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Search results for "Hospitals"

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Journal Article > Commentary

Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.

Guenter P, Boullata JI, Ayers P, et al; Parenteral Nutrition Safety Task Force, American Society for Parenteral and Enteral Nutrition. Nutr Clin Pract. 2015;30:570-576.

Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.

Newspaper/Magazine Article

Why pay for mistakes?

Leape L. Boston Globe. August 23, 2007;Op-Ed section:9A.

Recently, CMS ruled that Medicare will no longer cover certain preventable errors. In this op-ed piece, the author discusses why this new rule will drive hospitals to implement safety measures.

Award

22 California hospitals earn top status for outstanding patient safety & health care quality.

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.

Book/Report

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

This third 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 more than $9 billion in excess cost during 2002-2004, and more than 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 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.

Journal Article > Study

Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging.

Freed GL, Uren RL, Hudson EJ, Lakhani I, Wheeler JRC, Stockman JA III; Research Advisory Committee of the American Board of Pediatrics. JAMA. 2006;295:905-912.

The investigators surveyed 200 hospitals and discovered a wide range of policies and practices with respect to requirements for board certification in obtaining or maintaining hospital privileges. Nearly 75% of hospitals carried no requirement for certification at initial privileging, though 70% did require it in the future. The authors discuss the lack of standardization in this process, the current views on recertification as a mechanism to ensure standards for physicians, and how these systems are certain to be pressured by an ongoing emphasis on patient safety and quality. Accompanying the article is an editorial (link below) that discusses the broader certification issue, calling for greater collaboration among hospitals, health plans, and physicians to improve quality by using clinical data as part of the certification process. A past related study discussed the role of board certification and its relation to the quality movement.

Newspaper/Magazine Article

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

This article highlights a commentary published in JAMA by two leading experts in patient safety which summarizes the progress made since publication of the landmark To Err is Human report in 2000.

Perspectives on Safety > Perspective

Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know?

with commentary by David Studdert, LLB, ScD, Legal Issues and Patient Safety, July 2017

This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

Perspectives on Safety > Interview

In Conversation With… Michelle Mello, MPhil, JD, PhD

Legal Issues and Patient Safety, July 2017

Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.

Special or Theme Issue

The 2016 John M. Eisenberg Patient Safety and Quality Awards.

Jt Comm J Qual Patient Saf. 2017;43:315-337.

Spotlighting the accomplishments of the 2016 recipients of the John M. Eisenberg Patient Safety and Quality Awards, this issue includes an interview with Carolyn Clancy, MD, as well as articles on the I-PASS Study Group, and Christiana Care Health System, Wilmington, Delaware.

Journal Article > Commentary

State sepsis mandates—a new era for regulation of hospital quality.

Hershey TB, Kahn JM. N Engl J Med. 2017;376:2311-2313.

Delays in diagnosis and treatment of sepsis can have serious consequences. This commentary discusses successful programs, built on policy mandates, that aim to ensure effective standardized approaches are in place at health care facilities to prevent harm associated with sepsis.

Patient Safety Primers

Leadership Role in Improving Safety

Though hospital boards have traditionally had relatively little oversight over quality and safety performance, emerging data indicates that board engagement is correlated with improved safety, and specific management strategies can be used to enhance an organization's quality and safety performance.

Journal Article > Study

Associations between hospital characteristics, measure reporting, and the Centers for Medicare & Medicaid Services overall hospital quality star ratings.

DeLancey JO, Softcheck J, Chung JW, Barnard C, Dahlke AR, Bilimoria KY. JAMA. 2017;317:2015-2017.

The Centers for Medicare and Medicaid Services (CMS) recently implemented the star rating system for hospitals as an overall measure of quality and safety. Although studies have found a correlation between the star ratings and clinical outcomes, this study found that high star ratings were more likely to be given to specialty or critical access hospitals. These hospitals are exempt from some of the CMS quality measure reporting requirements, and thus they did not report the same data as lower-rated hospitals. Other studies have also called into question the methodology behind the star rating system.

Journal Article > Commentary

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

Pradarelli JC, Thornton JP, Dimick JB. JAMA Surg. 2017 May 3; [Epub ahead of print].

This commentary explores the responsibility of organizations, device manufacturers, and clinicians for ensuring surgeon technical expertise in the use of robotic surgical equipment. The authors describe how hospitals and individual practitioners can enhance their capabilities with new technology to ensure safe patient care.

Journal Article > Commentary

AORN Position Statement on Patient Safety.

AORN J. 2017;105:501-502.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, patient engagement, and appropriate staffing levels.

Journal Article > Study

Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals.

Pakyz AL, Wang H, Ozcan YA, Edmond MB, Vogus TJ. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Health care–associated infections (HAIs) are a preventable safety problem. This cross-sectional study looked at hospital factors related to HAI incidence. Investigators explored whether the Leapfrog Hospital Safety Score, a composite safety score calculated from publicly reported measures, is associated with HAIs. They also examined the incidence of HAIs in hospitals with Magnet status, conferred by a nurses' trade association in recognition of a positive nursing work environment. Lower Leapfrog safety scores were associated with more Clostridium difficile infections but no differences in other HAIs, and Magnet status was associated with lower rates of methicillin-resistant Staphylococcus aureus infection but worse than expected performance on C. difficile infections. These mixed results do not indicate a strong or consistent relationship between global measures of safety and quality and specific adverse events. A past PSNet interview with Leah Binder, President and CEO of The Leapfrog Group, discussed the development of the Hospital Safety Score.

Newspaper/Magazine Article

Secret data on hospital inspections may soon become public.

Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.

Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.

Journal Article > Study

Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial.

Ehlers LH, Simonsen KB, Jensen MB, Rasmussen GS, Olesen AV. Int J Qual Health Care. 2017;29:406-411.

Hospital accreditation surveys are critical to identifying and ameliorating safety risks. This trial in Denmark randomized hospitals to receive either announced or unannounced hospital accreditation surveys. Investigators found no differences in adherence to performance indicators among hospitals who received unannounced compared to planned survey visits. They conclude that unannounced visits are no more likely to detect quality concerns.

Award > Award Recipient

2016 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.

Joint Commission. April 4, 2017.

The Eisenberg Award honors individuals and organizations who have made vital contributions to improving patient safety and quality. The 2016 honorees are Dr. Carolyn Clancy, the I-PASS Study Group, and Christiana Care Health System, Wilmington, Delaware. The awards were presented at the National Quality Forum's annual conference on April 4, 2017, in Washington, DC.

Journal Article > Review

Measurement as a performance driver: the case for a national measurement system to improve patient safety.

Krause TR, Bell KJ, Pronovost P, Etchegaray JM. J Patient Saf. 2017 Apr 4; [Epub ahead of print].

The lack of effective measures of patient safety hinders sustained error reduction. This review examined published estimates of patient harm in health care and variations in measures used to determine those numbers. The authors suggest that a national nonpunitive approach to data collection would enhance opportunities for improvement.

Journal Article > Commentary

Standardizing concentrations of adult drug infusions in Indiana.

Walroth TA, Dossett HA, Doolin M, et al. Am J Health Syst Pharm. 2017;74:491-497.

Standardizing drug concentrations addresses a medication safety concern for both adult and pediatric inpatients. This commentary describes a state-wide consensus project that reconciled existing lists of adult IV drug concentrations to develop a final list of 26 IV concentrations to reduce risks of medication errors.

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