This area contains collection of links to National Patient Safety initiatives, articles and updates to support medication safety and infection control.

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* Source: The Joint Commission

April 2008

The Wall Street Journal reports the federal government plans to identify some of the most troubled nursing homes in its public database, part of a trend toward giving consumers access to nursing home information online.

The Philadelphia Inquirer reports that federal inspectors have documented serious contamination concerns in one of the country’s premier childhood vaccine manufacturers.

The Wall Street Journal reports the Food and Drug Administration is under fire from Congress for gaps in its foreign drug facility inspections.

U.S. News & World Report highlights a congressional hearing during which experts discussed whether federal health officials are doing enough to protect patients from infections acquired in hospitals, clinics and doctor’s offices.

Baltimore Sun reports that the federal government isn’t doing enough to protect patients from getting infected at hospitals, endangering tens of thousands of lives and costing billions of dollars.

The Philadelphia Inquirer reports that an examination of hospital billing data indicates patients who were discharged after four or fewer days in the hospital were significantly more likely to die than those who remained in the hospital for five, six or more days.

U.S. News & World Report states that, with regard to the Pennsylvania Health Care Cost Containment Council’s hospital-acquired infections report, “Publishing a report such as this is a courageous act.”

The Patriot-News cautions the hospital-acquired infections report should not be used by consumers to judge or compare hospitals, since the reporting process is complicated and new, and some hospitals might not even be detecting or reporting all of their infections.

The Pittsburgh Business Times reports that hospitals and doctors are being driven to reduce infections picked up at their facilities, and the stepped-up infection monitoring and control will cost more, but how much more isn’t yet known.

A Patriot-News editorial states, “Far too many patients are still contracting infections during hospital stays in Pennsylvania. But for the first time there may be signs of progress.” 

The Associated Press reports on a safety alert issued by the Joint Commission advising more needs to be done to prevent medication errors in children, and calling on hospitals to utilize more stringent safety guidelines.

A Carlisle Sentinel editorial states “the 2006 statistics are out on how many people contracted infections in Pennsylvania hospitals...and this is good news,” adding that Pennsylvania is one in only five states to publish the data, and the only state collecting information in all areas of serious infection.

Upcoming events. April 22—Keys to Patient Safety: Ensuring Competent and Quality Contracted Services (Harrisburg)

The Morning Call reports that former patients and federal health officials recently came to the same conclusion in separate report cards on the overall quality of health care in Pennsylvania: It’s average.

The Patriot News reports that Pennsylvania hospitals might be getting better at counting and reporting infections and, according to a Pennsylvania Healthcare Cost Containment Council report hospitals might be getting better at preventing infection.

The following publications also reported on the newly-released data. HAP (including DVHC of HAP) cited in all articles.  Associated Press, Daily American, Philadelphia Business Journal, Philadelphia Inquirer, Pittsburgh Post-Gazette   

Educating patients and consumers about infection risk factors and prevention tips helps empower their decision-making and makes them active participants in their health care. This report is one of many tools available to help consumers and providers assess ongoing efforts to eliminate hospital-acquired infections and can help trigger discussions between patients and their doctors and nurses in making care decisions. Along with this report, patients can take advantage of other education resources developed by well-respected organizations, such as:

• Care For PA, HAP’s consumer website
  
• Community-acquired MRSA infection prevention tips
• Preparing for Surgery (IHI)
  
• 4 Things You Can Do to Prevent Infections (Joint Commission on Accreditation of Healthcare Organizations)
  
• Patient and Family Fact Sheet on Central Line Infections
  
• “30 Things You Can Do to Eliminate Infections” (Hospitals & Health Networks magazine, Sept. 2006)
  

Pennsylvania Patient Safety Authority Issues New Advisory
The Pennsylvania Patient Safety Authority issued its latest Patient Safety Advisory (pdf), which covers diagnostic ionizing radiation and pregnancy; medication assessment and falls risk; timely treatment of stroke symptoms; preventing the retention of foreign objects; and pneumatic tube safety. The advisory also includes a feature about “meaningful engagement in patient safety improvement” and “getting boards on board” with patient safety, written by authority chair Ana Pujols-McKee, M.D. HAP is working with the authority on a state-specific initiative in this area.

March2008

The Morning Call reports that for the first time, it takes only a couple of mouse clicks to access information about how Pennsylvania hospitals stack up against each other.

The Wall Street Journal reports that, in a bid to save costs and stem a rising tide of medical waste, hospitals are recycling a growing number of medical devices labeled as single-use, from scissors and scrubs to the sharp blades surgeons use to saw through bones.

The Associated Press reports that the Government Accountability Office is investigating whether the Food and Drug Administration’s review process cleared two blockbuster medications without sufficient proof of their safety or effectiveness.

The Philadelphia Inquirer reports that reducing complications a high priority nationwide, and area health care providers are working to identify where problems occur, and taking steps to prevent them.

The Wall Street Journal reports that hospitals are taking steps to prevent errors in the use of high-alert medications that, when given in the wrong dose or used incorrectly, have the highest risk of seriously harming or even killing a patient.

Congressman Tim Murphy Cosponsors Bill to Stall Medicaid Regs. U.S. House Commerce Committee Chairman John Dingell (D-MI) and Representative Tim Murphy (R-PA) have introduced H.R. 5613, supported by HAP, which would prevent the Centers for Medicare & Medicaid Services (CMS) from moving forward with seven Medicaid regulations before April 2009. The rules affect payments for graduate medical education, rehabilitation services, hospital clinic services, safety net providers, and case management services. In addition, the bill would halt CMS action on state provider tax laws and appeals filed through the Department of Health and Human Services. Some of the regulations have moratoria imposed by Congress that will expire on May 25.

HCAHPS Patient Experience Data Set for March 28 Release. On March 28, the Centers for Medicare & Medicaid Services (CMS) will release survey results about patients’ experience of care, known as HCAHPS, on the Hospital Compare website. This will include survey information from patient discharges from October 2006 through June 2007; care dimensions measured include communication, responsiveness, impressions of the hospital environment, pain management, discharge information, and overall care. The HCAHPS survey used to capture this information is different from traditional patient satisfaction surveys in that it asks how often different aspects of care were provided. Additionally, CMS has moved Medicare payment and volume data, which is now displayed on a separate Medicare website, to Hospital Compare. Hospitals may view their own HCAHPS data and see how it compares to state and national averages on the QualityNet website. Hospitals should anticipate media inquiries about their HCAHPS data as well as the payment data. Additional information will be sent to members early next week.

DPW to Issue New Funds for Hospital OB, Nenonatal Services. HAP was successful in gaining additional funding for hospital obstetrical and neonatal services in the current state fiscal year. The Department of Public Welfare (DPW) is providing public notice of its intent to establish a one-time additional class of disproportionate share hospital (DSH) payments for certain qualifying hospitals based on obstetrical and neonatal intensive care cases. A total of 73 hospitals qualify for these funds; information was sent to those hospitals in HAP Memo 08-34. DPW expects to make the state share payment by the end of April. Once federal approval has been received, the federal share will be made. Ensuring access to appropriate prenatal, obstetrics, and postpartum services is an essential investment in Pennsylvania’s future. HAP has worked with Senator Jane Orie (R-Allegheny) and Representative Kathy Manderino (D-Philadelphia) on legislation addressing access to obstetrical and neonatal intensive care services. Senate Bill 966 and House Bill 1514, the Access to Obstetrical and Neonatal Care Act, provide additional payments to qualifying hospitals that have a high volume or percentage of Medicaid cases. While these bills were not enacted into law, DPW agreed to follow the basic requirements in these bills to provide additional funding to eligible hospitals. The current budget provides approximately $11 million in state and federal funds for this purpose. HAP is seeking action on S.B. 966 and H.B. 1514, and requesting $33 million in state and federal funds for fiscal year 2008–2009.

Study: Physician Self-Referral Decisions Influenced by Payment Status. A study published this week in Health Affairs has found that “physicians at physician-owned facilities are more likely than other physicians to refer well-insured patients to their facilities and route Medicaid patients to hospital outpatient clinics.” The study analyzed more than one million discharge abstracts from hospital outpatient departments and ASCs located in the Pittsburgh and Philadelphia metropolitan areas. The study concluded, “The worry is that physician-owned facilities will siphon off profit centers that have traditionally cross-subsidized care for uninsured and Medicaid patients, as well as unprofitable services such as burn treatment. The findings from this paper are consistent with that fear.” As HAP has noted in response to previous reports about non-general acute care hospitals, these facilities typically do not take those patients who cannot pay, treat far fewer Medicaid patients than do acute care hospitals, and do not treat patients with complex conditions. The result is that community hospitals take in and treat the sickest and most needy patients.
HAP will continue to press for equitable requirements for licensed health care facilities, regardless of ownership or setting. HAP’s advocacy will continue to emphasize that facilities that are providing the same or similar services should adhere to the same or similar standards of licensure, public reporting, reimbursement, and provision of care to the uninsured, Medicaid, and other publicly-supported patients.

PHCQA Launches Hospital Quality Website. The Pennsylvania Health Care Quality Alliance (PHCQA) this week launched a new website that compiles hospital quality data from existing data sources to help promote quality and transparency in health care. The PHCQA website, a cooperative effort of hospital, physician, health insurance, and government leaders, includes hospital-specific process and performance measures associated with treatment of heart attacks, heart failure, and pneumonia. PHCQA is using data that is already publicly available through the Centers for Medicare & Medicaid Services (CMS) and Pennsylvania Health Care Cost Containment Council (PHC4) websites. Details were sent to members in HAP Memo 08-31.

HHS Secretary Visits PA, Outlines Health IT Initiative. Health and Human Services (HHS) Secretary Michael Leavitt this week convened a meeting of health care stakeholders in Philadelphia, hosted by Thomas Jefferson University Hospital, and last week he convened a similar meeting in Pittsburgh, hosted by the Jewish Healthcare Foundation. In both meetings, Leavitt discussed the need to create a more coherent health care system through the effective use of health information technology (IT) and greater transparency of health care costs and quality. Leavitt outlined a new Medicare health IT demonstration project, Connecting to Better Health Care, that will reward physician practices for using CCHIT-certified electronic medical records, electronically reporting basic quality measures, and for demonstrating improvement in those measures over time. At the Pittsburgh meeting, Leavitt formally designated the Pittsburgh Regional Health Initiative as one of the 14 initial HHS Chartered Value Exchanges (CVE) and challenged them to consider pursuing the demonstration project. At the Philadelphia meeting, Leavitt generated stakeholder interest in pursuing both CVE designation and the demonstration project. David Nash, M.D., of Jefferson Medical College, was charged by Leavitt with continuing discussions in southeastern Pennsylvania and also coordinating with efforts in southwestern Pennsylvania.

Providers Urged to Participate in MCPSS Survey. The Centers for Medicare & Medicaid Services (CMS) is conducting its annual Medicare Contractor Provider Satisfaction Survey (MCPSS) by contacting a sample of Medicare providers. The survey is designed to garner quantifiable data on provider satisfaction levels with key services provided by the Medicare fee-for-service contractors (FFS) who process and pay more than $280 billion in Medicare claims each year. Providers selected to participate in the survey are being contacted by the survey contractor, Westat. CMS is encouraging providers contacted by Westat to complete the survey. According to CMS, the results of the study will “help us improve the services we provide you and be used by CMS as an additional measure to evaluate performance of Medicare Administrative Contractors (MACs) and support process improvement efforts.” Westat will contact selected providers by telephone in the coming weeks to encourage their participation. MCPSS results will be available to contractors and the public in July 2008.

February 2008

The New York Times reports that patients treated in hospitals on weekends have inferior outcomes when compared to those receiving care on weekdays.

The Associated Press reports on a published list of 131 nursing homes nationwide with poor inspection records, released by the Centers for Medicare & Medicaid Services.

Forbes’ special series of articles, pictures and video entitled, “How Safe Are America’s Hospitals?” reports on patient safety, infections and specialty hospitals.

The Philadelphia Inquirer reports that reducing complications a high priority nationwide, and area health care providers are working to identify where problems occur, and taking steps to prevent them.

The Pittsburgh Post-Gazette also reports on the Forbes series, stating that one in 200 patients who spend one night or more in a hospital will die from a medical error, and one in 16 will pick up an infection.

The New York Times reports that some cases of carbon monoxide might be caught if doctors began routinely testing emergency room patients for exposure.

January 2008

The San Francisco Chronicle reports that entire classes of mainstay antibiotics are being threatened with obsolescence, and bugs far more dangerous than staph are evolving in ominous ways.

The Des Moines Register reports that doctors agree medical errors should be reported to their hospitals, but a significant number admit they don't always report their own.

USA Today reports that hospitals are attacking potentially fatal bacterial infections by marrying a series of proven medical treatments.

A New York Times op-ed states that most doctors are afraid to take responsibility for medical errors, but studies have shown that physicians’ apologies may protect against litigation.

The New York Times reports that in nearly a third of cases of sudden cardiac arrest in the hospital, the staff takes too long to respond, increasing the risk of brain damage and death, a new study finds.

USA Today reports that the first major study of how quickly hospitals respond to in-house cardiac arrests found delays in almost a third of cases.

The Centre Daily Times reports that state Rep. Kerry Benninghoff has introduced a bill that would add methicillin-resistant Staphylococcus aureus, or MRSA, to the list of reportable diseases in Pennsylvania.

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."