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Search results for "Policy Makers"

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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 > Commentary

Addressing disease-related malnutrition in hospitalized patients: a call for a national goal.

Guenter P, Jensen G, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:469-473.

Previous studies have explored safety issues related to parenteral nutrition processes, but problems associated with general nutrition for inpatients have received scant attention. This commentary advocates for promoting awareness around malnutrition as a hospital-acquired condition and outlines 12 actions to improve the safety of nutrition care for hospitalized patients, including use of routine assessments and checklists.

Journal Article > Study

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.

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Rajaram R, Chung JW, Kinnier CV, et al. JAMA. 2015;314:375-383.

Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare and Medicaid Services reduces payments to hospitals with the highest rates of these conditions. This analysis sought to assess the association between measures of hospital quality, such as accreditation, and penalties for HACs. Researchers found that accredited hospitals were more likely to incur HAC penalties. Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients. These results add weight to concerns about unintended consequences of pay-for-performance programs leading to widening health disparities and selective treatment, or "cherry-picking" of healthier patients. A related editorial co-authored by two United States Senators calls for including socioeconomic status in the HAC penalty formula.

Journal Article > Commentary

Isolation precautions for visitors.

Munoz-Price LS, Banach DB, Bearman G, et al. Infect Control Hosp Epidemiol. 2015;36:747-758.

This expert guidance provides recommendations to help hospitals develop policies to reduce the spread of health care–associated infections by individuals visiting patients in isolation. The authors discuss contact precautions and outline specific conditions where these suggestions should be employed.

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.

Tools/Toolkit > Measurement Tool/Indicator

ISMP National Vaccine Error Reporting Program.

Horsham, PA: Institute for Safe Medication Practices.

This reporting program collects data on errors and concerns associated with vaccines.

Book/Report

Hospital Reporting Program: Annual Summary.

Portland, OR: Oregon Patient Safety Commission.

This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.

Journal Article > Study

Relationship between state malpractice environment and quality of health care in the United States.

Bilimoria KY, Chung JW, Minami CA, et al. Jt Comm J Qual Patient Saf. 2017;43:241-250.

Medical malpractice law is intended to foster high quality care and discourage negligence among health care providers. This observational study took advantage of differing malpractice laws by state and examined the extent to which the malpractice environment is associated with hospital quality. Investigators assessed quality using several measures: validated processes-of-care measures, such as whether evidence-based actions were appropriately taken for common conditions like myocardial infarction, pneumonia, heart failure, and surgical care; patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems; imaging efficiency as reported by Medicare's Hospital Compare website; AHRQ Patient Safety Indicators; and 30-day readmission and hospital mortality rates. There were no associations between any of these quality outcomes and the rate of paid claims per 100 physicians. Areas with a higher malpractice geographic cost index had lower 30-day mortality but higher readmission rates, and higher malpractice costs were correlated with more inefficiency in some types of imaging. The authors conclude that malpractice environment does not appear to be associated with quality, but higher malpractice costs may lead to overtreatment.

Journal Article > Government Resource

Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.

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Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.

Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.

Journal Article > Commentary

Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System.

King HB, Kesling K, Birk C, et al. Mil Med. 2017;182:e1612-e1619.

The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.

Book/Report

Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.

Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.

Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.

Book/Report

Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use.

Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.

Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.

Journal Article > Study

Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system.

Sage WM, Harding MC, Thomas EJ. Health Serv Res. 2016;51(suppl 3);2615-2633.

Medical malpractice claims represent a mechanism to address medical errors. This pre–post study found that malpractice claims for a large university health system declined substantially after a state law was enacted that reduced patients' ability to sue and collect damages following medical errors. Data demonstrated that the university worked to provide compensation to some patients involved in cases that were not viable for litigation. The authors call for limiting nondisclosure agreements following claim settlement in order to enhance transparency.

Journal Article > Study

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

Gallagher TH, Farrell ML, Karson H, et al. Health Serv Res. 2016;51(suppl 3):2569-2582.

Communication and resolution programs emphasize transparency through early disclosure of adverse events and expedite attempts to resolve incidents. This study examined whether collaboration of health care organizations and malpractice insurers with state regulators through the development of a communication and resolution program certification pilot would enhance health care quality. The authors concluded that the development of such a program can lead to improved patient-centered accountability following an adverse event. They suggest that when designing such a process, care must be given to ensure that regulators' responsibility to act in the public's best interest is not compromised.

Journal Article

Headline-grabbing study brings attention back to medical errors.

Abbasi J. JAMA. 2016;316:698-700.

The presence of medical errors in health care is universally recognized, but the estimated number of preventable adverse events remains controversial. Discussing a controversial study that reported more than 250,000 deaths attributable to medical error occur each year in the United States, this news article offers insights from patient safety leaders regarding the various challenges to identifying and measuring medical error.

Newspaper/Magazine Article

The next wave of hospital innovation to make patients safer.

Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.

Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.

Book/Report

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

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Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.

The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.

Journal Article > Review

The aging surgeon.

Katlic MR, Coleman J. Adv Surg. 2016;50:93-103.

Senior clinicians often elicit respect from their junior colleagues. This respect can affect colleagues' willingness to intervene should they observe poor performance in their role models. This review discusses the need to manage aging surgeons appropriately as a matter of safety. The authors recommend that peer support, confidential skill assessments, and effective policy can help hospitals track changes in surgeon performance to mitigate potential safety problems while preserving the dignity of their clinical staff.

Book/Report

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.

Despite the reduction of drug shortages in recent years, access to certain types of drugs, such as generic sterile injectable medications, remains limited. Analyzing data on drug shortages in the United States, this government report identifies factors that contribute to shortages and suggests prioritizing efforts to address the most pressing problems including suppliers that fail to comply with standards.

Journal Article > Study

Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates.

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Patrick SW, Fry CE, Jones TF, Buntin MB. Health Aff (Millwood). 2016;35:1324-1332.

Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.

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