:472-8.
This systematic review evaluated new technologies for assisting hand hygiene monitoring, including automated counting systems, video monitoring, and fully automated monitoring systems. Currently, there is very limited data about how accurate, effective, and valuable these strategies are in enhancing hand hygiene compliance.
Tinoco A, Evans S, Staes CJ, et al. J Am Med Inform Assoc. 2011;18:491-7.
This study found that computerized surveillance systems detected more hospital-acquired infections than manual chart review, but both methods detected similar rates of adverse drug events. The authors discuss the tradeoffs of each surveillance method and highlight how each system used information from different sources.
Wiener RS, Schwartz LM, Woloshin S. Arch Intern Med. 2011;171:831-7.
Since the introduction of new diagnostic technologies in the late 1990s, pulmonary embolism diagnoses have increased, but mortality from pulmonary embolisms has not decreased. This combination of findings likely represents overdiagnosis—either due to false-positive diagnoses or detection (and treatment) of clinically insignificant clots.
Smits M, Huibers L, Kerssemeijer B, et al. BMC Health Serv Res. 2010;10:335.
This study found a low rate of patient safety incidents involving telephone care interactions. Most incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing medical advice by telephone.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
A quality improvement intervention that focused on management of acute pain resulted in both improved pain relief for patients and a reduction in medication errors associated with opioid pain medications.
A hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, and although this information was copied and pasted in the record on 4 consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge.
For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
Shaw R. Quality and Safety in Health Care. 2005;14.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
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