OCTOBER 25, 2012

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

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
The National Association for Healthcare Quality (NAHQ) and eleven other organizations are calling for hospitals to step up efforts to encourage better reporting of patient safety. The introduction to this report issues this call to action: "We call upon leaders of healthcare organizations to implement protective structures to assure accountability for integrity in quality and safety evaluation and comprehensive, transparent, accurate data collection, and reporting to internal and external oversight bodies." The report recommends four actions: 1) Establish accountability for the integrity of quality and safety systems, 2) Protect those who report quality and safety findings, 3) Report quality and safety data accurately, and 4) Respond to quality and safety concerns with robust improvement. (National Association for Healthcare Quality, October 2012)

Mini-Sentinel Findings Shed Light on Assessing Relative Safety Risks
The post-market surveillance system's effectiveness in assessing risks and benefits has been demonstrated in a mini-sentinel assessment which found that similar blood pressure medications carry different risks of developing an adverse swelling condition. The study also allowed the FDA to examine the risk of adverse effects associated with several drugs in the same class that had not previously been studied. These types of studies are essential for understanding the risks and benefits of medications in real-world practice. (Inside Health Policy, October 18, 2012)

FDA's Compounding Oversight Problems Exacerbated by Unclear Records Authority
Because of the unclear nature of the FDA's authority to request records of compounding pharmacies it has been difficult to determine whether a pharmacy is compounding a drug specifically for a patient or is illegally compounding on a broader scale. The nationwide meningitis outbreak linked to the New England Compounding Center has led to a review of the scope of its operations, and this in turn has called into question the FDA's authority. (Inside Health Policy, October 15, 2012)

Stakeholders Look to Congress to Address Compounding after Court Sidesteps Issue
In a follow-up story Inside Health Policy reported that following the dismissal of an important animal drug compounding case, stakeholders are looking to Congress to clarify the FDA's authority over drug compounding. Speculation surrounding the lame duck Congress suggests that action is unlikely. (Inside Health Policy, October 19, 2012)

The Impact on Hospitals of Reducing Surgical Complications Suggests Many Will Need Shared Savings Program with Payers
Reducing surgical complications is critically important yet results in a loss of revenue to hospitals. This article recommends hospitals aggressively pursue arrangements with payers to share in the savings that complication reduction programs generate. (Health Affairs, October 2012)

How to Make Your Hospital Stay Safer and Cheaper: A Checklist
Elizabeth Bailey, author of The Patient's Checklist: 10 Simple Hospital Checklists to Keep You Safe, Sane and Organized, is interviewed in this PBS NewsHour piece. Bailey wrote the book after her father "...went 'crazy almost overnight' from an entirely preventable medication error due to a series of lapses in basic doctor-patient communication." (PBS NewsHour, October 23, 2012)

Effect of Nonpayment for Preventable Infections in U.S. Hospitals
This New England Journal of Medicine article reports on a study, funded by the Agency for Healthcare Research and Quality, examining changes in trends for two health care-associated infections that were targeted by the CMS policy to discontinue reimbursement for certain hospital-acquired infections (central catheter-associated bloodstream infections and catheter-associated urinary tract infections) as compared with outcomes for a hospital-acquired infection that was not targeted by the policy (ventilator-associated pneumonia). The study involved 398 hospitals and 14,817 to 28,339 unit-months, depending on infection type, during the period of January 2006 through March 2011. The authors' conclusion reads, "We found no evidence that the 2008 CMS policy to reduce payments for central catheter-associated bloodstream infections and catheter-associated urinary tract infections had any measurable effect on infection rates in U.S. hospitals." (New England Journal of Medicine, October 11, 2012)

National Patient Safety Foundation Announces Leadership Transition
Diane C. Pinakiewicz, MBA, CPPS, will be leaving her position as President of The National Patient Safety Foundation (NPSF) effective November 12, 2012. Patricia McGaffigan, RN, MS, the NPSF's current Vice President, Program Strategy and Management, will assume interim duties while the search for a permanent successor occurs. (National Patient Safety Foundation, October 15, 2012)

Joint Commission Ranks 620 Hospitals as Top Performers on Quality Measures
The Joint Commission has announced that 620 hospitals have been named as top performers in quality and safety. This represents an increase of 53% from last year's list. The designation is based on a hospital's performance across 45 accountability measures. To be designated a top performer, a hospital must achieve a composite score of 95% or greater in each measure. (Modern Healthcare.com, September 19, 2012)

The New VIPs

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Improving Quality of Care: The IT Inside

David Blumenthal MD, MPP
Chief Health Information and Innovation Officer, Partners HealthCare, Samuel O. Thier Professor of Medicine and Professor of Health Care Policy, Harvard Medical School, Boston, MA