Patient Safety Monitor

Patient Safety Monitor Alert

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Issue 47, November 30, 2005

• Sim patients help with training

  Baystate Medical Center in Springfield, MA, has begun using patient simulators for training staff...

• Editorial: Hospitals must provide more information to learn from mistakes

  A Philadelphia Inquirer editorial demands that the region’s hospitals be more forthcoming...

Issue 46, November 30, 2005

• Beth Israel Deaconess adopts rapid response teams

  Beth Israel Deaconess Medical Center in Boston is slowly rolling out a rapid response team (RRT...

• Hospital noise can affect patient safety

  Hospitals are noisier then they used to be, and a new study suggests that the noise is impeding the...

• WHO patient safety chairman: Hospitals more dangerous than airplanes

  Patients in a hospital face a far larger risk of death than passengers in an airplane, according to...

• JCAHO commissioner recommends changes to the malpractice system

  A Joint Commission on the Accreditation of Healthcare Organizations commissioner recommended...

• Department of Defense halfway toward total electronic medical recordkeeping

  The Department of Defense (DOD) has announced it is more than 50% of the way toward implementing...

Issue 37, September 28, 2005

• Eisenberg Patient Safety Awards announced

  The Joint Commission on the Accreditation of Healthcare Organizations and National Quality Forum...

• Maine hospitals to join statewide effort

  The state of Maine has introduced the Safety Star program, a statewide program similar to the...

• Advice for patients in the hospital

  A good attitude and polite assertion of rights is important for patients and families while in the...

Issue 36, September 28, 2005

• Katrina highlights need for electronic medical records

  Tens of thousands of New Orleanians no longer have medical records, as Hurricane Katrina ravaged...

• Study: Long hours, drinking have similar effects on physicians

  A new study claims physicians on heavy call perform at the same level of those who serve light call...

• Med labeling death settlement includes teaching opportunity

  As part of a settlement with the family of a woman killed when given the wrong drug, Virginia Mason...

• Canadian hospital group launches patient education effort

  The Ontario Hospital Association has started a public information campaign aimed at helping...

Issue 35, September 28, 2005

• Be prepared with this free healthcare facility evacuation special report

  The recent damage that Hurricane Katrina caused in the Gulf Coast region of the United States is a...

• Physicians describe treating patients in crippled New Orleans hospitals

  Physicians relied on experience and creativity to treat patients after Hurricane Katrina devastated...

• Communication critical for care

  Although language barriers present hospital staff with a basic communicative challenge, the...

• Aspirin use before bypass may be beneficial

  New research suggests that the use of aspirin before bypass surgery may help patients recover from...

Issue 34, September 1, 2005

• Maggots, leeches to receive regulatory scrutiny

  The ancient practice of using maggots and leeches to clean wounds and defend against infection has...

• Once a laughingstock, the VA is now a modern medicine model

  Veterans Administration hospitals, once considered lumbering and ineffective, are now viewed as...

• The Internet provides help, confusion for patients

  Patients are increasingly turning to the Internet for healthcare information. That sometimes can...

• IL pharmacist strike over, but safety issues remain

  Walgreens pharmacists returned to work last month after a 19-day strike, but the union claims that...

Issue 33, August 29, 2005

• JCAHO, WHO team up for patient safety

  The JCAHO’s Joint Commission International Center on Patient Safety has been designated the...

• Consumers may purchase wrong drugs via Internet, overseas

  The brand name of a drug in the U.S. may be the brand name of a completely different medication...

• Patient waits are getting longer, and some patients are walking away

  The New York Times continues its "Being a Patient" series this week with a look at the increasingly...

• Red socks help prevent patient falls

  A hospital in Massachusetts has started a new patient falls program loosely based on the...

Issue 32, August 29, 2005

• Patients feel alienated, degraded when in the hospital

  An Aug. 16 New York Times article explores the feelings patients have when treated in hospitals. In...

• Medical study review system flawed

  A third of studies submitted to prestigious journals and peer-reviewed are ultimately found to be...

• CA pharmacies trying automated dispensers for prescriptions

  California has allowed a limited number of pharmacies to try automated drug dispensers, where...

• Physician offers patients advice in newspaper column

  Patients have a role to play in creating a culture of hospital safety. In a Framingham, MA-based...

Issue 31, August 12, 2005

• Report cards draw raves from consumer groups, criticism from hospitals

  Consumer advocates are strongly in favor of state laws that require hospitals to release patient...

• AHRQ: Critical care patients at higher risk for adverse events

  Over one-fifth of patients admitted to a number of acute care units were involved in an adverse...

• Drug could help late-shift fatigue

  A new drug may help relieve the fatigue caused by working late shifts and off-hours, according to a...

• Electronic wristband designed to reduce wrong-site surgeries

  Marking incision sites is key to reducing wrong-site surgeries. A new product has been designed to...

Issue 30, August 3, 2005

• Study: A quick reminder for physicians can reduce catheter infections

  A study commissioned by the University of Michigan shows that reminding physicians about catheters...

• CMS to give reporting hospitals a bigger increase

  Hospitals that report quality data to Medicare will receive a bigger payment increase in 2006...

• Voluntary error reporting database passed by Congress

  Congress has approved a bill creating a nationwide, voluntary medical error database. Healthcare...

• Banning prescription drug ads could cost $10B

  A ban on prescription drug ads proposed by Senate Majority Leader Bill Frist could cost the...

Issue 29, July 28, 2005

• JCAHO, QIOs, Medicare scrutinized in newspaper series

  Medicare’s system of hospital oversight and cost control received tough scrutiny in a series...

• Harvard Medical School, more physicians consider apology policy

  More hospital systems are considering policies that have physicians and hospitals apologize for...

• Mass General to create new center on race and medicine

  Massachusetts General Hospital has announced plans to open a new center to study the gap in medical...

• CA county to tighten rules on reporting medical errors

  The San Mateo County Board of Supervisors has proposed an ordinance to tighten the rules on...

Issue 27, July 18, 2005

• Culture change critical to patient safety success

  A change in hospital culture is needed to help increase patient safety, said speakers at a...

• Quality Improvement Organization funding questioned

  Quality improvement organizations (QIO), which are funded by CMS, are designed to help hospitals...

• NJ bill would establish pharmacy panel to improve safety

  A bill working its way through New Jersey’s state house would create a task force to review...

• Proposed overhaul of medical center must make patient safety a priority

  Palomar Pomerado health is in the initial phases of a significant facility expansion in Poway, CA...

Issue 26, July 12, 2005

• MO groups form patient safety center

  Three Missouri healthcare groups have formed a patient safety center for the state, according to...

• Safety culture credited with catching tool-cleaning error

  Wake Forest University Baptist Medical Center in Winston-Salem, NC, discovered that some surgical...

• NC hospital uses temporary tattoos for surgery

  Surgical patients at WakeMed Hospital in Raleigh, NC, receive temporary tattoos so medical staff...

• IL pharmacists set to strike

  Walgreens pharmacists in Illinois and northern Indiana are set to strike Wednesday night over what...

Issue 25, June 29, 2005

• Patient safety focus decreased anesthesiologist malpractice claims

  Anesthesiologists enjoy lower malpractice insurance premiums and face fewer lawsuits because of a...

• IL hospitals cracking down on newborn safety

  Hospitals in Illinois are adding new technology to help keep newborns safe, according to an article...

• Increase in walk-in centers has some concerned about safety

  Walk-in healthcare centers are springing up all over the country, offering patients convenience and...

• MA pharmacy chain investigated for prescription mistakes

  CVS pharmacies in Massachusetts are under investigation, after health officials learned of...

Issue 23, June 15, 2005

• Study: Patient safety, profits linked

  An AHRQ study of Florida hospitals has found that more profitable facilities have better patient...

• New FL hospital opens as paperless facility

  Baptist Medical Center South in Jacksonville has opened its doors, and patients are walking into a...

• MI safety commission to release findings to governor

  The Michigan Health and Safety Coalition has completed a $75,000 study of healthcare in the state...

• HHS wants national Web-based electronic medical records

  Health and Human Services Secretary Mike Leavitt has announced a national collaboration to create...

Issue 22, June 9, 2005

• IL to launch hospital apology pilot program

  Illinois will become the first state to use an apology program for hospitals, according to a...

• FL doctor fights government involvement in patient safety

  A St.Petersburg doctor has sued the state of Florida in an effort to prevent rules limiting the use...

• British law on right-to-die faces legal challenge

  A British man has sued to keep himself on food and water as his body deteriorates, even if...

• Poll: Nurses remain concerned about medical safety

  A new Harris Interactive poll shows 72% of nurses feel there have been improvements in medication...

Issue 21, June 2, 2005

• JCAHO announces 2006 National Patient Safety Goals

  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released its 2006...

• Rapid approval process broken, says congressman

  The Food and Drug Administration's new rapid approval process for new drugs may harm patients...

• Canadian Red Cross pleads guilty to distributing tainted blood

  The Canadian Red Cross has pleaded guilty to distributing tainted blood throughout the 1980s. The...

• Poll: Public supports pay-for-performance for docs if it means cheaper healthcar

  A Harris Interactive poll commissioned by the Wall Street Journal shows the public’s appetite...

Issue 19, May 18, 2005

• Physicians leery of new AZ apology law

  Physicians in Arizona have mixed feelings about a new law in Arizona that removes apologies as an...

• Hospitals band together to fight MA nursing bill

  Several Western Massachusetts hospitals are coordinating efforts to sink a state bill establishing...

• Political odd couple makes pitch for electronic medical records

  Senator Hillary Clinton (D-NY) and former Speaker of the House Newt Gingrich (R-GA) have teamed up...

• PA physician employs state whistleblower law to report problems at hospital

  A former physician with the West Penn Allegheny Health System has reported the group to the state...

Issue 17, April 27, 2005

• NJ hospitals team up with IHI

  The New Jersey Council of Teaching Hospitals will take part in the Institute for Healthcare...

• FBI investigates fake surveyor incidents

  Reports of fake JCAHO surveyors in hospitals across the country has prompted an investigation by...

• PA law requiring medical error notification gets mixed reviews

  Three years after Pennsylvania required hospitals to notify patients of medical errors, it's...

• Harvard Medical CIO backs mandatory electronic health records

  John Halamka, Chief Information Officer of Harvard Medical School and CareGroup, backed President...

Issue 16, April 20, 2005

• MI hospitals form alliance to improve patient safety

  A consortium of nine Michigan hospitals have teamed up to share information, tips and strategies to...

• Survey: Many seniors don’t take their medicine

  A recent national survey shows nearly 40 % of low-income seniors do not take all of the medications...

• Recent flu mailing may have been result of labeling error

  An Ohio laboratory made headlines last week when it inadvertently sent a virulent strain of...

• JCAHO International Patient Safety Center unveils Web site

  The Joint Commission International Center for Patient Safety has created www.jcipatientsafety.org...

Issue 15, April 13, 2005

• MO nurses speak out for better patient-to-nurse ratios

  Nurses in Missouri were scheduled to appear before Missouri state legislators and argue that high...

• Keyboards can harbor bacteria for up to 24 hours

  A new study suggests that bacteria can linger on a keyboard for up to 24 hours, which can lead to...

• University of Minnesota hosts medical error competition for med students

  Students across the country traveled to the University of Minnesota April 10 and 11 to take part in...

Issue 14, April 13, 2005

• Peoria Hospital using computer program to reduce medication errors

  The computerized error reduction system used by St Francis Hospital in Peoria, IL, is being used as...

• FL cancer patients exposed to radiation error

  An improperly installed radiation machine exposed dozens of patients at a Florida cancer treatment...

• CMS launches new quality Web site

  The Centers for Medicare & Medicaid Services (CMS) launched a Web site on April.

• ASHE recommends precautions for surgical prep solutions

  Despite risks of surgical fires, authorities and hospitals should allow the use of alcohol-based...

• Schiavo case highlights end of life decision

  Terri Schiavo died March 31, 13 days after hospice workers removed the feeding tube that sustained...

Issue 13, March 31, 2005

• CMS announces proposed rule updating CoPs

  The Centers for Medicare & Medicaid Services (CMS) announced on March 24 a proposed rule updating...

• Patient’s family sues hospital for wrongful death

  The family of a patient who died as a result of a preventable medical error committed at Virginia...

• CA hospitals having difficulty meeting new nurse staffing ratio

  Officials at California hospitals say they are failing to meet a new court order mandating one...

• Technology allows doctors to treat patients by remote control

  Technology developed by two Johns Hopkins intensive-care specialists allows specialized physicians...

Issue 12, March 24, 2005

• Survey: Many hospitals oppose mandatory error reporting

  Many hospital administrators believe mandatory reporting of medical errors will lead to more...

• California government to fund training for nurses

  California Governor Arnold Schwarzenegger said on March 18 that he wants to help recruit and train...

• Hospital’s failure with electronic medical records a caution for others

  While government officials are making a push for electronic medical record systems and citing...

• Medical professionals get lesson in penmanship

  Salem (OR) Hospital recently held a handwriting class for area medical professionals to reduce the...

Issue 11, March 16, 2005

• JCAHO announces plans for international center for patient safety

  The Joint Commission on Accreditation of Healthcare Organizations announced on March 11 plans to...

• Hospital uses carnival theme to educate staff on safety

  Trinity Health Center in Minot, ND, kicked off National Patient Safety Awareness Week with a staff...

• Study finds computerized ordering may increase error

  Researchers at the University of Pennsylvania found that a leading electronic system increased the...

• Organization finds patient safety risks in the ED

  The Emergency Medicine Patient Safety Foundation (EMPSF) promoted National Patient Safety Awareness...

Issue 10, March 9, 2005

• Practitioners and insurers weigh risks of obesity surgery

  As weight-loss surgery becomes increasingly popular, practitioners and insurers are weighing the...

• CA judge rules governor illegally delayed nurse-to-patient ratios

  A judge ruled on March 4 that California Governor Arnold Schwarzenegger acted illegally when he...

• Age bias may hinder care of elders

  Patients over age 65 generally receive less aggressive treatment for cancer than younger patients...

Issue 9, March 3, 2005

• AHRQ report finds improvements, disparities in healthcare

  The American healthcare system has improved, but disparities related to race, ethnicity, and...

• FL will release hospital infection data

  Florida residents will be able to compare how well hospitals in the state prevent infections...

• UK nurses and pharmacists may receive expanded prescribing powers

  In an effort to speed up patients’ treatments, the United Kingdom announced that nurses and...

• Military may need to hire additional pharmacists to meet JCAHO standard

  The Air Force and Navy will likely need to hire several hundred additional pharmacists over the...

Issue 8, February 24, 2005

• Study finds only half of surgery patients receive recommended antibiotics

  Although giving patients antibiotics before their operations is recommended to prevent surgical...

• Duke continues quest for culture of safety

  Two years ago yesterday, Duke University Health System experienced a medical error that sparked a...

• Patient safety advocates push for disclosure of hospital-acquired infections

  Patient safety advocates are demanding that the public be informed which hospitals have infection...

• County’s ER crisis jeopardizing patient care

  A new report commissioned by the Palm Beach (FL) County Medical Society confirms that the county's...

Issue 7, February 17, 2005

• Patients report neglect, mistreatment at Dallas VA hospital

  Current and former patients at the Dallas Veterans Affairs Hospital reported neglect and overall...

• Study finds older doctors may provide lower quality care

  A new Harvard Medical School study suggests that older doctors provide lower-quality care, know...

• Hospitals and libraries collaborate for patient safety

  Partnering for Patient Empowerment Through Community Awareness, a hospital-library collaborative...

• JCAHO joins push for tort reform

  The JCAHO calls for increased attention to patient safety and the prevention of medical injury in...

Issue 6, February 9, 2005

• Hospital funding hinges on care of aggressive patients

  A week after losing its JCAHO accreditation, Los Angeles-based Martin Luther King/Drew Medical...

• NQF publishes report on cardiac surgery performance measures

  The National Quality Forum (NQF) published a new set of national consensus standards for improving...

• Deadly superbug spreads throughout Canadian hospitals

  Methicillin-resistant staphylococcus aureus (MRSA) has increased more than tenfold in Canadian...

• WI budgets $10 million for electronic medical records

  Wisconsin’s budget proposal includes $10 million for a grant and loan program to increase the...

Issue 5, February 7, 2005

• Proposed 2006 National Patient Safety Goals out for field review

  Accredited organizations have until February 26, 2005, to submit an electronic evaluation of the...

• Study recommends improved communication among healthcare workers

  Poor communication and collaboration among healthcare professionals leads to continued medical...

• Massachusetts Hospital Association announces safety plan

  Public posting of nurses’ workloads and hours spent directly caring for patients is one...

• JCAHO encourages patients to "Speak Up" to avoid medication errors

  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced on January 27...

Issue 4, January 27, 2005

• First report on adverse events in hospitals released

  The Minnesota Department of Health released on January 19 a report from the state’s 145...

• STS releases new guidelines to improve bypass outcomes in women

  The Society of Thoracic Surgeons released a gender-specific practice guideline to provide surgeons...

• Canadian hospitals collaborate to improve patient safety

  Teams of health providers and managers at seven Saskatchewan hospitals are collaborating to improve...

• National Patient Safety Awareness Week scheduled for March

  National Patient Safety Awareness Week will be held from March 6-12, 2005.

Issue 3, January 21, 2005

• New Web-based education aims to change staff attitudes

  In an effort to relay the importance of patient safety to healthcare workers, the National Patient...

• Vermont hospitals begin new programs to increase patient safety

  Residents and graduate nursing students at Fletcher Allen Health Care in Burlington, VT, are...

• Ernest A. Codman Award application deadline approaches

  The JCAHO’s Ernest A. Codman award recognizes achievement in using processes and outcome...

• Minnesota hospitals receive award for reduced VAP rates

  The intensive care units (ICU) at Mercy Hospital in Coon Rapids, MN, and Unity Hospital in Fridley...

Issue 2, January 17, 2005

• PA regional collaboration cuts medical errors

  The Regional Medication Safety Program for Hospitals aims to provide hospitals with tools to reduce...

• Research finds disruptive behavior among hospital staff affects patient outcomes

  New research conducted by VHA Inc. in Irving, TX, finds that disruptive behavior between physicians...

• Robot pharmacist reduces medication errors

  Evergreen Hospital Medical Center in Kirkland, WA, has seen a 25% decrease in medication errors...

• Literature review shows reduced work hours have mixed results for safety

  Reducing resident work hours does not affect patient mortality, according to a literature review of...

Issue 1, January 7, 2005

• Cincinnati Children’s Hospital Medical Center uses robot to reduce errors

  In order to reduce the potential for errors and improve patient safety, Children’s Hospital...

• New study analyzes relevance of AHRQ safety indicators for pediatric hospitals

  Pediatric hospitals often have difficulty measuring progress in patient safety improvements because...

• Consultants find that cultural problems at LA hospital may cost millions to fix

  Fixing the problems at Martin Luther King Jr./Drew Medical Center in Los Angeles will likely take...

• Sentinel event advisory group recommends topics for field review

  The sentinel event advisory group met in November and December to identify possible National...