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Journal Article > Study
McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.
This study shares the efforts of six different health care organizations in implementing interventions to improve patient safety. All of the organizations identified culture change as the most important factor in promoting safety, though the mechanisms to achieve such change differed. The authors provide a contextual background of safety culture, including definitions, attributes, and strategies to approach the issue, and present a detailed account of each case study. They point out that creating a desired culture of safety may be both foundational to safety efforts and also very challenging to accomplish. The shared stories offer a practical perspective regarding the issues that face most organizations committed to improving patient safety.
San Francisco, CA: The Leapfrog Group; May 2, 2006.
This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.
The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.
This report calls for providing "safe, well-coordinated, accessible, and efficient" care through five key steps: expanding health insurance coverage, implementing evidence-based patient safety and quality interventions, increasing use of health information technology, public reporting of safety and quality measures, and rewarding achievement in quality through "pay-for-performance." The authors ascribe the current quality problems in the U.S. health care system to system failures, including misaligned payment incentives, inadequate motivation to challenge the status quo, inadequate information systems, duplicative regulatory systems, and an overemphasis on autonomy.
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.
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 > Commentary
When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?
Naessens JM, Culbertson RA, Lefante JJ, Campbell CR. Qual Manag Health Care. 2007;16:153-165.
The authors propose criteria for classifying a multi-location hospital as a single reporting entity and provide a case study to assess these criteria.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
Collins LM. Deseret Morning News. July 8, 2007;A1.
This article reports on Utah health officials' recent efforts to mandate error reporting, make that information open to the public, and use the data to improve patient safety.
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.
Ostrom CM. Seattle Times. October 23, 2007:A1.
This article discusses a conflict that has arisen between the Washington State Hospital Association and state lawmakers regarding public disclosure of incident reporting data.
Journal Article > Commentary
Pronovost PJ, Berenholtz SM, Needham DM. JAMA. 2007;298:2063-2065.
Tracking progress in patient safety can be challenging despite past descriptions of a framework to do so. In this commentary, Dr. Peter Pronovost and colleagues discuss the increasing pressure to evaluate and improve patient safety and the growing interest in creating safety report cards to publicly report such efforts. The authors warn that measuring safety is still an immature science but offer a conceptual model to guide organizations in developing their safety scorecard and understanding the measures they choose to include. A worksheet is provided that focuses on three questions: Is the measure important?, Is the measure valid?, and Can this measure be used to improve safety in the organization? A past AHRQ WebM&M commentary discussed the unintended consequences of public reporting on quality.
Journal Article > Review
Systematic review: the evidence that publishing patient care performance data improves quality of care.
Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Ann Intern Med. 2008;148:111-123.
This review examined how publicly reported performance data affect quality of care and found that, although releasing such data stimulates quality improvement activities, the impact on clinical outcomes remains unclear.
Golden, CO: HealthGrades, Inc.; April 2008.
This analysis of patient safety in Medicare patients from 2004-2006 concludes that while modest improvements have been made, patient safety incidents still account for more than 200,000 preventable deaths and nearly $9 billion in excess costs yearly. The report identifies "Distinguished Hospitals for Patient Safety"—the 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 and Research 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.
Rusk K. Assignment 7. ABC7news.com. May 26, 2008.
In the context of statewide efforts to prevent medication errors, increase reporting, and share best practices, this news video addresses how hospitals are employing both low- and high-tech solutions to improve patient safety. The story also covers barcoding, the Five Rights, transparency, and efforts to get safety information into patients' hands.
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
O'Reilly KB. American Medical News. August 11, 2008;51:1.
This article reports on hospital officials' public admissions of error and discusses the potential impact of these disclosures on patient safety.
Greene L. St. Petersburg Times. August 19, 2008.
This article reports on recent apologies made by Florida hospital officials for medical errors.
Neary L. "Talk of the Nation." National Public Radio. August 26, 2008.
This radio interview features Donald Berwick and Robert Wachter discussing how Web sites reporting national hospital data can drive improvement and safety.