CMS Releases Hospital Error, Injury Data

By Emily P. Walker, Washington Correspondent, MedPage Today

The Centers for Medicare and Medicaid Services began reporting hospital-specific rates of eight hospital-acquired conditions (HACs), so patients can compare how often the nation's 4,700 hospitals make preventable medical errors.

The eight conditions are foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, vascular catheter-associated infection, catheter-associated urinary tract infection, and manifestations of poor glycemic control.

"By making HAC data transparent, CMS sheds light on those preventable events where patients are harmed while seeking care," the agency said in a press release.

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Nursing Home Med Errors Vary by Form of Drug

By Michael Smith, North American Correspondent, MedPage Today

Residents in nursing and old age homes are four times as likely to get an incorrect dose of medication if it's in liquid rather than pill form, researchers reported.

In a study in 55 British homes, errors included such things as incorrect measurements and not shaking a suspension, according to David Phillip Alldred, PhD, of the University of Leeds in Leeds, England, and colleagues.

Errors also were more likely with inhalers and other drug formulations, compared with pills or tablets dispensed using a monitored dosage system, Alldred and colleagues reported online in BMJ Quality and Safety.

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Patient Safety beyond the Hospital | Health Policy and Reform

Tejal K. Gandhi, M.D., M.P.H., and Thomas H. Lee, M.D.

The vast majority of health care is delivered in ambulatory settings, yet we are only just beginning to understand the safety risks that exist outside of hospital walls. There are 900 million visits to physicians’ offices in the United States each year, as compared with 35 million hospital discharges,¹ and spending on outpatient care is the fastest growing segment of health care spending.² Yet most patient-safety research and safety-improvement work have been done in inpatient settings; indeed, a search of the Patient Safety Network Web site of the Agency for Healthcare Research and Quality shows that since 2005 only about 10% of patient-safety studies have been performed in outpatient settings.

Experience to date indicates that safety issues in the ambulatory setting differ from those in the inpatient setting in obvious and not-so-obvious ways. There are differences in the types of errors (treatment errors predominate in inpatient settings, whereas diagnostic errors do in outpatient settings), the provider–patient relationship (e.g., adherence is more critical in outpatient settings), organizational structure (ambulatory practices tend to lack the infrastructure and expertise to address quality and safety improvement), and regulatory and legislative requirements (e.g., there are staffing ratios and accreditation requirements for hospitals that do not exist for private practices).³ In addition, the signal-to-noise ratio is much lower in outpatient settings: in ambulatory care, a physician may see 100 patients with chest pain before seeing one with an actual myocardial infarction.

The outpatient setting also presents greater challenges for information transfer. Particularly in the case of patients with complex medical needs, the responsibility for care is often shared by multiple providers at many institutions. These clinicians may never meet, and they often use different medical-record systems. Such care has long, fragile feedback loops. In the hospital, if a patient has an adverse drug event, clinicians become aware of it very quickly; in the outpatient setting, a complication or missed diagnosis may not be identified for months, if ever.
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Study: Medical errors cost nation almost $20B each year - The Hill's Healthwatch

By Mike Lillis

Preventable medical errors cost the country $19.5 billion in 2008 — or roughly $13,000 for each avoidable case, according to a report published Monday by the Society of Actuaries (SOA).

And that number is likely low, according to consultants at Milliman, who crunched the data.

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Transparency and Public Reporting Are Essential for a Safe Health Care System

What will it take to motivate hospitals to do what we know works to make health care safer? Of the three major approaches to improving patient safety—regulation/accreditation, financial incentives, and public reporting—the most promising is public reporting of performance information and feedback to providers. Transparency is an idea whose time has come and both hospitals and the public will be better off because of it.

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The Health Care Blog: Another Look: Incident Reporting Systems

by BOB WACHTER

When the patient safety field began a decade ago with the publication of the IOM report on medical errors, one of its first thrusts was to import lessons from “safer” industries, particularly aviation. Most of these lessons – a focus on bad systems more than bad people, the importance of teamwork, the use of checklists, the value of simulation training – have served us well.

But one lesson from aviation has proved to be wrong, and we are continuing to suffer from this medical error. It was an unquestioning embrace of using incident reporting (IR) systems to learn about mistakes and near misses.
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Pitching Patient Safety and Hospital Transparency on YouTube - Health Blog - WSJ

By Laura Landro After a medical error, hospitals’ traditional approach has been to retreat behind a wall of silence, on the advice of risk managers and attorneys. But some hospitals are taking a different approach, fully disclosing medical errors, apologizing and offering financial compensation up front – and inviting patients and families to participate in patient safety improvement efforts. Read More

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