FEBRUARY 2, 2012

Welcome to the Patient Safety Update eNewsletter
This issue sponsored by The Medical Home Summit

Report Finds Most Errors at Hospitals Go Unreported
The Obama administration and hospital industry leaders have placed a high priority on reducing medical errors. A new report reports that at many hospitals, this high-level commitment has not been translated into practice. The inspector general found that hospitals made few changes to policies or practices after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any systemic quality problems. Organizations that inspect and accredit hospitals generally do not scrutinize how hospitals keep track of medical errors and other adverse events, the study said. (The New York Times - January 16, 2012)

How Safe Are Our Hospitals?
Hospital Compare shows most hospitals in the country experienced similar rates of complications and errors, but some hospitals, which Medicare officials called "the outliers," were labeled "worse" or "better" than the national rate based on their overall patient safety records. The evaluations reflect experiences of patients treated between October 2008 and June 2010. The Centers for Medicare and Medicaid Services' website, Hospital Compare, began reporting patient safety ratings for thousands of the nation's hospitals, including those in the Washington area, in October 2011. (Kaiser Health News - January 30, 2012)

Padi-Lock Increases Patient Safety and Reduces Legal Liabilities by Reducing I.V. Tube Related Entanglement, Impingement and Death
Entanglement of I.V. lines is a growing concern throughout the United States and has been the culprit to multiple cases of medication administration errors, medical line disconnections, as well as, death due to strangulation among infants. The Padi-Lock, designed by Padi-Lock, LLC, solves these problems by eliminating the cost and time required in restarting the I.V. access, whether it is a central line, peripheral or P.I.C.C. line. (San Francisco Chronicle - January 31, 2012)

National Business Group on Health: Hospitals, Health Care Facilities Should Require Flu Vaccinations for All of Their Employees
The NBGH released a position statement which states hospitals should require annual flu vaccination of all employees as a condition of employment, unless employees can demonstrate medical contraindications (with physician documentation) or religious objections. The statement also says employees who invoke either of these exemptions should not engage in direct patient care if they have flu-like symptoms. Instead, hospitals should either reassign these employees to non-patient care areas or require them to wear masks at all times during flu season when delivering care to patients. (MarketWatch - February 2, 2012)

Premier, Safe Injection Practices Coalition Release Meeting Proceedings
Premier and the Safe Injection Practices Coalition are providing the proceedings of a stakeholder meeting held in late April 2011, convened by both entities to raise awareness, continue the national dialogue and expand safer and innovative approaches and product designs to protect patients from unsafe injection practices. (Infection Control Today - January 31, 2012)

Some US Hospitals Are Challenging the Status Quo to Raise Safety Standards
The Centers for Medicare and Medicaid Services and the state of Maryland have rated patient safety at hospitals in the District of Columbia, Maryland and Virginia. Dozens of hospitals in the region are working on strategies, including using checklists to ensure that hospital employees consistently follow safety standards, ramping up pressure on employees to wash their hands, flattening hierarchies to improve communication between doctors and nurses, designing equipment to reduce errors, and digitizing patient records. (Business Insider - February 1, 2012)

Study: Caps on Nursing Overtime Improve Patient Safety
A newly published study finds that state-mandated caps on nurses' mandatory overtime hours are effective and reduce overtime hours for newly registered nurses. Past research has demonstrated that fatigue caused by long hours without sufficient rest between shifts can lead to mistakes that endanger patients and nurses. (Renal Business Today - January 30, 2012)

Washington Physicians Fight for Patient Access to Care and Patient Safety Legislation
More than 140 physicians met with legislators to voice their opinions on several bills that could significantly impact patient access to care and patient safety. The Washington State Medical Association (WSMA), which held its annual Legislative Day this week, is working hard on legislation to preserve programs that are on the cutting block, and promote legislation that would benefit patients. (MarketWatch - January 27, 2012)

VA National Center for Patient Safety

The NCPS was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Their goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety managers at 153 VA hospitals and patient safety officers at 21 VA regional headquarters participate in the program.

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The Campaign for Better Care

Renee Hodin
Community Catalyst, Boston, MA