JUNE 7, 2012

Welcome to the Patient Safety Update eNewsletter
This issue sponsored by The Quality Colloquium

Senate Passes FDA Safety and Innovation Act
While the Senate has passed the Food and Drug Administration Safety and Innovation Act it still fails to address significant flaws, according to the Consumers Union of Consumer Reports. Their concerns relate to the use of recalled devices as predicates for approval, the failure to create a national registry for tracking implant problems and notifying patients, stronger authority for the FDA to require post-market studies and maintaining the current level of conflict of interest protections. (MarketWatch, May 24, 2012)

State Fines 13 Hospitals $825K for Patient Safety, Care Violations
The California Department of Public Health announced on June 4th that fines have been levied against 13 California hospitals for safety lapses and failures in patient care. These fines result from the enforcement of a 2006 law requiring hospitals to report all significant patient injuries. Infractions included a foreign object incident, an improperly monitored full-term infant and a sexually assaulted patient. (California Healthline, June 4, 2012)

Patient Safety Education at Japanese Medical Schools: Results of a Nationwide Survey
The result of a survey regarding the role of patient safety education in Japanese medical schools found that the amount of time spent training medical students was fewer than five hours in forty per cent of the schools. The five hours were spent in lectures focused on error theory and legal ramifications with little or no attention to root cause analysis. (7th Space, May 10, 2012)

Effective Communication Means Better Patient Safety
HealthGrades has released a new report demonstrating a strong link between communication and patient safety. More overall patient safety events occurred in hospitals that scored in lower ranges of each of three communication categories: nursing communication, physician communication and patient discharge instructions. (Nursing.com, May 28, 2012)

New Guideline Advises Yearly Lung Cancer Screening with CT
The American College of Chest Surgeons published a study (see JAMA Online First, May 20, 2012 http://jama.jamanetwork.com/article.aspx?articleid=1163892) which included recommendations for annual low-dose computed tomography (LDCT) screening for older smokers and former smokers. The study concludes, "Low-dose computed tomography screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalizability of results." (MedScape Today, May 24, 2012)

90% of Oncologists Experiencing Drug Shortages
An April 11-12, 2012 MDLinx poll of 200 oncologist found that more than 90% reported shortages of key drugs in their practices. Doxorubicin, cytarabine and methotrexate were the most commonly identified as being in short supply. A February study by Epocrates Web found 82 of 206 (40%) respondents indicated that "a patient died sooner due to drug shortages. Yet according to the FDA (http://www.medscape.com/viewarticle/763296) the number of new drug shortages in the United States in 2012 is half that of the same time period last year. (Medscape Today, May 24, 2012)

Working the Night Shift May Boost Breast Cancer Risk
Evidence now suggests that working the night shift harms health increasing the risk of breast cancer, diabetes and obesity. Researchers at the Institute of Cancer Epidemiology at the Danish Cancer Society found a 40% increase in risk for breast cancer among women working night shifts. (Time Healthland, May 29, 2012)

Pysician-Patient Alliance for Health & Safety: Don't Post-Surgical Patients Deserve Better Care?: Patient Deaths Underscore Need for Continuous Electronic Monitoring
The Physician-Patient Alliance for Health & Safety (PPAHS) is encouraging the adoption of the recently released recommendations of the Anesthesia Patient Safety Foundations (APSF). Patient who are put on patient-controlled analgesia (PCA) pumps are not observed according to the same standards post-operatively as they are in the operating room. The APSF is calling for continuous monitoring of oxygenation and ventilation. (San Francisco Chronicle, May 31, 2012)

Online Patient Safety Curriculum

The National Patient Safety Foundation offers a 10 module patient safety curriculum. These modules are designed to help the learner understand the context, key principles, and competencies associated with the discipline of patient safety, and how these tenets and skills are applied in everyday practice.

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Physician Training and the Culture of Quality

David B. Nash, MD, MBA, FACP
Dean, Jefferson School of Population Health; Dr. Raymond C. and Doris N. Grandon Professor of Health Policy, Thomas Jefferson University