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- Specialization of Care 1
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- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Medical Complications 10
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Search results for "Book/Report"
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
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.
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2016.
Fingar KR, Barrett ML, Elixhauser A, Stocks C, Steiner CA. HCUP Statistical Brief #195. Rockville, MD: Agency for Healthcare Research and Quality; November 2015.
Defining preventability has become increasingly important due to its use as a measure for cost and reimbursement mechanisms. This report presents data on hospitalizations for conditions that might be averted through quality ambulatory care and reveals that preventable hospital stays decreased between 2005 and 2012.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
London, UK: Parliamentary and Health Service Ombudsman; November 26, 2014.
The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication is the first in a series that will provide information about complaints submitted to trusts (from 2013 to 2014 and in the first half of 2014 to 2015) to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
Washington, DC: US Department of Health and Human Services; May 7, 2014.
Comparing safety data reported to the US Department of Health and Human Services regarding rates of adverse drug events, patient falls, and health care–associated infections, this publication estimates reductions in patient mortality, readmissions, and health care costs following the launch of the Partnership for Patients initiative.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.
This investigation found that although use of electronic health records (EHRs) in Medicare and Medicaid programs increased between 2011 and 2012, EHR systems lack the ability to track quality and safety to measure improvements. The report recommends developing a comprehensive strategy to compile clinical quality measurement data.
Sorra J, Famolaro T, Yount ND, Smith SA, Wilson S, Liu H. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
This annually released report of the AHRQ Hospital Survey on Patient Safety Culture comparative database presents benchmarking data for safety culture from 653 hospitals nationwide, including trending data on changes in safety culture perception over time for more than 300 hospitals. The full report contains detailed comparative data for various hospital characteristics (type and size) and respondent characteristics (work areas, staff positions, and direct patient contact). Areas of strength included teamwork, leadership, and continuous improvement, all of which have been emphasized in patient safety efforts. However, as in prior reports, concerns were voiced about the safety of handoffs. Most respondents reported that staffing was suboptimal for supporting patient safety, and a non-punitive approach to errors remains elusive for most hospitals.
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013. Publication GAO-14-55.
Evaluation of provider behavior can identify problems that affect patient safety. This report analyzed data and expert interviews from four Veterans Affairs medical centers to identify weaknesses in peer review processes. Investigators found inconsistent adherence to peer review policy elements, such as timely review performance and peer review trigger development, and make recommendations to drive actions that address these issues.
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013.
This white paper details how health care organizations can identify health information technology concerns and improve systems to reduce risks.
National Advisory Group on the Safety of Patients in England. London, England: Crown Publishing; August 2013.