JULY 19, 2012

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

Consumer Reports Scores Hospitals on Safety, Finds Too Many Pose Risks to Patients
On a scale of 1 - 100, more than half of the 1,159 hospitals rated by Consumer Reports in 44 states scored below 50. This is the first time Consumer Reports has scored hospitals. The process utilized six categories: 1) infections, 2) readmissions, 3) overuse of scanning, 4) communication about new medications and discharge, 5) complications, and 6) mortality. The report is available online at www.ConsumerReports.com and will be included in four regional editions of the August, 2012 issue. (Infection Control Today, July 6, 2012)

The Final Check: Reducing Mislabeled Specimens
According to the Collage of American Pathologists, 1 in 1,000 blood specimens are labeled with the wrong patient's name -- which can produce harmful effects for two patients. Palmetto Health Richland Hospital, the South Carolina Hospital Association and Outcome Engenuity, LLC have designed a simple intervention, called The Final Check, to dramatically reduce mislabeled blood samples. The Final Check is free and can be downloaded at http://www.thefinalcheck.org/. (National Patient Safety Foundation, July 10, 2012)

GlaxoSmithKline Agrees to Pay $3 Billion in Largest U.S. Healthcare Fraud Settlement
GlaxoSmithKline has agreed to pay over $3 billion in fines and settlements for a variety of wrongdoings. Besides fraud and abuse settlements, the company will pay $243 million in criminal fines for failing to report safety data regarding the diabetes drug Avandia and $657 resolving allegations around statements made about the safety and efficacy of Avandia. The company also pled guilty to charges concerning misbranding related to Paxil and Wellbutrin. (ModernHealthcare.com, July 2, 2012)

Study Examines Patient Experience at Safety-Net Hospitals
In a study published in the Archive of Internal Medicine researchers from the Harvard School of Public Health used HCAHPS survey results from 2007 and 2010 to determine performance and improvement of patient experience to compare patient-experience scores from Safety Net Hospitals (SNH) against all others. SNHs had lower scores on nearly every measure of patient experience. Safety Net Hospitals tend to be large, for-profit or publically owned, a teaching hospital, serve fewer Medicare patients but have more Medicaid and minority patients than other hospitals. The authors conclude that the implementation of the Value-Based Payment program created by the Affordable Care Act will undoubtedly exacerbate this problem. (medicalxpress.com, July 16, 2012)

Physician-Patient Alliance for Health & Safety: Monitoring the High-Acuity Patient: Does Risk Stratification Increase or Decrease Patient Safety?
Who is a candidate for outpatient surgery is becoming an increasingly important issue as pressures mount to find less costly alternatives for patient care. Michael Wong of the Physician-Patient Alliance for Health & Safety (PPAHS) notes, "Studies have shown that any patient receiving opioids may be at risk of postoperative respiratory depression and if undetected, respiratory arrest." Current care standards for postoperative monitoring are insufficient to detect all episodes of slow breathing. Frank Overdyk, MD of the Medical University of South Carolina says, "Patient surveillance systems that use continuous monitoring with oximetry and capnography would facilitate early recognition of patient deterioration." (Market Watch, July 12, 2012)

July 25th Is Patient Safety Day
Since 2001, July 25th has been designated Patient Safety Day. Recently, July was named Patient Safety Month. A Patient Safety Day video can be seen at http://www.youtube.com/watch?v=cqBvyQbYbvA.

Medical Devices Will Begin Getting Special Codes to Help Improve Patient Safety
The Food and Drug Administration is now requiring medical device manufacturers to place a unique device identifier (UDI) or bar code on all devices such as placemakers or implants. The UDI will help to track faulty devices and to identify counterfeit ones. FDA officials estimated the requirement will cost manufacturers $550 million over the next decades. (NJ.com, July 3, 2012)

Blumenthal Holds Conn. Hearing on Patient Safety
U.S. Sen. Richard Blumenthal wants the efforts underway in Connecticut to create a culture of safety to serve as a national model. The Connecticut Hospital Association began a state-wide initiative this year to address the problem which costs the nation $4.4 billion and 100,000 lives annually. The intensive effort is aimed at reducing what a 2010 federal report cited as 950 Medicare deaths and 22,000 hospital-acquired infections in Connecticut. (boston.com, July 2, 2012)

Patient Controlled Analgesia (PCA) Checklist

More than 56,000 adverse events and 700 patient deaths were linked to PCA pumps in reports to the FDA between 2005 and 2009. The Physician-Patient Alliance for Health & Safety (PPAHS) offers this checklist to aid in initiating and continually assessing patients' use of PCA.

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Using Patient-Centered Outcomes Research to Improve Care

Jed Weissberg, MD
Senior Vice President, Quality & Care Delivery Excellence, Kaiser Foundation Health Plan & Hospitals, Kaiser Permanente, Oakland, CA