Alarm Fatigue, Patient Safety, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Dec 5, 2014)

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.”

However, Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, cautions that these numbers may not reflect actual improvements to patient safety. According to Modern Healthcare:

Pronovost said his hospital improved HAC rates by 37% in 2013 by focusing on clinical documentation and coding in response to penalties. “Yet we improved them by focusing on documentation rather than improving quality and safety,” he said. “Is this in the best interest of patients or the public? I do not think so.”

In addition, The Joint Commission and ECRI Institute both believe that more needs to be done to improve patient safety.

The Joint Commission

The Joint Commission recently added a new Patient Safety Systems chapter to its accreditation manual that requires hospitals to have an organization-wide integrated patient safety program.

ECRI Institute

In its recent report, “Top Ten Health Technology Hazards for 2015”, ECRI Institute has again named alarm hazards as the number one health technology hazard. Alarms may impede patient safety and clinician workflow:

Inappropriate alarm configuration practices—that is, the selection of values or settings that are inappropriate for the circumstances of the patient’s care—could lead to (1) caregivers not being notified when a valid alarm condition develops, or (2) caregivers being exposed to an excessive number of alarms, specifically ones that sound for clinically insignificant conditions (e.g., those that don’t require a staff response).

Skeptical Scalpel Reviews California Hospitals Adverse Events, Data Not Good

Patient safety blogger the Skeptical Scalpel, who in September wrote a guest blog on our website about whether pain is a vital sign, examined a Bay Area television station’s expose on adverse events in California hospitals. The expose found that, on average, each California hospital experiences fewer than 4 adverse events per year. Skeptical Scalpel suggests the number is under reported based on a deeper review of the data.

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