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- Perspectives on Safety 3
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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Perspectives on Safety > Perspective
with commentary by Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer, Risk Management and Patient Safety, December 2010
In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.
Perspectives on Safety > Interview
Surgical Errors, September 2007
Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Journal Article > Review
Hwang RW, Herndon JH. Clin Orthop Relat Res. 2007;457:21-34.
The authors discuss the financial incentives of improving patient outcomes as the business case for patient safety.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Lubell J. Modern Healthc. August 20, 2007;37:10.
This article discusses the challenges hospitals face in responding to recent Centers for Medicare and Medicaid Services (CMS) policy changes affecting reimbursement for eight hospital-acquired conditions.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Ostrom CM. Seattle Times. January 29, 2008;News section:A1.
This article discusses a voluntary initiative in the state of Washington to cease billing patients for costs associated with preventable errors.
Journal Article > Commentary
Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.
In October 2008, Medicare will put into effect a new policy that withholds payment for eight preventable complications of care, with plans already in place to expand this list in 2009. This initiative has prompted several discussions in the safety community, ranging from the business case for adopting such a policy to whether any of the targeted conditions can be accurately identified as present on admission. This commentary further explores the basis of Medicare's efforts and focuses on criteria that should be considered when withholding payment for complications of care. The authors provide a framework that requires each proposed complication to be important, measurable, and truly preventable to meet the burden of proof for inclusion. Only foreign objects retained after surgery and catheter-related blood stream infections serve as "wise and just" complications based on their assessment. While the authors acknowledge the opportunity for Medicare to align payment incentives and stimulate improvements in quality and reduce costs, they caution against rapid adoption and a failure to carefully evaluate the benefits and risks of the initiative.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Journal Article > Commentary
The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.
Streiff MB, Haut ER. JAMA. 2009;301:1063-1065.
This commentary addresses the Centers for Medicare and Medicaid Services' classification of venous thromboembolism as a never event.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
America's hospitals continued to improve the quality of care they provide for myocardial infarction, congestive heart failure, pneumonia, and surgical care, according to the newest report from The Joint Commission. Compared to the prior report published in 2007, hospitals increased their provision of evidence-based treatments across all four disease processes. In particular, significant improvements were achieved in use of measures to prevent surgical site infections. While the prior report provided data on adherence to the National Patient Safety Goals, these measures were not discussed in the current report.