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McCarty JF. Plain Dealer. January 16, 2007:A1.
This article reports on an incident of a retained foreign object discovered years after a patient's death, as well as the subsequent lawsuit.
National Quality Forum. Washington, DC: National Quality Forum; 2010.
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intended to be universally applicable, "gold standard" interventions for reducing preventable harm, and have been widely endorsed and implemented. As in the 2009 update, the 34 specific practices are organized into seven content areas: creating a culture of safety, providing patient-centered care and disclosing errors, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. There are no major changes in the recommended practices since 2009, but the report contains specific recommendations on engaging patients and families in safety efforts.
Journal Article > Study
Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.
Cooper WO, Guillamondegui O, Hines OJ, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Journal Article > Study
The association between complications, incidents, and patient experience: retrospective linkage of routine patient experience surveys and safety data.
de Vos MS, Hamming JF, Boosman H, Marang-van de Mheen PJ. J Patient Saf. 2019 Mar 6; [Epub ahead of print].
Little is known whether the relationship between safety data and patient experience data can inform opportunities for improving care. In this retrospective study, researchers used data on complications and safety incidents as well as patient-reported events and experiences for 4236 hospitalized surgical patients at a single academic medical center to understand the relationships between these sources of information. They found that patient-reported issues were associated with the presence of complications or safety events among patients with nonpositive (neutral or negative) experiences, but not among those with positive experiences. Patients who experienced complications or safety events but did not identify problems with their care demonstrated a decreased risk of a nonpositive experience compared with patients who experienced no complications or safety events and did not report issues. The authors conclude that using data in this manner can help inform opportunities for improving care and that health care professionals can optimize the patient experience even when complications and safety events happen. A past PSNet perspective highlighted the experience of a health care professional as a patient.