The PSNet Collection

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Woman works to end Black maternal health crisis after daughter dies after giving birth.

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Kindelan K. ABC News. April 14, 2022.

Maternal injury is a persistent challenge in the Black community. This article discusses the case of one mother whose discounted health concerns contributed to diagnostic delay and death. The piece shares social media tools to assist Black mothers in keeping themselves safe during pregnancy and after birth.

Ensuring critical instruments and devices are appropriate for reuse.

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Quick Safety. February 14, 2022;(64):1-3.

Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices is vital for infection prevention. This newsletter article shares actions to improve infection prevention, including standardized examination processes, infection preventionist involvement, and training focused on the safety impacts of incomplete processing and inappropriate reuse of single use items.

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

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Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Medicare penalizes dozens of hospitals it also gives five stars.

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Rau J. Kaiser Health News. February 8, 2022.

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.

COVID Risk In Hospitals.

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Weber L, Jewett C. Kaiser Health News. 2021-2022.

The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series examines factors contributing to hospital-acquired COVID-19 infection that include weaknesses in oversight, patient legal protections, and documentation.

How low can they go? Rural hospitals weigh keeping obstetric units when births decline.

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Huff C. Kaiser Health News. November 12, 2021.

This article discusses the challenge of providing safe maternity care in rural environments when demand for service cannot support its cost, and keeping teams actively experienced in provision of reliable maternal care.

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

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Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.

The less-discussed consequence of healthcare's labor shortage.

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Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

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Maternal Safety

Use systems redesign and the law to prevent medical errors and accidents.

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Saks MJ, Landsman S. Stat News. August 4, 2021.

This article introduces the systemic task of medical error reduction and discusses the need for a business case, enterprise-wide accountability and legal process change to drive improvement.

'There is a real cost’: as Covid shows, barring bedside visitors from ICU deprives patients of the best care.

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Renault M. Stat. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.

In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.

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Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

COVID-19 dominates annual list of patient safety concerns.

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Brooks M. Medscape Medical News. March 15, 2021.

Safe care is influenced by both global and local changes in the environment. This news story summarizes a prioritized list of patient safety concerns--many of which were heightened due to the COVID-19 pandemic. Inequities due to ethnicity, lack of emergency readiness and ineffective pandemic readiness are highlighted.

7 ways to prevent medical errors.

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Caceres V. US News World Report. March 1, 2021.

Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhance the safety of their care that include preparing for doctor’s appointments, asking questions and seeking second opinions.

Enhancing a culture of safety through disclosure of adverse events.

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Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27

Error disclosure is supported by a robust safety culture and a defined communication and management approach. This article discusses the engagement of anesthesiologists in the disclosure processes to ensure learning, patient centeredness, and care improvement.

When machine learning goes off the rails. A guide to managing the risks.

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Babic B, Cohen IG, Evgeniou T, et al. Harv Bus Rev. 2021 January/February;99(1):76-84.

This article discusses how machine learning can create unanticipated risks in the context of health care delivery. The authors summarize areas of concern healthcare leadership should explore when determining the implementation of machine learning in their organizations.

Medicare cuts payment to 774 hospitals over patient complications.

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Rau J. Kaiser Health News. February 19, 2021.

Financial incentives have shown both benefits and limitations in addressing hospital-acquired harm. This news article summarizes an annual tally of hospitals facing Medicare payment reductions for high rates of infections and other preventable hospital-acquired conditions.

The plague year. The mistakes and the struggles behind America’s coronavirus tragedy.

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Wright L. New Yorker. January 4, 2021;96(463):20-59.

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic.

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