http://www.mocps.org/rssMOCPS News FeedThe latest news from the Missouri Center for Patient SafetyThu, 11 Mar 2010 20:40:04 GMTGAO Reports on Implementation of the Patient Safety and Quality Improvement Act of 2005This report by the GAO, “Patient Safety Act: HHS Is in the Process of Implementing the Act, So Its Effectiveness Cannot Yet Be Evaluated” highlights the delay in issuing regulations to implement the Act, resulting in very few Patient Safety Organizations currently up and running, collecting data, or sharing best practices.
http://www.gao.gov/cgi-bin/getrpt?GAO-10-2812010-02-03 00:00:00Join Us on April 6 for “Learning Together” , the MOCPS 4th Annual ConferenceOn-line registration is up and brochures are in the mail for the 4th Annual Missouri Center for Patient Safety Conference, “Learning Together”, on April 6, 2010 in Columbia, Missouri. Our Keynote, Sorrel King, author of “Josie’s Story”, will share her sad and inspiring story of impacting health care delivery following her daughter’s death from medical errors. General sessions include Johns Hopkins CUSP program, a program inspired by Ms. King; proactively identifying errors using Trigger Tools, IHI and AHRQ representatives discussing methods of teaching patient safety – consumers, providers, students; and a session by Missouri Excellence in Safe Care award winners. Announcements of activities and opportunities for upcoming Center projects will also be announced. Vendor and sponsorship opportunities are still available. Registration runs through March 15. 2010-02-03 00:00:00MOCPS PSO Implementation Moves ForwardAs a result of a 2009 Missouri HealthNet regulation requiring Missouri Medicaid hospital and ambulatory surgery center providers to contract with a federally-designated Patient Safety Organization, among other provisions, the majority of Missouri’s hospitals and a number of ambulatory surgery centers have contracted with the Center as their PSO. The Center has hosted audio conferences and Webinars on topics of the federal PSO legislation, establishing a Patient Safety Evaluation System, defining Patient Safety Work Product and the MOCPS PSO data system overview. The audio and PowerPoint for these sessions are now posted on the MOCPS website, along with other PSO related resources. Contracted PSO participants are also invited to attend the first annual MOCPS PSO Participant Meeting scheduled on April 7, in Columbia. 2010-02-03 00:00:00“Five Moments for No Momo” Pilot LaunchedOn February 3, the Center launched the “Five Moments for No Momo” hand hygiene pilot project with eight organizations in Southeast Missouri. Modeled after the World Health Organization’s five moments for hand hygiene, the pilot involves hospitals and nursing homes working together to improve hand hygiene awareness, using toolkit resources for organization-wide implementation. Information about the project and pilot results will be available at a later date.
2010-02-03 00:00:00Minnesota Issues 6th Annual Report on Adverse Events http://www.health.state.mn.us/patientsafety/publications/2010ahe.pdf2010-02-02 00:00:00OIG Memo on Public Reporting of Adverse Events in HospitalsThe Office of Inspector General has issued a memo to leaders of CMS and AHRQ addressing the apparent limited and inconsistent public reporting of adverse events - a strategy seen as a way to improve safety. The memo addresses a review of 17 error reporting systems, identifying no centralized reporting system to submit data and learn solutions to avoid repeating errors. No recommendations were provided in the memo.
http://www.oig.hhs.gov/oei/reports/oei-06-09-00360.pdf2010-02-02 00:00:00Ohio Supreme Court: Never events don’t form negligence per seOhio Supreme Court: Never events don’t form negligence per se
This bulletin describes the Ohio Supreme Court decision in a slip and fall case considered to provide what is needed to keep the creation of never events from creating negligence per se in the courtroom. The issues relates to hospitals facing potential unintended consequences of medical negligence lawsuits involving never events, in addition to the non-payment consequences.
http://www.bricker.com/publications/articles/1561.pdf2010-02-02 00:00:00National Quality Forum Updates Safe PracticesNational Quality Forum Updates Safe Practices
The National Quality Forum has endorsed an update of its Safe Practices for Better Healthcare, a guide for health care systems to provide safe care. The 34 endorsed practices include issues of health care-associated infections, pediatric imaging and workforce development, including updates with the latest evidence.
http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx2010-02-02 00:00:00AHA-NPSF Patient Safety Leadership Applications Due February 15The AHA-NPSF Patient Safety Leadership Fellowship, a year-long learning experience for leaders in quality and patient safety, focusing on culture and high reliability healthcare practices is now accepting applications through February 15. http://www.hpoe.org/hpoe/PSLF/pslf-landing-page.shtml 2010-02-02 00:00:00Joint Commission Alert - Preventing Deaths During, After Pregnancy The Joint Commission has issued a Sentinel Event Alert about pre-existing medical conditions such as high blood pressure, diabetes, and obesity putting women at greater risk of death during or shortly after pregnancy. The CDC statistics reveal there are 13.3 maternal deaths per 100,000 live births; far above the 3.3 deaths per 100,000 live births target established by Healthy People 2010.
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm2010-02-02 00:00:00FDA Announces Recall of Infusion Set NeedlesThe FDA has recalled more than 2 million Huber needles and infusion sets made by Nipro Medical Corp for Exel International. The needles, used to access ports of chronically ill patients to withdraw blood and inject medications, were found to cut and dislodge silicone slivers from the ports.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm198676.htm2010-02-02 00:00:00California Hospitals Fined for Medical ErrorsThe California Public Health Department has fined 13 California hospitals up to $50,000 each for medical errors that in some cases killed or seriously injured patients. The errors included assessment and monitoring, medication, surgical errors, including staff competency issues.
http://www.cdph.ca.gov/Pages/NR10-006-CDPHISSUES16ADMINISTRATIVEPENALTIESTO13HOSPITALS.aspx2010-02-02 00:00:00Childbirth Connection Releases Action Plan to Improve Maternity CareChildbirth Connection’s Transforming Maternity Care Project has established a vision and action plan to improve the quality and value of maternity care. The vision includes quality measures, a restructured payment model, research to reduce disparities and use of evidence-based practices.
http://www.childbirthconnection.org/article.asp?ck=106232010-02-02 00:00:00AHRQ Issues Patient Safety Primer on Disruptive BehaviorThe Agency for Healthcare Research and Quality has released a Patient Safety Primer on disruptive and unprofessional behavior. The primer addresses how such behavior impacts an organization’s ability to develop a culture for safety by threatening teamwork and a blame-free culture necessary for discussing safety issues. The primer provides information on preventing and addressing disruptive behavior.
http://psnet.ahrq.gov/primer.aspx?primerID=152010-02-02 00:00:00USA Today Identifies Improvement Needed in Nation’s Nursing Homes This USA Today article analyzes findings from the Centers for Medicare & Medicaid Services report of quality in the nation’s nursing homes. The article reveals that one in five nursing homes have consistently poor quality ratings, based on the CMS star rating of nursing home based on inspection results, complaints and other data.
http://www.usatoday.com/news/health/2010-01-28-nursing28_ST_N.htm2010-02-02 00:00:00Sen. Grassley Raises Concerns about Information Technology Adversely Impacting CareU.S. Sen. Chuck Grassley from Iowa has sent letters to 31 hospitals raising concerns about patients being endangered from errors caused by information technology systems. The letter asks hospitals about their relationships with vendors, including non-disclosure clauses that would prohibit sharing of information about product defects, and liability exposure if patients are harmed as a result of the product. Concerns about administrative complications, formatting, usability, errors, and interoperability of the information systems were expressed.
http://grassley.senate.gov/news/Article.cfm?customel_dataPageID_1502=24867#2010-02-02 00:00:00National Network Established for Medication Error ReportingThis Wall Street Journal article discusses efforts by the Institute for Safe Medication Practices (ISMP) and the American Society of Health-System Pharmacists to establish the National Alert Network for Serious Medication Errors. The network will send email alerts to 35,000 pharmacists, physicians and nurses when dangerous or life-threatening errors are reported to the ISMP. The intent is to widely spread information about errors to ultimately prevent such errors from happening again.
http://online.wsj.com/article/SB10001424052748703626604575010932945077528.html 2010-02-02 00:00:00Is ‘sorry’ the hardest word in health care?This article in the New York Times discusses the evolution of disclosure and how disclosure is handled by major companies; in particular its use in health care settings and by drug companies.
http://www.nytimes.com/2010/01/10/business/10stream.html?hpw 2010-02-02 00:00:00White Paper – Nursing Communication and Patient SafetyThis white paper, “Five Reasons Top Hospitals Are Changing the Way They Connect Nursing Communications Technology," published by AmCom Software discusses the nursing dilemma - how to respond effectively to a continual stream of requests while keeping patient safety in the forefront. The report discusses how to leverage existing nurse call systems and related technologies to improve patient safety.
http://www.amcomsoftware.com/gwf/?id=MTM1&name=Dec+09_Modern+Healthcare+Nurse+Call+wp+email2010-02-02 00:00:00Article, “Patient Safety Improving Slightly, 10 Years after IOM Report” This article from American Medical News discusses a report published in Health Affairs that found "unmistakable progress" in the patient safety improvement, despite setbacks; critics say mandatory disclosure of medical errors is the key to breakthrough safety improvement.
http://www.ama-assn.org/amednews/2009/12/28/prsb1228.htm2010-02-02 00:00:00Checklist for Surgical Success - Articlehttp://www.npr.org/templates/story/story.php?storyId=1222261842010-02-02 00:00:00Gov. Nixon Eliminates State Boards and CommissionsGov. Jay Nixon’s recent action to eliminate and consolidate 31 state boards and commissions included elimination of the Missouri Commission for Patient Safety. The Commission was eliminated because its recommendations are being implemented by the Missouri Center for Patient Safety, as a result of the Center’s Founding Members taking action on the Commission’s recommendations.
http://governor.mo.gov/newsroom/2010/2010_Eliminated_Boards2010-02-02 00:00:00Joint Commission Reports – Hospital Quality is ImprovingThe Joint Commission’s annual report on hospital quality and patient safety assesses 31 measures for heart attack, heart failure, pneumonia, surgery and children’s asthma. The report revealed improvement in each set of measures, evidencing improvement in the quality of care provided in hospitals.
http://www.jointcommission.org/NR/rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf2010-02-02 00:00:00AHRQ Releases New Health Literacy Tool The Agency for Healthcare Research and Quality has released a component of its Consumer Assessment of Healthcare Providers and Systems ™ addressing health literacy in English and Spanish. The additional component adds 29 items measure how well health care professionals communicate with their patients.
https://www.cahps.ahrq.gov/content/products/HL/PROD_HL_Intro.asp?p=1021&s=2152010-02-02 00:00:00AHRQ Revises Tips to Help Hospitals Improve Patient Safety The Agency for Healthcare Research and Quality has revised its resource of 10 evidence-based tips and tools to prevent adverse events from occurring in hospitals. New additions include resources to reduce hospital readmissions, prevent hospital-acquired venous thromboembolism, educate patients about using blood thinners safely, use evidence-based principles for hospital design, and working with Patient Safety Organizations.
http://www.ahrq.gov/qual/10tips.pdf2010-02-02 00:00:00Guide Helps Hospital Address Avoidable ReadmissionsThe Health Research & Educational Trust has released a free guide to help hospitals address avoidable hospital readmissions. The guide provides a four-step approach to reducing readmissions and strategies to employ at different stages of the care continuum.
http://www.hret.org/hret/programs/readmissions.html2010-02-02 00:00:00Medical Students Call for End to Secrecy about Medical ErrorsThis New York Times article describes observations of two Harvard medical students about their training and the need to prevent medical errors. The students call for a culture shift that would encourage students and their teachers to speak openly about medical mistakes.
http://www.nytimes.com/2010/01/26/health/26error.html2010-02-02 00:00:00