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

Weekly Must Reads in Patient Safety (Jan 9, 2015)

The Physician-Patient Alliance for Health & Safety wishes you and your loved ones a Happy and SAFE New Year!

Safety first

We particularly emphasize SAFE, because the latest news on patient safety shows that there is a lot work yet to be done … or perhaps we haven’t started? …

No Improvement in Patient Safety in Last 15 Years

HC Pro’s Patient Safety Monitor reports that, according to health experts testifying to a Senate subcommittee, that there has been no improvement in patient safety in the last 15 years:

If the truth hurts, any patient safety advocates that tuned into the Senate subcommittee hearing on patient safety were probably cringing.

No one minced words at the hearing for the Subcommittee on Primary Health and Aging on July 17, as health experts testified that patient safety has remained largely stagnant for the last 15 years. In some respects, it’s worse, failing to prevent as many as 400,000 patient deaths each year, four times more than estimates from the Institute of Medicine (IOM) in 1999.

Penalties for Hospital-Acquired Conditions

Validating this sober assessment, more than 700 hospitals “will see their total Medicare payments docked by 1 percent in fiscal 2015 as part of the first year of a federal penalty program aimed at reducing preventable harm and improving patient safety”, reports Modern Healthcare. Hospital-acquired conditions included pressure ulcers and pulmonary embolisms.

Although one would think that teaching hospitals would be the vanguard of innovation and safety, hospitals penalized include many well-known teaching hospitals – including Intermountain Medical Center, Ronald Reagan UCLA Medical Center, the Cleveland Clinic, Geisinger Medical Center, Brigham and Women’s Hospital, NYU Langone Medical Center and Northwestern Memorial Hospital.

That said, if you have a choice of hospitals, data from AHRQ’s Healthcare Cost and Utilization Project suggests that being admitted at a hospital in the West is preferable to going to one in the South:

Rates of potentially preventable hospitalizations in the United States declined 14 percent from 2005 to 2011, but rates varied widely by geographic region, according to a new statistical brief from AHRQ. Potentially preventable hospitalizations are admissions for certain acute illnesses or worsening chronic conditions that may have been avoided with higher-quality outpatient treatment and disease management. Data from AHRQ’s Healthcare Cost and Utilization Project showed that rates of potentially preventable hospitalizations in 2011 were lowest in the West (at 1,220 discharges per 100,000 population) and highest in the South (at 1,845 discharges per 100,000). Hospitals in the South had a 17.2 percent higher rate of potentially preventable hospitalizations than the overall national rate in 2005, but by 2011 it was reduced to 10.5 percent higher than the national rate.

Pregnancy-related deaths on the rise in the US

Moreover, a new study has found that even something as common as childbirth may no longer be safe:

A century ago, deaths during pregnancy or childbirth were not uncommon; however, advances in prenatal care have made great strides in increasing the likelihood of a good outcome for both mothers and their offspring. However, a new study has reported that pregnancy-related mortality has increased in recent years in the United States.

The Answer

Maureen F. Cooney, DNP, FNP, BC (Westchester Medical Center, Valhalla, NY), who spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, says the answer (at least for patients receiving opioids) is continuous monitoring. However, she reminds us that technology alone is not the answer. We also need trained bedside nurses to keep patients safe from opioids and the dangers of high-alert medications:

Continuous monitoring of patients receiving opioid therapy to prevent opioid-related respiratory depression certainly offers the hope of reducing devastating outcomes from our well-intended efforts to assure patient comfort. However, in this climate of rapid, high-tech, outcomes-driven healthcare, it is essential to keep in mind the end user—particularly the bedside nurse.

Thanks @HIEcentral for tweeting about this!

2 thoughts on “Weekly Must Reads in Patient Safety (Jan 9, 2015)

  1. neldridge202

    Nothing is validated by the fact that “more than 700 hospitals “will see their total Medicare payments docked by 1 percent in fiscal 2015 as part of the first year of a federal penalty program aimed at reducing preventable harm and improving patient safety”. The program was set up by law to penalize the 25% of hospitals with the highest measured adverse event rates. Even if all hospitals had very low rates of AEs then someone (25% or 700+) would have to be in that 25%. To take it to an absurd limit, the way it’s set up if 75% of hospitals had zero events per year and 25% had one event per year then that 25% would be penalized. Unfortunately, this isn’t the case in reality…

    • Sean Power

      Thanks for sharing your thoughts. From my own personal perspective, let’s hope that the program is successful that your “absurd limit” becomes a reality – wouldn’t it be great if 75% of hospitals had zero events per year and the other 25% only one event per year. Together the health care community can make strides towards safer patient care.

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