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Search results for "Hospitals"

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Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Journal Article > Commentary

The tension between promoting mobility and preventing falls in the hospital.

Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.

This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Perspectives on Safety > Annual Perspective

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Newspaper/Magazine Article

A lost voice.

Baker M. Seattle Times. February 10, 2017.

Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.

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.

Book/Report

National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.

Book/Report

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

Journal Article > Review

Towards international consensus on patient harm: perspectives on pressure injury policy.

Jackson D, Hutchinson M, Barnason S, et al. J Nurs Manag. 2016;24:902-914.

Pressure ulcers are never events that continue to occur, despite potential repercussions on reimbursement. This review highlights the need for improved data collection, evidence-based policy, and strategy implementation to prevent this hospital-acquired condition.

Journal Article > Study

Tune-in and time-out: toward surgeon-led prevention of "never" events.

Jones N. J Patient Saf. 2016 Jan 11; [Epub ahead of print].

This study surveyed surgical nurses at an Australian hospital regarding their perceptions of surgeon adherence to the World Health Organization surgical safety checklist. Though nurses felt surgeon-led time outs are valuable and lead to fewer adverse events, 94% of them reported experiencing hostility from surgeons, such as a "condescending, sarcastic attitude" related to the time out process.

Journal Article > Study

Suicide attempts after emergency room visits: the effect of patient safety goals.

Robst J. Psychiatr Q. 2015;86:497-504.

Suicide is considered a never event, and addressing suicidality for patients with a mental health diagnosis became a National Patient Safety Goal in 2007. The goal mandated assessment of suicide risk in patients with a primary mental health diagnosis. This study examined the incidence of suicide after emergency department treatment among Medicaid recipients in Florida before and after the goal was introduced. Investigators found that the rate of suicide declined among patients with a mental health diagnosis compared to those with a physical health diagnosis. These observational data suggest that implementing the goal may have increased identification of suicidal patients, resulting in appropriate treatment and reduced suicide attempts. A previous WebM&M commentary discussed suicide after discharge.

Journal Article > Commentary

The problem with preventable deaths.

Hogan H. BMJ Qual Saf. 2016;25:320-323.

A key goal of patient safety improvement is preventing error, but challenges remain in distinguishing which harms are preventable. Discussing approaches to measuring preventable harm related to patient mortality, this commentary highlights limitations of hospital standardized mortality ratios as a quality measure and suggests combining multiple metrics designed with the complexity of health care in mind to uncover quality issues.

Journal Article > Study

The hidden costs of reconciling surgical sponge counts.

Steelman VM, Schaapveld AG, Perkhounkova Y, Storm HE, Mathias M. AORN J. 2015;102:498-506.

Retained foreign objects after surgical procedures are considered a never event. The traditional method of preventing such incidents is the count—manually tracking and reconciling the number of sponges and instruments used during the procedure. Prior studies have shown counting to be inaccurate and an inadequate method of preventing retained foreign objects. This study analyzed the costs associated with manual counts at an academic medical center and found that this resulted in a total annual cost of more than $200,000, most of which was attributable to unavailability of the operating room. At this hospital, there were 212 incorrect counts (potential retained foreign objects) over a 9-month period. Given that manual counting is questionably effective at best, the fact that it is associated with worsened efficiency and increased costs may prompt use of newer methods to prevent retained foreign objects.

Journal Article > Commentary

Getting rid of "never events" in hospitals.

Morgenthaler T, Harper CM. Harv Bus Rev. October 20, 2015.

Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo Clinic reduced never events by using a mortality-review process to identify opportunities for improvement and developing and disseminating safe practices through the organization.

Book/Report

2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.

Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.

Book/Report

Never Events for Hospital Care in Canada: Safer Care for Patients.

Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180.

The never events list was developed to reduce harmful clinical incidents. This report reviews the results of a consensus effort to determine a list of never events for hospital care in Canada, including patient suicide, wrong-site surgery, and use of improperly sterilized instruments.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

Journal Article > Study

How surgical trainees handle catastrophic errors: a qualitative study.

Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-1184.

According to this qualitative study, surgery resident physicians perceive that catastrophic errors result from system problems and provide lessons for future practice. Participants did not feel comfortable discussing errors with staff and reported work culture as a barrier to asking for support, demonstrating the need to teach trainees about error disclosure.

Journal Article > Review

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.

Perspectives on Safety > Interview

In Conversation With… Christine Cassel, MD

Organizations Working to Improve Quality and Safety, June 2015

Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.

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