December 2007

The Pittsburgh Business Times reports that the Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative is preparing to launch a web-based training program for medical professionals who are involved in eliminating hospital acquired infections and other quality improvement efforts.

USA Today reports that hospitals across the USA have been stepping up their fight against all types of infections, especially superbugs that have been found to be more common and more deadly than previously believed.

USA Today reports that although virtually all doctors think they should report impaired or incompetent colleagues or serious medical errors to the relevant authorities, nearly half don’t, a study suggests.

November 2007

The Wall Street Journal reports that adding a rapid-response team--a crisis team that is mobilized within the hospital--reduced overall death rates in a pediatric hospital, according to a Stanford University study that found an 18 percent reduction in mortality during a 19-month period. (see attached article)

The Philadelphia Inquirer reports that new, highly drug-resistant strains of common bacteria have emerged during the last several years. What really scare doctors are bacteria strains that can survive virtually all of the dozens of antibiotics in the modern medical arsenal.

The Herald reports that Mercer County hospitals have reported recent cases of the so-called “superbug” MRSA, an antibiotic-resistant staph infection, and are taking steps to prevent it from spreading.

A Wall Street Journal commentary by John Kerry and Newt Gingrich hails the benefits of e-prescribing, noting “This is something Republicans and Democrats can agree on. While we continue to debate how to cover the uninsured, improve quality, and lower costs, there is too little being done to modernize health care. E-prescribing for Medicare is just the beginning of the modernization and digitization our ailing health-care system urgently needs.”

State News:

The Express Times reports on yesterday’s Northampton County Council meeting to discuss the creation of a bi-county health department.

The York Daily records reports on yesterday’s Great American Smokeout and the smoke-free efforts of its community, including Memorial, York and Gettysburg hospitals.

October 2007

The Associated Press reports that testing all new hospital patients for a dangerous staph “superbug” could help wipe out a germ that likely kills more Americans than AIDS, consumer advocates say and early evidence suggests.

The Indiana Gazette reports that area school and hospital administrators are well aware of the dangers of an antibiotic-resistant bacteria receiving national attention, and they are taking steps to educate students and staffs on how to identify and avoid the infection.

The Herald-Standard reports that Uniontown Hospital and local school districts have taken steps to stem the spread of potentially deadly infections from a drug-resistant staph “superbug.”

MSNBC.com reports that testing all new hospital patients for a dangerous staph “superbug” could help wipe out a germ that likely kills more Americans than AIDS, consumer advocates say and early evidence suggests. Yet few U.S. hospitals do it, and many fight efforts to require it.

The Leader Times reports that officials at Armstrong County Memorial Hospital said that recent MRSA reports are misleading and causing unnecessary fear.

In a Philadelphia Inquirer op-ed, the director of the Agency for Healthcare Research and Quality writes that, “Pa. and N.J. are taking steps to reduce hospital-acquired infections.”

State News:

The Erie Times-News reports that while the dreamy term of “universal health care” grows stronger in the American political lexicon, Gov. Rendell said a plan he’s promoting comes closest to reality.

September 2007

The Associated Press reports that British hospitals are banning neckties, long sleeves, and jewelry for doctors, and their traditional white coats, in an effort to stop the spread of deadly hospital-borne infections, according to new rules.

For the first time in at least a decade, the five largest hospitals in Lackawanna and Luzerne counties had no mortality rates significantly higher than expected, a report released today by the Pennsylvania Health Care Cost Containment Council reveals.  Read more in Times-Tribune article.
 

The Washington Post reports that trying to get accurate information on a hospital’s quality by looking at websites can leave would-be patients frustrated, due to partial or dated data, a new study finds.

Patient Safety Grant Program—One million charitable grant fund established by Cardinal Health to support initiatives by health care providers that enhance patient safety and quality of care. Grants of up to $50,000 to hospitals nationwide with 501(c)(3) status. Letter of Intent (required) deadline: October 12, 2007. Application deadline: January 14, 2007.

Hospital dress codes aim to cut infections. Washing hands remains an effective way to fight hospital-acquired infections. But in England, hospitals are raising the bar a few notches by banning neckties, long sleeves and jewelry. Read more in the Patriot News article.

Yahoo! News reports that patients facing surgery who try to check out the quality of hospitals beforehand by doing Internet searches often find conflicting and incomplete information posted, according to a study published on Monday.

Safety and efficacy of atorvastatin-induced very low-density lipoprotein cholesterol levels in patients with coronary heart disease: A post hoc analysis of the Treating to New Targets Study
This secondary analysis of the Treating to New Targets study adds support to the concept that for patients with established atherosclerotic cardiovascular disease, a further risk reduction without sacrifice of safety can be achieved by reducing cholesterol to very low levels. The American Journal of Cardiology

The Wall Street Journal reports that hospitals around the country are scrambling to put new programs in place to prevent pressure ulcers, commonly known as bedsores, after the Centers for Medicare and Medicaid Services announced that as of October 2008, it no longer will reimburse hospitals for treating eight reasonably preventable conditions. (see attached article)

The Associated Press reports that cutting the grueling work hours of doctors-in-training had little effect on reducing patient deaths, according to two large studies.

The Physician’s News Digest conducts an interview with Melissa Speck, HAP’s director of policy development, about the impact of Pennsylvania’s new infection reporting law.

The Bucks County Courier Times reports that British hospitals are banning neckties, long sleeves, and jewelry for doctors--plus traditional lab coats--in an effort to stop the spread of deadly hospital-borne infections, according to new rules published Monday.

Modern Healthcare Online reports that the health care industry’s continued failure to prevent hospital-acquired infections appears to have no end in sight, despite a steady stream of calls for improvement and the threat of regulation at the state level picking up steam. Allegheny General Hospital cited.

August 2007

Death and disability from warfarin-associated intracranial and extracranial hemorrhages
In warfarin anticoagulated patients with atrial fibrillation, intracranial hemorrhages caused about 90% of the deaths from warfarin-associated hemorrhage, as well as the majority of disability among survivors. When considering anticoagulation, clinicians should weigh the risk of intracranial hemorrhage far more than the risk of all other forms of major hemorrhage. The American Journal of Medicine

Patients form advocacy groups to improve safety
Patient advocacy groups are springing up across the country to work toward reducing medical errors and ensuring patient safety. The founder of the group Save the Patient wanted to improve communication among doctors, hospitals and patients. "I want people to understand ... how to take care of themselves," she said. Chicago Tribune (free registration)

Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people ages 50 and older: A meta-analysis
Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people ages 50 or older. For best therapeutic effect, these authors recommend minimum doses of 1200 mg of calcium and 800 IU of vitamin D, for combined calcium plus vitamin D supplementation. From The Lancet (free registration required) The Lancet

Environmentally Safe Health Care Agencies: Nursing's Responsibility, Nightingale's Legacy - The intent of this article is to raise the awareness of nursing staff regarding the importance of proper health care waste management so as to enhance the quality of the health care environment. Read more at medscape.com (requires free registration)

The Tribune-Review reports that national infection control policies should be changed to include regular testing of hospital water systems for bacteria that cause a particularly deadly form of pneumonia, according to a study led by the University of Pittsburgh School of Medicine.

Deals link pay to performance at hospitals - Pay-for-performance contracts are evolving, albeit slowly, into a standard part of new provider agreements that health care insurers negotiate with hospitals. Read more in The Philadelphia Business Journal

A Tribune-Review editorial states that, “Pay for performance is an idea as old as the hills. Glad the government is catching up… Medicare’s policy has the earmarks for producing vastly improved health care in the United States."

The Associated Press reports that Medicare will stop paying the costs of treating infections, falls, objects left in surgical patients and other things that happen in hospitals that could have been prevented.

A Carlisle Sentinel editorial states that, “Medicare officials say that no longer paying for the treatment of “preventable” errors will save the government billions of dollars--so much so that private insurers are looking at taking a similar step…Holding hospitals and physicians accountable in this way also could lead to better health care and save lives.”

The New York Times reports that in a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries, and infections that occur in hospitals.

The Pocono Record reports that Northern Lehigh High School sent out letters Monday that several of its athletes had contracted methicillin-resistant Staphylococcus aureus, or MRSA, and walking pneumonia. Coaches and trainers of local sports teams are doing their best to keep the same thing from happening in the Poconos.

A Patriot-News editorial states that, “The Governor’s plan on hospital acquired infections and Medicare’s policy not to pay for many types of infections and errors will bring a missing incentive to hospital care to get it right the first time, every time."

USA Today reports that newborns in hospital intensive care units are vulnerable in so many ways. Now, a growing number of hospitals are trying to protect babies like these from a newly recognized threat--the medical equipment that provides them with lifesaving blood, medicine, or nutrition.

The Star-Ledger reports that beginning next year, Medicare no longer will pay extra to treat certain infections that patients pick up in the hospital. Nor will Medicare pay for second surgeries to retrieve objects left behind in bodies or treatment for transfusion patients given the wrong blood type.

The Pittsburgh Business Times reports that western Pennsylvania hospitals are gearing up to meet new mandatory infection reporting rules by investing in equipment that tracks hospital-acquired infections.

The Times Leader reports that as Medicare and insurance companies look more closely at performance and efficiency, area hospitals are participating in more programs aimed at improving care, efficiency, and patient satisfaction.

CMS Released IPPS Final Rule for FY 2008
On August 1, the Centers for Medicare & Medicaid Services (CMS) issued the inpatient prospective payment system (IPPS) final rule for fiscal year (FY) 2008. Some of the key provisions within the rule include:

• Quality Measure Reporting: The rule adds one outcome measure for reporting—Pneumonia, 30-day mortality—for a total of 28 measures for a full update during FY 2009. CMS did not finalize the other proposed measures because it has not received National Quality Forum (NQF) endorsement.
• Limited-Service Hospitals and Patient Safety: The final rule imposes a new requirement that hospitals disclose to patients if they are physician-owned and make available a list of physician investors. The only exception is for physicians with investments in the form of publicly traded stock or mutual funds.

The Philadelphia Inquirer letter to the editor by I. Steven Udvarhelyi of Independence Blue Cross and Kenneth J. Braithwaite of the Delaware Valley Healthcare Council states, “Thank you for showcasing efforts by hospitals to combat health care-associated infections and a new Pennsylvania law designed to step up infection prevention.”

USA Today reports on the risks of outpatient vs. in-hospital surgery. UPHS cited.  

July 2007

The Philadelphia Inquirer reports that Governor Rendell will sign a bill today designed to reduce the spread of bacteria acquired at hospitals.

Tougher hospital infection control measures coming to Pa.  HARRISBURG, Pa. - Pennsylvania's hospitals and nursing homes will be required to promptly report patient infections to state authorities and take measures to reduce such infections under a bill passed by state lawmakers Saturday. Read more in Mark Levy's article on Philly.com

Health Care-Associated Infection Bill Advances. The state House of Representatives yesterday approved a comprehensive amendment to Senate Bill 968, the Health Care-Associated Infection Prevention and Control Act. The amendment, which passed by a vote of 197–0, included HAP’s changes requiring the adoption of the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) internet-based surveillance system as the primary framework for hospitals to report health care-associated infections to the Pennsylvania Department of Health, Pennsylvania Health Care Cost Containment Council, and the Patient Safety Authority. Final action in the House is expected later today. The bill would then move back to the Senate for concurrence before heading to the Governor for signature.

The REPUBLICAN & Herald reports that hospital-acquired infections have gone under the microscope in other than the clinical sense. Identifying and controlling infections has emerged as a key strategy in getting a handle on runaway health care costs.

A Times-Tribune editorial states that, "The state government, which has done a good job in identifying infections as a cost-driver, should develop a grant program to help hospitals statewide employ active surveillance as a means to save lives and money."

The New York Times reports that a veterans' hospital in Pittsburgh has significantly reduced the number of patients who develop deadly drug-resistant infections, long a problem in the U.S.

CNN.com reports that studies are now finding that not all hospitals are created equal for every medical emergency.

Building a Better ER. Hospitals Launch Programs to Get Emergency Room Patients Fast Care.

It's bad enough to get sick or injured, but even the most stoic of patients can end up moaning in frustration when stuck in an emergency room for five or six hours. Read more in ABC News article:

A Philadelphia Inquirer editorial states that, "surgical errors are statistically rare. But the only acceptable number is zero. Shining a bright light on these foul-ups is smart preventive medicine."

The New York Times reports that in most hospitals, quiet surroundings are considered vital to recuperation.one hospital has found a way to dial down the volume on the usual din through a fairly simple noise-reducing program.

June 2007

Pennsylvania Hospitals National Pacesetters for Quality, Patient Safety Since they became “mentor hospitals” in the national “100,000 Lives” and “5 Million Lives” campaigns, seven Pennsylvania hospitals and health systems have had a huge impact on health care across Pennsylvania and the nation. These organizations have developed life-saving innovations and have agreed to share them with others in the United States, as well as provide support, advice, and tips. Read More in article from Care For Pennsylvania.

The Hanover Evening Sun reports that the quality of care for cardiac surgery at York Hospital was good, according to 2005 figures.

A Pittsburgh Post-Gazette editorial states that, "A report released last week by the Pennsylvania Health Care Cost Containment Council showed that in 2005 UPMC received dramatically higher payments for heart operations than other Pittsburgh-area hospitals."

June Journal Focuses on SCIP

The Journal of the American College of Surgeons has devoted its June issue to recent studies on the American College of Surgeons National Surgical Quality Improvement Program, which tracks the outcomes of various surgical procedures and provides data to help hospitals improve patient safety and quality of surgical care. Several of the 20 articles show how the program has helped reduced complications among surgical patients and enables surgeons to better assess a patient’s risks before an operation. The program, used in 155 private hospitals, includes a data collection module for process measures used by the Surgical Care Improvement Program (SCIP).

High-Risk Medications. ISMP Alert Reminds Practitioners about Heparin-Insulin Mix-Ups

A recent Institute for Safe Medication Practices (ISMP) alert reviews several different mix-ups between heparin and insulin. ISMP recommends that in cases of unexpected, unexplained hypoglycemia, that practitioners should consider the possibility of a medication error, discontinue all current infusions, hang new solutions, treat the patient as necessary with dextrose, and check for unintended additives by sending the discontinued infusion bags for analysis. The alert also provides tips to prevent confusion between heparin and insulin vials during drug preparation, as well as tips to detect errors between heparin and insulin at the point of administration before they reach the patient.

May 2007

Patient Safety Authority Releases Pharmacy Safety Advisory

The Pennsylvania Patient Safety Authority (PSA) this week issued a Supplementary Advisory (pdf) with detailed results from a recent voluntary assessment of electronic pharmacy systems in Pennsylvania. The assessment found that pharmacy computer systems “are not detecting all unsafe drug orders,” and the PSA is encouraging all Pennsylvania facilities to test their systems to ensure that they are catching potentially harmful medication errors.

The Morning Call reports that a bacteria that lies dormant in a person's intestines until antibiotics turn it into a nasty and sometimes deadly disease appears to be more prevalent in Pennsylvania, new state data show.  

The Philadelphia Business Journal reports that the number of hospitalizations where patients had the clostridium difficile-associated disease (CDAD) that can be a hospital-acquired infection nearly tripled during the past decade, according to a research brief.

The Tribune-Review reports that the number of Pennsylvania patients afflicted by a nasty intestinal bug more than doubled in a ten-year period, according to a state report that raises fresh concerns about a dangerous strain of the bacteria.

The Bucks County Courier Times reports that the number of Pennsylvanians hospitalized with a new strain of drug-resistant bacteria more than doubled during the last ten years and that's a growing public health concern, experts say.

The Pittsburgh Post-Gazette reports that increasing numbers of hospitalizations in the state have been linked to infections from a spore-forming pathogen known as C. diff, according to a new report.

Program Key to Improving Quality, Safety, Patient Satisfaction, and Revenue

Don’t miss HAP’s 2007 Pennsylvania Hospital Capacity Management Summit, June 4-5, and learn how hospitals across the country are tackling the challenges of overcrowding. This highly interactive conference will cover practical patient flow techniques that you can apply toward immediate positive change in your organization. The sessions will focus on the key drivers affecting ED and inpatient capacity, and flow problems. You’ll learn about leading-edge techniques, technologies, and improvement tools, and how to utilize benchmarking to assist with overall delivery from experts across the nation. Organizations strongly are encouraged to send teams to the meeting to maximize the learning experience! This program is a must for chief executive officers, chief operating officers, nurse executives, nurse managers, nurses, administrative directors, managers of ORs and EDs, performance improvement directors, physician leaders, ED physicians, surgeons, and others. A full program brochure and registration form (pdf) are available at the HAP website.
 Free Webcasts from International Forum on Quality & Safety in Health Care Available

The Institute for Healthcare Improvement (IHI) announced the availability of webcast presentations from the International Forum on Quality & Safety in Health Care that was held April 18-20 in Barcelona, Spain. There is no charge to access the presentations on the IHI website.
 

Reuters reports that errors in medical care affect 10 percent of patients worldwide, according to the United Nations health agency, which issued a checklist to help doctors and nurses avoid common mistakes.

The Washington Post reports that in an age of impersonal medicine, some doctors still buck the trend and go to extraordinary lengths to give their patients personal care. Patients who encounter that kind of care don't just find the difference striking, they often credit it with improving their health.

April 2007

The Tribune-Review reports that Pennsylvania hospitals last year reported 195,832 medical errors and near-misses--mistakes caught early without causing complications, according a report from the Patient Safety Authority.

Department of Aging Launches Fall Prevention Program, “Healthy Steps for Older Adults.” The pair of two-hour workshops, intended for adults over age 50, will be offered in 34 counties in PA, and will address participants’ medications, sensory deficits, home environmental safety, mobility exercise, health and behavioral status, foot care, and nutrition hydration. Interested persons can call their local Area Agency on Aging or toll-free at (866) 286-3636.
A Washington Post column states that the number of organizations trying to evaluate hospitals is growing fast, along with the breadth and sophistication of their analysis. The problem; however, is that hospitals that look great according to one data set often come up short on other scorecards.

The Philadelphia Inquirer reports that the number of patients who are victims of medication mistakes or experience serious drug reactions--known collectively as adverse drug events--jumped 41 percent in the eight-county Philadelphia area from 1997 to 2005.

The Wall Street Journal reports on hospitals' use of color-coordinated wristbands, including the work done by northeastern Pennsylvania's "Color of Safety" task force. "The wristbands designed to protect patients are actually increasing the risk of harm, safety experts say, endangering patients transferred between hospitals and ..." Read more. 

March 2007 

The Philadelphia Business Journal reports that a new strategy for reducing medical errors has been implemented at Methodist Hospital, a division of Thomas Jefferson University Hospital and the Jefferson Health System.

The Pittsburgh Post-Gazette reports about a new therapy being offered at Allegheny General Hospital where doctors lower the body temperature of cardiac arrest patients to reduce chances of brain and organ damage.

The Pittsburgh Post-Gazette reports that researchers at Allegheny General Hospital took part in a study suggesting that a metallic alloy device, known as the HeartNet Ventricular Support System, may counteract harmful changes to the heart that can occur in some patients with heart failure.

The Washington Post reports that a major medical group is recommending for the first time that women at greatest risk of breast cancer undergo MRI exams every year to try to catch more tumors at their earliest, most treatable stages.
 

The Associated Press reports that more than half a million people a year with chest pain are getting an unnecessary or premature procedure to unclog their arteries because drugs are just as effective, suggests a landmark study that challenges one of the most common practices in heart care.  

USA Today reports that miscommunications between patients and health care providers are increasing the chances that people who need medical care will be hurt or killed in the process, according to a report from a health care accreditation group.

USA Today reports that overdoses of prescription and over-the-counter drugs are sending more people than ever to emergency rooms, a new government report says. 

Culture of Safety

Encouraging staff and patients to communicate freely

Adapted from Tips: Techniques to Improve Patient Safety, Second Edition, Joint Commission Resources. 

The following are tips to create a culture of safety:

• Although the National Patient Safety Goals specifically address patient safety, ensure that staff recognizes that a culture of safety should also include staff, visitors, and all individuals interacting with the organization.

• Ensure physician involvement and buy-in in the culture of safety.

• Share lessons learned from root cause analyses with people at the blunt end (leaders), as well as those at the sharp end (clinical staff).

• Develop and encourage use of informal means for communicating concerns, problems, and errors.

• Assign one or two clinical staff members to be on the receiving end of information related to safety concerns. The people must be credible and nonjudgmental; have good rapport with physicians, nursing, and other clinical staff; and, be comfortable asking questions in non-accusatory ways.

• Take a proactive approach to errors. Annually select at least one high-risk process for proactive risk assessment.

• Study and learn from near misses--they reflect your success in preventing harm and are opportunities to learn.

• Actively search for information in the professional literature about how to do things safely and then practice what you learned.

• Provide team training so that all staff is aware of your organization’s commitment to a culture of safety and know how to implement this culture.

• Encourage patient and family involvement in the care process through informational sessions, brochures, and posters.

• Share information about your safety efforts with others outside your organization at conferences, through published articles, and via informal communication.         

Copyrighted - Joint Commission Resources, Inc., all rights reserved  

7 Dangerous Drug Mistakes:  Experts explain the dangers of mixing drugs, not checking labels, and other common drug mistakes. The football player Terrell Owens blamed his recent trip to the hospital on a bad mix of painkillers and a supplement. The son of Anna Nicole Smith reportedly died with a mixture of the antidepressants Lexapro and Zoloft and the drug methadone in his system. Read more in WebMD article. 

Cultural Competence and Patient Safety Understanding the cultures and diversity of individuals Adapted from Tips: Techniques to Improve Patient Safety, Second Edition, Joint Commission Resources.

Patient demographics are more diverse than ever and health care providers need to provide care in a way that is culturally and linguistically appropriate to their patients. Some cultures focus on the spiritual or nutritional aspects of care; others rely on traditional remedies. Some cultures prohibit the mixing of sexes so that only same-gender individuals may provide care. These beliefs directly affect the patient’s willingness to be treated and follow treatment programs. Many health care organizations have made an effort to recruit staff representing the communities the organization serves. Staff members who practice or are familiar with the values, beliefs, traditions, customs, and cultures present in the hospital’s community can be recruited through development of relationships with cultural groups in the area. Staff need to use appropriately trained medical interpreters and translators. Family members and friends of the patient should not translate if at all possible as they are not familiar with medical terminology, may withhold information during the translation process, or may change the meaning of what is said by the patient or health care provider. Staff should listen carefully and respect beliefs about illness and traditional cures. These beliefs can help practitioners develop care plans and treatment programs that the patient is more likely to follow. Staff should ask the patient what he or she thinks caused the problem, how it is affecting him or her, and what type of treatment the patient thinks he or she should receive. To make sure that a patient understands instructions, staff should ask for a return demonstration of what was explained. This step lets staff gauge the patient’s level of understanding and gives the patient an opportunity to ask questions. Finally, do not assume that a general description of a cultural group applies to each individual member of that group. General culture tools provide basic information about belief practices, nutritional preferences, and communication issues. They are a good starting point in understanding and identifying appropriate cultural issues and practices. But, remember that there is a great diversity of individuals within each cultural group.  

Copyrighted - Joint Commission Resources, Inc., all rights reserved.

The Philadelphia Inquirer reports that most children treated at major pediatric hospitals are given medicines not approved by the Food and Drug Administration for use in patients so young. Children's Hospital of Philadelphia and St. Christopher's Hospital for Children cited.  

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