January 2015
Swank Health: Your monthly news from Swank HealthCare

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Did You Know?

Patient Safety: A look back to gain direction for the future

Top List

10 of the most important patient safety concerns for healthcare

What's Going On?

American Organization of Nurse Executives Conference (AONE)
National Rural Health Association Conference (NRHA)

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Recommended Readings

Recommended Courses*
  • #13014 / #21814 / #36614 Medical Errors: Part 1
  • #13114 / #21914 / #310714 Medical Errors: Part 2
  • #15314 / #22114 / #311314 Medical Errors: Specific Patient Population Concerns and Reporting
  • #15214 / #22014 / #311214 Medical Errors: Facility Concerns

* course numbers may vary by facility

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Did You Know?

Patient Safety: A look back to gain direction for the future

Sixteen years have passed since the publication of To Err is Human: Building a Safer Health System, the Institute of Medicine’s (IOM) groundbreaking report on medical errors in the U.S. Claims within the report stunned the nation: hundreds of thousands of patients are harmed every year as a result of healthcare with almost 98,000 of those incidents leading to death. Years later, new research proved those claims to be inaccurate – the actual numbers were much higher than those originally reported. Swift and aggressive actions were recommended by the IOM with a minimum goal of a 50% reduction in errors within 5 years. On a fundamental level, it challenged customary beliefs that errors occur in isolation and are primarily the result of incompetence and reckless behavior, instead placing the burden of responsibility on systems that should make it easier to do things right and harder to do things wrong.

Systematic improvement in patient safety has been the driving force behind vast changes and new initiatives at every level of the healthcare system over these 16 years. According to a recent report by the Agency for Healthcare Research and Quality, hospital cases of central line-associated bloodstream infections fell 49% from 2010 to 2013 with a cost savings of $149.6 million. Other noted improvements over that period, included a 28% reduction in catheter-associated urinary tract infections, a 20% reduction in pressure ulcers, and a 19% reduction in both adverse drug events and surgical site infections. Overall, the report for that period estimated a 17% reduction in in patient harm and a cost savings of nearly $12 billion.

While improvement has occurred in some areas, leaders in the field of patient safety say we’re nowhere near where we need to be. Last July, experts testified at a Senate Health, Education, Labor and Pensions subcommittee on preventable medical errors that lead to death or serious problems. “If the question is, are patients safer in U.S. hospitals today than they were 15 years ago, the unfortunate answer is no. We have not moved the needle in any demonstrable way overall,” said Dr. Ashish Jha, a Harvard School of Public Health professor whose research focuses on improving quality and reducing costs.

Last month in Boston, the National Patient Safety Foundation (NPSF) convened an expert panel to assess the state of the patient safety field since the release of the IOM report in 1999 and to set the stage for the next 15 years of work. Panel co-chairs are Donald Berwick, MD, MPP, former administrator of the Centers for Medicare and Medicaid Services and president emeritus and senior fellow at the Institute of Healthcare Improvement, and Kaveh Shojania, MD, director of the Centre for Quality and Improvement and Patient Safety, University of Toronto, and editor-in-chief of the BMJ Quality & Safety. The panel has been tasked with producing a retrospective of achievement in the field and developing strategic recommendations to drive patient safety through the next decade. A review of the evidence will play a role in forming the report, along with input from a wide range of experts and other stakeholders. The panel’s meeting, “The State of Patient Safety: 15 Years Since the IOM Report ‘ To Err is Human,’ “ takes place February 23-24, 2015 with a final report expected this summer.

What's Going On?

American Organization of Nurse Executives Conference (AONE)

April 15-18, 2015
Phoenix Convention Center – Phoenix, AZ

More Information »

National Rural Health Association Conference (NRHA)

April 14-17, 2015
Marriott Philadelphia Downtown – Philadelphia, PA

More Information »

Recommended Readings

Top List

According to the ECRI Institute in 2014, the following are 10 of the most important patient safety concerns for healthcare.

  1. Data Integrity Failures with Health IT Systems – Appropriately designed and implemented systems can provide complete, current, and accurate patient care information to help clinicians make appropriate treatment decisions, incorrect data can lead to incorrect treatment, potentially leading to patient harm.
  2. Poor Care Coordination with Patient’s Next Level of Care – Communication breakdowns often occur between hospitals and the next level of care.
  3. Test Results Reporting Errors – Breakdowns in test results reporting can occur for a variety of reasons, such as the following: the ordering provider never gets the results; delays occur in getting the results to the provider; or results with important findings are reported to the ordering provider who is unavailable and there is no backup process for reporting the results to someone else who can act on them.
  4. Drug Shortages – Hospitals have reported issues with replenishing supplies of medications, sometimes those that are needed to resuscitate patients in emergencies.
  5. Failure to Adequately Manage Behavioral Health Patients in Acute Care Settings – Staff in acute care settings are tasked with the challenge of managing the behavioral health needs of patients, particularly those who exhibit psychiatric illness or emotional agitation in addition to their acute clinical needs. Reports describe incidents of patient violence, some of which cause harm to the patient, staff, or others.
  6. Mislabeled Specimens – Specimen mislabeling commonly occurs due to collector distraction by workload or other patient needs.
  7. Retained Devices and Unretrieved Fragments – Retained items can involve an entire device, such as a surgical sponge or towel, unknowingly left behind, or a portion of a device that breaks away and remains inside the patient. Risks include prolonged or additional surgery to remove the item, or future complications if the item leads to infection or causes other damage to surrounding tissues.
  8. Patient Falls while Toileting – Patient falls are among the top patient safety events reported to the ECRI institute. Falls in those occur while patients are toileting are particularly problematic.
  9. Inadequate Monitoring for Respiratory Depression in Patients Taking Opioids – Opioids are considered a high-alert medication and have a heightened risk for causing significant patient harm if used in error.
  10. Inadequate Reprocessing of Endoscopes and Surgical Instruments – Healthcare organizations reprocess thousands of reusable surgical instruments and devices. With pressure to meet procedure volume, steps are sometimes skipped to hasten turnaround leading to the risk of

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Patient Safety

The “blame” approach to medical errors is consistent with the understanding that human perfection is unattainable.

A. True
B. False

According to the Agency for Healthcare Research and Quality (AHRQ), what is the most common type of healthcare-associated infection?

A. Surgical Site Infection
B. Central Line-Associated Bloodstream Infection
C. Catheter-Associated Urinary Tract Infection
D. Pneumonia

Which type of hospital-acquired infection is the leading cause of patient death?

A. Catheter-Associated Urinary Tract Infection
B. Ventilator Associated Pneumonia
C. Sepsis
D. Surgical Site Infection

According to reports by the Office of the Inspector General, what percentage of adverse medical events are preventable?

A. 22%
B. 33%
C. 44%
D. 55%

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Answer: False


Answer: Catheter-Associated Urinary Tract Infection


Answer: Ventilator Associated Pneumonia


Answer: 44%