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Search results for ""
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Journal Article > Study
Use of board certification and recertification of pediatricians in health plan credentialing policies.
Freed GL, Singer D, Lakhani I, Wheeler JRC, Stockman JA III; Research Advisory Committee of the American Board of Pediatrics. JAMA. 2006;295:913-918.
The authors surveyed health plans and found that 41% require board certification for general pediatricians at any time during their association with the plan. This is a companion study to the authors' work on hospital privileges.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Journal Article > Review
Neale G, Vincent C, Darzi SA. J R Soc Promot Health. 2007;127:87-94.
The authors discuss the history of quality and safety initiatives in the United Kingdom and offer suggestions on how to improve physician involvement in these initiatives.
Shorr AS. Healthc Exec. March-April 2007;22:19, 21-22, 24, 26.
The author discusses executive accountability for patient safety and active involvement in creating a patient-centric culture.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Journal Article > Study
Simon JS, Rundall TG, Shortell SM. J Am Med Inform Assoc. 2007;14:432-439.
The authors surveyed primary care medical groups and found that only 27% have electronic order entry with decision support for chronic disease care. External quality incentives were associated with driving adoption of such tools.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
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.
Journal Article > Study
Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
Leonardi MJ, McGory ML, Ko CY. Arch Surg. 2007;142:863-869.
The growing focus on health care quality has led to the development of several Web sites that make hospital quality information publicly available to consumers. This study evaluated six such Web sites (the Centers for Medicaid and Medicare Services' Hospital Compare, the Joint Commission's Quality Check, the Leapfrog Group, and three commercial sites) for ease of use, data accuracy, and consistency of hospital rankings for several surgical quality measures. In general, the governmental and non-profit Web sites were rated as easier to use and had more complete information. However, the authors found significant variation in the risk adjustment methods used and the types of outcomes reported on each Web site, leading to poor reproducibility of rankings for specific surgical procedures.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
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.
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.
Oakbrook Terrace, IL: The Joint Commission; November 2007.
Building on its inaugural publication, this report summarizes the quality and safety of care delivered to hospitalized patients between 2002 and 2006. The report suggests that hospital performance consistently improved from year to year as measured by adherence to evidence-based treatments for heart attacks, heart failure, and pneumonia, as well as more recent measures of surgical care. While similar improvements were noted in compliance with National Patient Safety Goals, significant room for improvement remains on additional quality measures, and noted variability exists in performance by hospital and by state. The report emphasizes the Joint Commission's efforts to improve performance measurement and reporting requirements in future years to adequately reflect the organization's goal of improved health outcomes. A past AHRQ WebM&M commentary discussed the unintended consequences of the public reporting of hospital quality.
Journal Article > Study
Li P, Schneider JE, Ward MM. Health Serv Res. 2007;42:2089-2108.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
Wilson B. Am Med News. November 26, 2007:50:16.
This article explores the recent trend of hospitals tying senior management compensation and incentives to mortality rates and compliance with safety measures.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of Inspector General; January 2008. Report No. OEI-02-06-00310.
This report examines the operation and staffing of 109 physician-owned specialty hospitals and identifies shortcomings in the availability of emergency services.