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- Error Reporting and Analysis
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- Legal and Policy Approaches 8
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- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 11
- Medication Safety 6
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- Internal Medicine 22
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Search results for "Governmental Reporting"
- Governmental Reporting
- Hospital Medicine
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.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092.
This report built on earlier research to examine rates of adverse events reported to state-level reporting systems compared with hospital data. It found that, even in states with required hospital reporting of adverse events, only about one in nine events is reported to the state. Because few of the events were found in each hospital's incident reporting system, the investigators concluded that the low rate of reporting was likely due to hospital failure to identify events rather than hospitals failing to report known events.
Web Resource > Multi-use Website
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The 2018 results are the sixth generation of the scores, which now include a medication error score. A related report from the Armstrong Institute examines avoidable death associated with grading hospitals.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Journal Article > Study
Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.
Adverse drug events (ADEs) are the most common type of errors in hospitalized patients. This study used data from the Medicare Patient Safety Monitoring System (which conducts detailed chart reviews of hospitalized Medicare patients) to arrive at national estimates for the incidence of ADEs in the Medicare patient population. Errors were common among patients receiving high-risk medications such as warfarin, insulin, and heparin—in fact, nearly 1 in 7 patients receiving heparin experienced an ADE. Medication errors were associated with an increased length of stay, as demonstrated in prior research. A related editorial discusses the MPSMS as an example of a patient-centered approach to detecting harmful errors. A case of an error associated with insulin prescribing is discussed in an AHRQ WebM&M commentary.
Journal Article > Study
Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?
Williams SD, Ashcroft DM. Int J Qual Health Care. 2009;21:316-320.
Assessment of the severity of medication errors reported to the National Reporting and Learning System (the United Kingdom's voluntary incident reporting system) varied widely depending on whether the reporter was a nurse, pharmacy technician, pharmacist, or physician, and whether the reporter personally witnessed the error.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress a series of analyses with the first related to understanding the issues around hospital-based adverse events. This related and simultaneously released report identifies and describes state reporting systems and how they utilize the captured information. The report concludes that as of January 2008, 26 states had reporting systems in place, 23 states used the data to hold individual hospitals accountable, and 18 states reported using the data to promote learning and develop prevention strategies. A past AHRQ WebM&M perspective discusses the role of state reporting systems in advancing patient safety.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
The Francis inquiry uncovered numerous problems in the National Health Service and led to many commentaries about improvement strategies. Summarizing achievements in applying recommendations following the inquiry, this report outlines where further work is needed to ensure that advances in safe care delivery are sustained. Companion materials available include an analysis exploring equality considerations and a table revealing the government response and progress for each of the 290 recommendations put forth in the original inquiry.
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.
Journal Article > Study
Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field.
Chen Q, Shin MH, Chan JA, et al. Am J Med Qual. 2016;31:178-186.
This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Cohn M. Baltimore Sun. July 26, 2014.
This news article reports weaknesses in a Maryland reporting program, including poor understanding about which errors should be reported and lack of regulations regarding disclosure. Limited public access to comprehensive incident reports and insufficient performance measurement hinder consumers' ability to select hospitals based on safety.
Journal Article > Study
Magill SS, Edwards JR, Bamberg W, et al; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. N Engl J Med. 2014;370:1198-1208.
Health care–associated infections (HAIs) are a serious and common cause of patient harm. The Centers for Disease Control and Prevention (CDC) created the National Healthcare Safety Network to provide information on incidence rates of infections, but most hospitals limit reporting to only certain complications. This multistate prevalence study found that approximately 4% of sampled patients had HAIs. Using a model to extrapolate these findings, nearly 650,000 patients in United States hospitals are estimated to have had an HAI in 2011. Infections associated with devices—including central lines, urinary catheters, and ventilators—have been a major focus of strategies to decrease HAIs, but together they accounted for only about a quarter of all HAIs. Clostridium difficile was responsible for more than 12% of infections, highlighting the importance of efforts to mitigate this life-threatening disease. A recent CDC report suggested the potential promise of antibiotic stewardship programs to decrease C. difficile rates.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
Journal Article > Commentary
Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.
Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635.