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Search results for "Government Resource"
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Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
Journal Article > Government Resource
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Journal Article > Government Resource
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.
Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.
Despite the reduction of drug shortages in recent years, access to certain types of drugs, such as generic sterile injectable medications, remains limited. Analyzing data on drug shortages in the United States, this government report identifies factors that contribute to shortages and suggests prioritizing efforts to address the most pressing problems including suppliers that fail to comply with standards.
Legislation/Regulation > Government Resource
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule.
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
This proposed rule suggests updates to the government requirements hospitals must comply with to participate in Medicare and Medicaid. Changes include emphasis on the role of leadership engagement and safety culture as ways to generate improvements in areas such as reducing hospital-acquired infections and readmissions. Comments on the proposed rule are due August 15, 2016.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Legislation/Regulation > Government Resource
Patient Safety and Quality Improvement Act of 2005—HHS guidance regarding patient safety work product and providers' external obligations.
Agency for Healthcare Research and Quality. Fed Regist. 2016;81;32655-32660.
Patient Safety Organizations (PSOs) were formed with provisions to protect voluntarily submitted incident data to enhance transparency and learning from medical error. Despite those expectations, PSOs still have obligations to report certain situations to external organizations. This guidance aims to clarify what and when external reporting should take place for PSOs to remain in compliance with federal requirements while appropriately protecting incident data.
Web Resource > Government Resource
National Health Service England.
The National Health Service (NHS) has been a global leader in patient safety improvement since the publication of An Organization With a Memory in 2000. This government resource combines several NHS initiatives—such as the National Reporting and Learning System, Critical Incident Framework and the Advancing Change Team—to oversee and provide support for clinicians.
Washington, DC: Commission on Care; June 2016.
The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future state of the Veterans Health Administration, this report determined that care quality often meets or exceeds expectations but that quality varies from location to location. The authors outline recommendations for system improvements to ensure the safety of care delivery.
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.
This analysis found that scheduling problems among patients seeking primary care from Veterans Affairs health systems continue to occur. The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary care and spotlights the need to develop and disseminate a comprehensive policy for Veterans Affairs schedulers to reduce risk of scheduling errors.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.
Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350.
Complaints are a proactive way to monitor and address recurring problems that may result in adverse events and system failures. This report discusses progress achieved through complaint response efforts in the United Kingdom and provides recommendations to augment how complaints are managed to develop further improvements.