SEPTEMBER 27, 2012

Welcome to the Patient Safety Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by The Quality Colloquium

Improving Patient Safety Has to Involve Stopping Errors with Infusion Pumps for Post-op Pain
Consumer Reports' "How Safe is your Hospital?" reports that only 158 out of the 1,000 hospitals surveyed received a grade above 60 on their 100 rating scale. Miscommunication regarding medications and infections were cited as leading causes for low scores. Infusion devices for administering pain medications were involved in more than 56,000 incidents and 700 deaths between 2005 and 2009. The author, an academic physician specializing in pain management, advocates for more scrutiny regarding the use of intravenous patient-controlled analgesia (IV PCA) suggesting several sources for assistance. She has also founded AcelRx, a company developing effective alternatives to patient controlled IV pain management techniques. (MedCity News,. September 25, 2012)

Hospitals in 'Patient Safety First' Collaborative Reduce Early Elective Deliveries by 65%
Patient Safety First...a California Partnership for Health (PSF) is a collaboration of 180 California hospitals, led by Anthem Blue Cross, the National Health Foundation and California's Regional Hospital Associations. Among the improvements is a 65% reduction in early-term births (prior to 39 weeks), important because early deliveries have a much higher rate of infant morbidity and mortality. "The reduction of early term elective deliveries by nearly two thirds is an amazing result and a testimony to the potential of the Patient Safety First collaborative," said Pam Kehaly, president of Anthem Blue Cross. Other significant achievements include a VAP rate reduction from 2.32 per 1000 to 1.21, a CAUTI rate decline from 1.59 per 1000 to 1.09, a CLBSI reduction from 2.21 to 1.34 per 1000, and a sepsis mortality rate decline from 23.35 per 100 to 20.15. The sepsis reduction alone saved more than 973 lives. Further, cost savings totaling more than $19 million came as a result of PSF's sepsis initiative alone. (The Daily Transcript's SanDiegoSource, September 13, 2012)

Public Citizen Urges HHS to Probe 'Superbug' Outbreak at NIH Center
Public Citizen, a non-partisan advocacy group focused on the rights of citizens, is urging HHS to open "an independent investigation" into the 2011 outbreak of antibiotic-resistant bacteria (Klebsiella pneumonia)" at the National Institutes of Health's (NHI) Clinical Center in Bethesda, MD. Public Citizen has raised concerns about the handling of the outbreak because it was not reported to the Maryland health department until December, 2011, fully 6 months after the outbreak. The fact that the law requires immediate reporting of such incidents has raised concerns about the NIH handling of the situation. Public Citizen is demanding answers about the incident which affected 18 patients and caused 11 deaths. (Inside Health Policy, September 13, 2012)

A New Way to Curb Medical Malpractice Claims? Oregon Considers "Safe Harbor" Policy
Oregon Governor John Kitzhaber's Patient Safety and Defensive Medicine Workgroup, comprised of physicians, healthcare executives, lawyers, the public as well as lawmakers, has been tasked with reducing medical malpractice lawsuits. The Workgroup is now preparing to present their findings on the creation of a safe harbor for adverse medical events. Among the issues the Workgroup is facing is determining whether the desired outcome is improved patient safety or a reduction in liability costs and therefore healthcare costs. Malpractice claim payouts in Oregon for 2011 were $31,966,750 or $3,212 per licensed physician compared with national average of approximately $3,950 per licensed physician. (The Legal Examiner, September 18, 2012)

FDA Pairs Up with University to Help Developers Study Drug Interactions
The University of San Francisco has partnered with the FDA in launching the development of a data base aimed at aiding pharmaceutical companies in gaining an earlier understanding of how patients might respond to drugs based on which proteins (called membrane transporters) the drug acts on in the body. This is an expansion of research begun by the International Transporters Consortium. More drug interaction studies are also intended as part of the development process. "You've got to have one site to go to that you can find info on A) the in vitro interactions and B) the clinical studies," said Kathleen Giacomini, chair of UCSF's Department of Bioengineering and Therapeutic Sciences and a consortium member. (Inside Health Policy, September 10, 2012)

Physician's Empathy Directly Associated with Positive Clinical Outcomes, a Large Study of Italian Diabetic Patients Confirms
Researchers form Thomas Jefferson University (TJU) together with Italian researchers report in the September 2012 issue of Academic Medicine (click here to review the study) that the patients of more empathic physicians have better outcomes and fewer complications. This study of 20,961 patients "...confirmed our hypothesis that a validated measure of physician empathy is significantly associated with the incidence of acute metabolic complications in diabetic patients, and provide the much-needed, additional empirical support for the beneficial effects of empathy in patient care" said Mohammadreza Hojat, PhD, director of the Jefferson Longitudinal Study of Medical Education. (Newswise, September 10, 2012)

Medicare Bills Rise as Records Turn Electronic
A New York Times analysis of Medicare data from the American Hospital Directory shows hospitals receiving $1 billion more from Medicare in 2010 than in 2005. The analysts attribute much of this increase to hospitals changing the billing codes they assign patients in the ER. The article also cites a recent report which asserts that aggressive billing by just 1,700 of the more than 440,000 physicians billing Medicare cost Medicare more than $100 million in 2010 alone. The author contends these upcoded costs are the result of the ease of the electronic medical record, which, according to one physician interviewed, "makes it faster and easier to be fraudulent." Medicare responded by pointing to the improvement in quality and "the strong protections in place to prevent fraud and abuse of this technology that we're improving all the time." (New York Times, September 21, 2012)

Patient Safety Project Reduces Infections by 40 percent, Saves $34M
The Agency for Healthcare Research and Quality (AHRQ) announced that its national patient safety project to reduce the rate of central line-associated bloodstream infections (CLABSIs) was able to prevent more than 2,000 infections by reducing the infection rate by 40% in more than 1,100 participating intensive care units in 44 states. This resulted in saving more than 500 lives and avoiding more than $34 million in unnecessary costs. Theresa Hickman, a nurse educator from Peterson Regional Medical Center in Kerrville, Texas, who spoke at the AHRQ annual conference, said, "We are a 125-bed, rural, nonprofit hospital, and during the last 31 months we have not had a single CLABSI in our facility. In my 32 years in nursing, this is the most powerful program I've ever seen." (Healthcare Finance News, September 12, 2012)

How to Stop Hospitals from Killing Us

This Wall Street Journal story is by Mary Makary, MD, a surgeon at Johns Hopkins Hospital, a developer of the surgical checklists adopted by the World Health Organization, and the author of Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, published this month by Bloomsbury Press.

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High Performance and Operational Excellence

Kathleen Jennison Goonan, MD
Massachusetts General Hospital, Boston, MA