Search results for "United States of America"

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

Severe hospital-acquired pressure ulcers are considered a never event, and they result in loss of payment for the hospitalization according to Centers for Medicare and Medicaid Services (CMS) policy. Bundled interventions have shown success at preventing these complications in research studies, but broader data on their effectiveness have been lacking. This study used administrative data to demonstrate that adoption of evidence-based strategies and implementation of the CMS policy was associated with a decrease in the incidence of hospital-acquired pressure ulcers in academic medical centers.

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.

As the patient safety evidence base matures, the focus is shifting from effectiveness (identifying which strategies can prevent errors) to implementation (ensuring that all patients receive effective strategies). Pressure ulcers are considered a never event, but their incidence has been increasing despite effective preventive strategies. This systematic review identifies several promising methods of implementing multicomponent interventions to prevent pressure ulcers and emphasizes the importance of leadership, simplification and standardization of safety strategies, and regular audit and feedback of pressure ulcer rates in ensuring intervention success. This study was funded by the Agency for Healthcare Research and Quality as part of the Making Health Care Safer II report and was published as part of a special patient safety supplement in the Annals of Internal Medicine.

This e-book provides tips for incorporating activities into daily hospital practice in conjunction with the 2013 National Patient Safety Goals.

This study reports on Kaiser Permanente's use of systems analysis approaches to review all cases of inpatient mortality, with the goal of identifying preventable harm.

Prior studies have raised the concern that minorities may be at higher risk of adverse events while hospitalized. This analysis of more than 100,000 hospital discharges found that black patients appeared to be at higher risk of hospital-acquired infections and certain adverse drug events. Interestingly, hospitals treating a higher proportion of black patients had higher rates of safety problems for all patients (regardless of race), implying that both patient factors and health care system factors may account for these disparities. Previous research has attempted to explore possible patient-level reasons for these findings.

The Centers for Medicare and Medicaid Services stopped reimbursing hospitals for additional costs associated with certain preventable adverse events in 2008. Despite the widespread controversy engendered by this policy, the actual financial effect has been small, leading to calls for expansion of the policy. This actuarial study used a case-control approach to estimate the annual marginal cost of preventable adverse events in hospitalized patients at $17.1 billion, largely attributable to post-surgical complications, health care–associated infections, and pressure ulcers. Never events accounted for approximately $3.7 billion in excess costs. The results of this study provide targets for policy efforts to control health care costs and improve patient safety.

This commentary reveals how one large health care system successfully reduced preventable deaths and suggests that adopting principles from high reliability organizations can improve safety.

This study explores the barriers five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure ulcers, and recommends steps organizations can take to ensure smoother implementation.

This article discusses how several health care organizations used health information technology to improve organizational transparency.

This Web site provides never event data to promote transparency and informed consumer decision making.

Patients with schizophrenia are at greater risk than the general population of experiencing preventable adverse events when hospitalized for medical or surgical conditions.

The term never event was originally coined to describe rare, devastating, and preventable events like wrong-site surgery or fatal medication errors. This definition has expanded over time to include a variety of serious adverse events; for some of them (i.e., certain health care–associated infections), the Centers for Medicare and Medicaid Services denies additional reimbursement. This article sought to determine if eight never events (mostly infectious complications of surgery) are truly preventable, by examining whether baseline patient characteristics could predict which patients would experience a never event. The authors found that incidence of most of these complications could be predicted on the basis of preexisting conditions or the specific surgical procedure performed, calling into question whether these events are truly preventable. This study exemplifies research into the "basic science" of patient safety; a prior commentary called for studies focusing on identifying truly preventable harm and developing accurate, reliable measurement standards.

This article found that the incidence of specific safety problems (as measured by the AHRQ Patient Safety Indicators) was similar for both small urban and small rural hospitals. A toolkit for implementing safety measures in rural hospitals has been published previously.

This study characterizes the types and severity of patient safety events at academic hospitals that were reported to a voluntary error reporting system.

Measuring safety in health care settings remains challenging despite efforts to develop scorecards, focus on preventive strategies, and invest in safety infrastructure. This study compared the detection of adverse events in hospitals using the AHRQ patient safety indicators (PSIs), provider-reported events, and the IHI Global Trigger Tool. Investigators discovered that each method yielded significantly different results. For instance, only 6.2% of hospitalizations with a PSI also had a provider-reported event, and only 10.5% of provider-reported events had a PSI. Based on their findings, the authors suggest that measuring safety requires a multifaceted approach, but they caution about using such indicators for public reporting and performance comparisons. An AHRQ WebM&M commentary discusses the limitations of using PSIs for public reporting and hospital comparison purposes.

Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.

The authors explain reporting and coding requirements for various types of sentinel event data and describe how these affect coverage.

This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.