Patient Safety Monitor

Patient Safety Monitor Alert

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Issue 51, December 19, 2007

• Survey shows physicians know ethics but don't always practice professionalism

  A recent survey in the Dec. 4 issue of the Annals of Internal Medicine, shows that of the more than...

• Washington governor asks for increased transparency to aid patient safety efforts

  Gov. Gregoire-WA has asked for more emphasis to be placed on transparency and patient safety...

• CVS looks to bring MinuteClinics to Boston area

  The retail clinic trend sweeping the nation may be found next in the Boston area, reports The...

• Six months after APIC study, not enough being done to prevent MRSA

  The December issue of the American Journal of Infection Control, a publication of the Association...

• Editor's note

  Patient Safety Monitor will not be published the week of December 24, 2007. It will return to its...

Issue 50, December 12, 2007

• AHRQ releases toolkits to help prevent medical errors

  Patient safety experts from the Agency for Healthcare Research and Quality (AHRQ) have developed 17...

• Study shows elderly ER visits could double over next five years

  A new study published in the Annals of Emergency Medicine says that between 1993 and 2003...

• South Carolina hospitals strained by influx of mentally ill patients

  A lack of mental health facilities in South Carolina leaves many mentally ill patients in the...

• Stroke patients rarely receive drug

  A recent University of Michigan study found that many stroke patients do not receive tPA, the first...

Issue 49, December 5, 2007

• Staph infection hospitalization and death rates rise rapidly between 1999 and 2005

  A report in the December issue of Emerging Infectious Diseases says the rate of hospitalization and...

• Colorado next state to offer Web-based hospital scorecard

  The state of Colorado and the Colorado Hospital Association have partnered to create a Web site...

• Large number of CT scans could lead to cancer

  A new study published in the November 29 issue of the New England Journal of Medicine says that...

Issue 48, November 28, 2007

• Study: Rapid response teams associated with declining child mortality rates

  A new study from the November 21 issue of The Journal of American Medical Association shows that...

• Berwick, Spear call for improved processes to impact healthcare in editorial

  While acknowledging that promoting the idea of improved processes in the healthcare system is not...

• State-of-the-art hospital to put patient safety first

  A new hospital in Boca Raton, FL, scheduled to open in 2012 is planning to include amenities such...

• RI hospital fined for third wrong-site surgery this year

  After a doctor began to operate on the wrong side of a patient's brain last week, Rhode Island...

Issue 47, November 21, 2007

• National Patient Safety Foundation's Lucian Leape Institute to hold roundtables at gala

  The Lucian Leape Institute, established in May 2007 by the National Patient Safety Foundation as a...

• Teamwork breakdowns in resident groups lead to medical errors

  In a recent study published by the Archives of Internal Medicine, communication and teamwork...

• Kerry and Gingrich call for stronger use of e-prescriptions

  In an editorial in the Wall Street Journal on November 16, John Kerry and Newt Gingrich ask the...

• MA hospitals will not require patients or insurers to pay for procedures resulting in an adverse event

  Massachusetts became only the second state in the country to not require payment from patients or...

Issue 46, November 14, 2007

• Surgical fires put patients at higher risk than previously thought

  Though surgical fires are often seen as less dangerous than wrong-site surgery, the occurrence of...

• RFID patch to help with patient identification

  A new team of two medical companies plans to produce washable skin patches containing RFID skin...

• Medical errors provide some benefit, argues one doctor

  Without medical errors, how could physicians learn what not to do? That is the argument of one...

• New study says telehealth could save ED millions of dollars each year

  The Center for Information Technology Leadership has released a new study on the effect telehealth...

Issue 45, November 7, 2007

• Joint Commission and AHRQ release special report

  The Agency for Healthcare Research and Quality and Joint Commission released findings about risks...

• Doctor devises new way to prevent wrong-site surgeries

  The CheckSite system, developed by Richard Chole, MD, PhD, gives surgeons another way to...

• Maryland Hospital Association decides on plan to combat nursing shortage

  Hospital leaders from Maryland unveiled their plan to double the number of nurses in the state by...

• Most patients don't know which medications they are taking

  A recent study showed that patients with high blood pressure who have little education could not...

Issue 44, October 31, 2007

• Kaiser Permanente appeals fine on hospital after medication error caused death

  Earlier this year, an infant died at Kaiser Santa Clara, the victim of a medication error, reports...

• Surgical mistakes, though smaller in number, still occurring in Massachusetts hospitals

  Between January 2005 and September 2007, Massachusetts' Department of Public Health reported 36...

• Tampa Bay VA hospitals struggling with patient flow, patient diversions

  Two VA hospitals in the Tampa Bay area have had to divert patients a large portion of the time, due...

• IHI launches Fall Harvest to boost 5 Million Lives campaign

  Between October 25 and November 7, the Institute for Healthcare Improvement (IHI) is adding to its...

Issue 43, October 24, 2007

• Kansas pharmacists work for hospital from home

  Many small rural hospitals struggle with finding a pharmacist for the overnight shift. However, two...

• Premier survey shows hospitals see HAIs as serious threat

  A recent survey published by Premier Inc. says that tracking Healthcare Acquired Infections (HAI...

• New Jersey calls for standardization of patient arm bands

  Upon admission to a hospital, patients are often given colored wrist bands to denote a specific...

• New Jersey calls for standardization of patient arm bands

  Upon admission to a hospital, patients are often given colored wrist bands to denote a specific...

• Communication breakdown between physicians and trainees a source of many hospital errors

  A new report out from the Agency for Healthcare Research and Quality (AHRQ) says that medical...

Issue 42, October 17, 2007

• Pilot site tries out MRSA prevention technique

  Sacred Heart Medical Center of Spokane, WA, has launched a screening program to catch patients...

• Patients want to be more involved in their own care than in the past

  The information age has given patients more access to information about health care, and as a...

• New study says U.S. loses billons each year to low health literacy

  The University of Connecticut has released a new study saying that the United States economy...

• MA one of first states to post patient falls data

  70 acute care hospitals from across Massachusetts are voluntarily posting their patient fall rates...

Issue 41, October 10, 2007

• University of Iowa Hospitals and Clinics address survey concerns

  After being surveyed in June and garnering less than favorable marks, the University of Iowa...

• FDA considers adding third class of drug

  The Food and Drug Administration last week proposed creating a third type of drug, in addition to...

• HHS awards contracts to nine health information exchanges around country

  Secretary Mike Leavitt of the Department of Human and Health Services (HHS) announced on October 5...

• White males most likely to receive simple procedure for heart disease

  Two new studies from Duke University show that white males are three times as likely as females or...

Issue 40, October 3, 2007

• With greater number of screening tests comes larger chance for cancer scare

  Although early detection has saved countless numbers of lives of Cancer patients, it has also...

• With greater number of screening tests comes larger chance for cancer scare

  Although early detection has saved countless numbers of lives of Cancer patients, it has also...

• Staff at NJ hospital using wireless devices to communicate

  Staff at Saint Barnabas Medical Center in Livingston, NJ used to hearing beepers, pages, and other...

• New group to study why some patients suffer serious illness when taking new medications

  A new group to study why some patients feel the effects of new medications more than others was...

• Pennsylvania's Patient Safety Authority says 23 % of reported events are medication errors

  Medication errors continue to rank high among reported events to the Pennsylvania Patient Safety...

Issue 39, September 26, 2007

• Study: Number, cost of U.S. hospital infections on the rise

  A new study of inpatient data from United States hospitals found that the number of infections...

• MO collaborative receives grant to improve med error reporting

  The Missouri Center for Patient Safety recently received a $254,000 grant from the National Council...

• FDA launches new drug safety newsletter

  The Food and Drug Administration (FDA) issued a new drug safety newsletter last week that describes...

• IN hospital system launches family-initiated RRT

  Indianapolis-based Community Health Network this month launched a rapid response team (RRT) that...

• FDA launches new drug safety newsletter

  The Food and Drug Administration (FDA) issued a new drug safety newsletter last week that describes...

Issue 38, September 19, 2007

• Group to encourage patient involvement in care

  The Partnership for Healthcare Excellence, a collection of consumer groups, physicians, nurses, and...

• Hospitalists increasingly used in hospitals, coordinate care

  Hospitals are the fastest growing medical specialty in the country, and the trend is not likely to...

• NHS: long sleeves pose MRSA risk

  The United Kingdon’s National Health Service will formally ban physicians from wearing...

• Stark cites medication overdosing as reason to revisit Medicare payments

  Congressman Pete Stark said he supports changes in Medicare payments to eliminate a perverse...

• The Joint Commission announces Eisenberg award winners

  The Joint Commission has announced the winners of the 2007 John M. Eisenberg Patient Safety and...

Issue 37, September 12, 2007

• E-prescribing more common, say advocates

  More hospitals and providers are using electronic prescribing programs to improve patient safety...

• Same-day visits could improve patient safety, increase satisfaction

  Physicians, clinics, and hospitals should follow the lead of restaurants and book patients for...

• Physicians criticize in-store clinic plans

  Physician groups are opposed to the Massachusetts Public Health Department's proposed regulations...

• Reported drug reactions triple

  Dangerous drug reactions have tripled over the past seven years, according to a new study in this...

Issue 36, September 5, 2007

• Physician recounts medical error to newspaper

  A Florida surgeon told a newspaper about his experience making a medical error during an...

• Patient advocates voice concerns about patient safety

  Patients and family members who have experienced medical error are more likely than ever to demand...

• Alberta releases infection control plan

  Alberta has adopted recommendations made by its Health Quality Council to lower the risk of...

• IN hospitals report on 2006 errors

  Indiana's medical centers reported 85 preventable medical errors to the state's Department of...

Issue 35, August 29, 2007

• Patients have a role in controlling infection

  Patients can help protect themselves from hospital-acquired infections by following some simple...

• Survey: Physicians sometimes discount complaints of side effects

  A recent survey of 650 patients shows that a majority believe their physician discounted their...

• Canadian physicians: Only we can prescribe medications

  The Canadian Medical Association has issued a statement saying only physicians should be allowed to...

• Leape: CMS changes are a welcome development for patient safety

  Harvard professor and Institute of Medicine Committee member Lucian Leape, MD, penned a column in...

Issue 34, August 22, 2007

• CMS to discontinue payments for some preventable errors

  The Centers for Medicare and Medicaid Services (CMS) will stop paying hospitals to treat some...

• Hospitals move to ’smart beds’ to increase patient safety

  More hospitals are purchasing so-called smart beds, which feature alarms and turning technology to...

• Apologies in the wake of errors may reduce patient stress, lawsuits

  A Chicago Tribune article explores the increasing use of apology by physicians. More hospitals find...

• NH Board of Pharmacy pushes anonymous reporting

  New Hampshire pharmacies may now anonymously report medication errors to the state’s board of...

Issue 33, August 15, 2007

• Wrong site surgery rates hold steady

  The rate of wrong site, wrong patient, and wrong procedure errors remains steady after years of...

• Column: Self-regulation doesn't work in healthcare

  The healthcare industry's history of regulating itself does not go far enough to protect...

• Outpatient surgical errors focus of USA Today article, letter

  Outpatient surgical centers face increased scrutiny from patients and healthcare professionals wary...

• AMA cautiously approves implanting microchips with patient information

  The American Medical Association has endorsed the use of implanted microchips to convey patient...

Issue 32, August 8, 2007

• Researchers urge less beta-blocker use

  Researchers are urging physicians to use alternatives to beta-blockers for patient treatments...

• Canadian physicians may engage in more disclosure

  Canadian physicians are being urged to disclose errors in patient treatment, according to a...

• IN hospital collaboration improves patient safety

  The six hospitals of the Indianapolis Coalition for Patient Safety have seen improvements in key...

• Op-ed: Hospitals should consider alternatives to restraints

  A columnist for The La Crosse (WI) Tribune recalled her grandmother's recent visit to a hospital...

Issue 31, August 1, 2007

• Potential MRSA cases shut down UK hospital ward

  An Irish hospital went into its emergency procedures after discovering 10 elderly patients were...

• Physicians experience stress after errors

  A new study shows that physicians experience stress, lack of sleep, and depression after making a...

• U.S. News blog: Cap nursing work hours

  Avery Comarow on his U.S. News & World Report blog lobbied this week to have nurse work hours...

• Op-ed writer, AMA trade barbs over store clinic safety

  Washington Post op-ed contributor Regina Herzlinger blasted the American Medical Association (AMA...

Issue 30, July 25, 2007

• Patient outcomes best in hospitals ranked highest in quality

  A new study finds that hospitals with the best quality rankings experience the fewest patient...

• In-store clinics rankle some physicians

  In-store clinics that provide rudimentary healthcare services are spreading in stores such as...

• Study: Race stills play a role in ER care

  A new Harvard study found instances of racial bias in the care delivered by emergency department...

• Feds investigate LA hospital

  Center for Medicaid and Medicare Services (CMS) investigators are examining Martin Luther King...

Issue 29, July 18, 2007

• Bypass death study rankles California surgeons

  A new study that shows how many patients die after heart bypass surgery has many California...

• Wiki offers advice on how to communicate with physicians

  The popular how-to Web site WikiHow has an entry advising the public on the best way to communicate...

• Nasal cannula may be treatment option for sleep apnea

  A new study shows that nasal cannula pumping high levels of oxygen may be a viable treatment option...

• Nurse's experience as patient used to improve communication

  A nurse's experience as a patient is being used to help improve how healthcare professionals...

Issue 28, July 11, 2007

• Editorial: Surgical error rate should be zero

  A Philadelphia Inquirer editorial touches upon the Pennsylvania Patient Safety Authority's study of...

• Study shows depth of Australian surgical error rates

  A new study outlined 130 cases of surgical error in Australia in 2004 and 2005. Of those, 27 cases...

• Utah mulls increased error surveillance

  Utah public health officials are pushing for greater patient safety error surveillance in the...

• Technology helps San Antonio hospitals reduce IV medication errors

  Nurses and medical staff at Christus Santa Rosa Hospital in San Antonio, TX, are using computerized...

Issue 27, July 4, 2007

• Wisconsin State Journal publishes patient safety series, interactive tool

  The Wisconsin State Journal published a five-day series on patient safety, along with over a dozen...

• Hospital uses wrong angiogram films during heart bypass

  A Modesto, CA, hospital inadvertantly referred to the incorrect angiogram films during a patient's...

• Hospital adapts to changing patient demographics, needs

  Staff members and management at St. John's Hospital in Maplewood, MN, have changed the way they do...

• Screening, isolation used for superbugs

  More hospitals are holding a tough line against MRSA and other so-called superbugs, according to a...

Issue 26, June 27, 2007

• The Joint Commission announces new National Patient Safety Goals

  The Joint Commission (formerly known as JCAHO) has released its 2008 National Patient Safety Goals.

• Government grades hospitals' heart care

  A new government report grades hospitals for their ability to care for heart patients. The report...

• OR hospital initiative yields positive results

  A majority of the 18 Oregon hospitals participating in a Patient Safety Alliance campaign were able...

• MA physicians scored high in 12 key areas

  Physicians in Massachusetts scored in the top 10% nationally in 12 of 17 measures. That achievement...

Issue 25, June 20, 2007

• Today is National Time Out Day

  The Association of PeriOperative Registered Nurses (AORN), The Joint Commission, and the American...

• Study: Reduced hours for residents lead to better care

  A new study found that hospitals that adopted stricter rules limited hours worked by residents led...

• Med errors, syringe safety top nursing concerns

  A new survey found that nurses are increasingly concerned about medication errors and safety...

• Joint Commission accreditation predictor of patient safety implementation

  Accreditation by The Joint Commission can be viewed as a "key predictor" of better patient safety...

Issue 24, June 12, 2007

• Joint Commission Resources looks for test hospitals for new study

  Joint Commission Resources (JCR) will begin a study on how to increase patient safety through...

• Joint Commission unveils new patient rights campaign

  The Joint Commission last week kicked off a new national campaign to educate patients about their...

• Arizona hospitals introduce wristband system for at-risk patients

  Two Arizona hospitals-Sun Health Boswell and Del E. Webb Hospital-began using uniform color-coded...

• Canadian patient safety group launches handwashing campaign

  The Canadian Patient Safety Institute (CPSI) on Sunday announced a new handwashing campaign...

Issue 23, June 6, 2007

• Simple test could prevent stroke care error

  A new study shows that the majority hospital staff do not check the swallowing ability of stroke...

• Suicide attempt lawsuit dismissed

  An Australian man who sued his hospital after attempting suicide saw his case dismissed by the New...

• Study: Most pediatric chemo errors reach patient

  A new study found that most medication errors made in pediatric cancer care eventually reach the...

• Patients and families increase involvement in care

  Patients and their families are increasingly involved in their own care, according to a Kaiser...

Issue 22, May 30, 2007

• Study: More ICU nurses lead to safer care

  A new study shows that hospitals with more nurses have better infection rates for elderly patient...

• AORN's Time Out Day gets new supporters

  Time Out Day, an event porposed by AORN, has received the support of the American College of...

• Increased feedback can improve patient safety

  The Univeristy of Pittsburgh Medical Center South Side has been seeking patient feedback to improve...

• Congress to consider health court legislation

  Both chambers of Congress have been sent an identical bill that would create pilot programs for...

Issue 21, May 23, 2007

• Hospital networks work to develop standardized patient safety practices

  Wellmont, Novant, and Adventist Health systems have started the Safest Hospital Alliance, an...

• Study: Physicians do not apologize as much as they claim

  A new study shows that physicians generally say they would disclose a significant error to...

• VA program focuses on patient safety

  The VA's National Center for Patient Safety is sending experts out to help VA hospital staff with...

• Physicians, lawmakers wary of pharma data mining

  Physicians and lawmakers in several states are trying to block a pharmaceutical practice of mining...

Issue 20, May 16, 2007

• Michigan hospitals try two-minute pre-op briefings

  The Beaumont Hospitals system in Michigan isamong the few systems trying two minute pre-operative...

• Hospitals go on offense against MRSA

  Hospitals are starting to take a hard line in enforcing protections against the spread of MRSA...

• Lyme activists try to alter medical recommendations

  Lyme disease guidelines promulgated in Maryland have been put on hold as activists work politically...

• Texas nurse: State should pass ratio law

  A letter to the editor of the Houston Chronicle outlined one nurse's rationale for supporting a...

Issue 19, May 9, 2007

• WHO announces nine patient safety solutions

  The World Health Organization (WHO) announced nine patient safety solutions for use around the...

• CEO pay increasingly tied to patient safety

  Hospital boards of directors have started to connect CEO bonuses to patient safety performance and...

• Survey: physicians see obstacles to patient safety improvements

  Physicians who completed the American College of Physician Executives' (ACPE) 2007 Quality of Care...

• Built-in home medical equipment may speed care, increase safety

  An experimental home in Florida has 50 medical devices built into the structure. Officials hope the...

Issue 18, May 2, 2007

• PA Patient Safety Authority releases annual report

  Pennsylvania hospitals are utilizing advisories and reporting more errors and near misses to the...

• Patients encouraged to question phsyicians on safety

  Australian patients should ask their physicians if they have washed their hands and to clearly mark...

• Med rec, handoffs examined in journal articles

  Medication reconciliation and hand-offs between the emergency department and hospital were examined...

• Support staff shortages could lead to patient safety concerns

  Support staff shortages in Ontario hospitals may lead to increase patient risk for infections...

Issue 17, April 25, 2007

• NY to get electronic records for needy patients

  New York City will provide free electronic medical record software to hospitals, clinics, and...

• Boston area hospitals reveal accreditation survey results

  Five Boston-area hospitals have released Joint Commission survey results, or a summary of those...

• Cardinal Health, Premier team up to develop standard terminology

  Cardinal Health and Premier have developed standardized catalog terminology to improve patient...

• Survey: Hospitals must redouble efforts to clean skin prior to surgery

  Many hospitals do not have protocols in place to properly clean surgical patients' skin before a...

Issue 16, April 18, 2007

• Joint Commission rescinds interim rule on MM.4.10

  The Joint Commission has rescinded the interim rule on Medication Management standard 4.10, element...

• Congressional Committee wants study on healthcare worker fatigue

  The House Committee on Energy and Commerce has asked AHRQ to study the effect of worker fatigue on...

• Johns Hopkins begins prescreening for superbugs in pediatrics

  Johns Hopkins has started screening all pediatric ICU patients for so-called superbugs, such as...

• Patient self-care for chronic illnesses may be safe alternative

  In an essay in the April 17 Public Library of Science Medicine, researchers suggest that patients...

Issue 15, April 11, 2007

• How Doctors Think debated

  Jerome Groopman's new book, How Doctors Think, is the topic of an online debate between Groopman...

• Column: VA leads in patient safety

  The VA hospital system has become a leader in the patient safety movement through best practices...

• UConn hospital staffers use good catches to prevent errors

  Staff members at John Dempsey Hospital at the University of Connecticut (Farmington) use a good...

• Hospital removes wrong testicle during surgery

  Surgeons at the Los Angeles VA Hospital removed the wrong testicle during surgery to remove an...

Issue 14, April 4, 2007

• Study: 250,000 preventable deaths occurred between 2003 and 2005

  A new HealthGrades study shows that there were 247,662 potentially preventable deaths in U.S...

• Second Boston hospital publishes central-line infection information

  Mount Auburn hospital in Cambridge, MA, has published its central-line infection rates, according...

• Canadian "Safer Healthcare Now!" campaign draws positive results

  The Canadian patient safety program "Safer Healthcare Now!" has led to improvements in hospital...

• Discharge information delays lead to safety concerns in UK

  A National Health Service survey shows United Kingdom hospitals are not sending discharge...

Issue 13, March 28, 2007

• Database to help reduce medication errors

  A new database used by Rice Memorial Hospital in Willmar, MN, may help to reduce medication errors...

• Simple fixes can lead to safer care

  Small changes with little expense can help improve patient safety in hospitals, according to a...

• UK patient dies from infection after beating leukemia

  A UK patient died from Legionaire's disease after successful leukemia treatment, according to an...

• IL hospital officials oppose mandatory nursing ratios

  Illinois hospital officials are speaking out against a bill that would create mandatory...

Issue 12, March 21, 2007

• Joint Commission releases quality performance report

  The Joint Commission has released a new report tracking patient safety and quality performance...

• MGH RFIs outlined in newspaper

  A Massachusetts General Hospital (MGH) memo obtained by The Boston Globe outlines some of the...

• Thinking errors can lead to misdiagnosis

  Misdiagnosis may be caused by faulty tests or patient misidentification, but it is more often the...

• Pay-per-view

  A recent survey conducted by the American College of Emergency Physicians (ACEP) and software...

Issue 11, March 14, 2007

• Consumer group launches online resources

  Consumers Advancing Patient Safety (CAPS) has launched a Web site, www.patientsafety.org, which...

• Indiana releases preliminary error report

  The Indiana Department of Public Health has released its preliminary report on medical errors in...

• PA hospital system upgrades technology to improve patient safety

  Wyoming Valley Health Care System has moved to electronic recordkeeping as a way to improve patient...

• Medical error leads to discovery of protocol violations

  Federal inspectors found several pharmacy protocol violations in the wake of a patient's death at...

• PAY-PER-VIEW: Summaries, outlines help patients understand safety information

  The administration at St. Luke's Behavioral Health Center in Phoenix believes that informing...

Issue 10, March 7, 2007

• USP: Communication failures lead to perioperative medication errors

  Communication failure is the leading cause of medication errors in the perioperative setting...

• Column: Physicians should not shy away from making recommendations

  A Boston Globe column hails today's patient-centered decision making process in medicine, but warns...

• FDA: Check software for Daylight Saving Time errors

  The Food and Drug Administration has warned hospitals to check their software to make sure the...

• Letter: Nursing ratios good for hospitals

  A Texas nurse wrote a letter to the Houston Chronicle in support of a proposed bill that would...

Issue 8, September 4, 2007

• HCPro News: Exhibit Schedule Announced

  HCPro will be exhibiting at a number of upcoming conferences, and we invite you to come see us...