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Search results for "Hospitals"

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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.

Journal Article > Commentary

Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.

Gellad WF, Good CB, Shulkin DJ. JAMA Intern Med. 2017;177:611-612.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This commentary discusses US Veterans Affairs health system initiatives that focus on education, prescription monitoring, pain management, and use of guidelines to reduce risks associated with opioids.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Journal Article > Study

Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions.

Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.

This retrospective analysis of Medicare claims data found that the decrease in readmissions following the Hospital Readmission Reduction Program occurred across target conditions and other diagnoses. Hospitals penalized by the Centers for Medicare and Medicaid Services had greater reductions in readmissions for the targeted conditions. These results support the effectiveness of the nonpayment policy.

Journal Article > Study

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

Brennan PL, Del Re AC, Henderson PT, Trafton JA. Transl Behav Med. 2016;6:605-612.

Opioids are considered high-risk medications and overdoses are common. Guidelines have been developed to facilitate safe prescribing practices. This study across 141 facilities within the Department of Veterans Affairs (VA) health system demonstrated that as adherence to urine drug screening guidelines increased from 2010 to 2013, the risk of suicide and overdose events among VA patients receiving prescription opioids decreased over the same period. The authors conclude that opioid therapy guidelines may have a positive impact on patient safety.

Journal Article > Commentary

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.

Neuss MN, Gilmore TR, Belderson KM, et al. J Oncol Pract. 2016;12:1262-1271.

Administration errors involving chemotherapeutic agents can result in patient harm. This set of standards provides guidance to help ensure reliable use of these high-alert medications for both adult and pediatric patients. Components of the revised standards are expanded to include two-person verification, vinca alkaloid mini-bag administration, and labeling enhancements for home-based chemotherapy.

Legislation/Regulation > Organizational Policy/Guidelines

ASHP IV Adult Continuous Infusions.

Bethesda, MD: American Society of Health-System Pharmacists; 2016.

Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.

Journal Article > Study

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

Cases & Commentaries

Wrong-Time Error With High-Alert Medication

  • Web M&M

Annie Yang, PharmD, and Lewis Nelson, MD; September 2016

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

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.

Journal Article > Study

Despite federal legislation, shortages of drugs used in acute care settings remain persistent and prolonged.

Chen SI, Fox ER, Hall MK, et al. Health Aff (Millwood). 2016;35:798-804.

Drug shortages have been a persistent problem for several years and have been shown to affect patient safety. The Food and Drug Administration Safety and Innovation Act of 2012 was intended to address these shortages. This analysis found that while shortages have decreased since the act was passed, problems with drug supply for acute care facilities remain.

Journal Article > Review

The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action.

Reed BN, Fox ER, Konig M, et al. Am Heart J. 2016;175:130-141.

Patients hospitalized with cardiovascular conditions are particularly vulnerable to medication errors. This review explains how drug shortages associated with cardiovascular medications pose risks to patients and provides recommendations for clinicians, policymakers, and manufacturers to address this problem.

Book/Report

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.

Journal Article > Review

U.S. compounding pharmacy-related outbreaks, 2001–2013: public health and patient safety lessons learned.

Shehab N, Brown MN, Kallen AJ, Perz JF. J Patient Saf. 2015 May 21; [Epub ahead of print].

Pharmacy-compounded sterile preparations have been linked to infection outbreaks in recent years. This review analyzes the evidence to determine the incidence of this trend, identify contributing factors, and explore strategies to reduce its impact on public health and patient safety.

Perspectives on Safety > Interview

In Conversation With… Tejal K. Gandhi, MD, MPH

National Organizations in Safety, April 2014

Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.

Journal Article > Study

Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.

Pakyz AL, Edmond MB. Infect Control Hosp Epidemiol. 2013;34:780-784.

Twenty-seven states mandate reporting of central line–associated bloodstream infections. However, these regulations do not appear to have any effect on infection rates.

Newspaper/Magazine Article

Hospitals lagging in PSO contracts.

Clarke C. HealthLeaders Media. June 6, 2013.

This news piece examines why few hospitals participate in the AHRQ Patient Safety Organizations program.

Newspaper/Magazine Article

Organ donor's surgery death sparks questions.

Cohen E. CNN. April 9, 2012.

This news article reports on errors that contributed to the death of a live organ donor and describes regulations to protect organ donors' safety.

Audiovisual > Audiovisual Presentation

Drug shortages and how they affect your healthcare.

Faye J. NBC-17 News. November 10, 2011.

This news segment discusses how drug shortages can affect providers, patients, and decisions about medication therapy.

Legislation/Regulation

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

Oakbrook Terrace, IL: Joint Commission; May 17, 2011.

This announcement reveals the new National Patient Safety Goal for 2012, which aims to reduce catheter-acquired infections in hospitals.

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