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USA: Safety alert issued over age-related COVID-19 vaccine mix-ups

Three pharmacy and medication safety organisations are warning clinicians about a reported increase in age-related COVID-19 vaccine mix-ups.

The Institute for Safe Medication Practice's National Vaccine Errors Reporting Program said it's seen a "steady stream" of mix-ups involving the Pfizer vaccine intended for kids ages 5-11 and formulations for people 12 and older. ISMP said the reports involved hundreds of children and included young children receiving formulations meant for those 12 and up or vice versa.

The safety organisation said some errors were linked to vial or syringe mix-ups. In other situations, healthcare providers gave young children a smaller or diluted dose of the formulation meant for people 12 and up.

"Vaccine vials formulated for individuals 12 and up (purple cap) should never be used to prepare doses for the younger age group," the organisation said.

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Source: Becker's Hospital Review, 7 December 2021

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USA: Rising focus on patient safety and regulatory compliance driving growth in medical device complaint management market

The medical device complaint management market is experiencing significant growth due to the increasing focus on patient safety and regulatory compliance. As medical devices become more complex and the regulations governing them become more stringent, it has become essential for manufacturers to have effective complaint management systems in place to ensure the safety and satisfaction of their customers.

The global medical device complaint management market is expected to grow at a CAGR of 6.3% from 2021 to 2026. 

One of the key factors driving the growth of the medical device complaint management market is the increasing emphasis on patient safety. In recent years, there has been a growing awareness of the potential risks associated with medical devices, and patients are increasingly demanding higher levels of safety and quality. This has led to a greater focus on complaint management among medical device manufacturers, who are now investing in advanced complaint handling systems to ensure that they are able to identify and address issues before they become major problems.

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Source: Digital Journal, 20 April 2023

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USA: Rise in infant deaths hits Black families hardest, study finds

A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants.

The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth.

“In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore.

The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities.

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Source: The Washington Post, 13 March 2023

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USA: Reports of squamous cell carcinoma (SCC) in the capsule around breast implants - FDA safety communication

The U.S. Food and Drug Administration (FDA) is providing an update on reports of squamous cell carcinoma (SCC) in the scar tissue (capsule) that forms around breast implants. Previously, on 8 September 2022, the FDA released a safety communication informing the public of reports of cancers, including SCC and various lymphomas, in the capsule that forms around breast implants.  The various lymphomas are not the same as the lymphomas described previously by the FDA as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).  

This update includes information from the FDA’s review of literature and medical device reports (MDRs). The FDA is aware of 19 cases of SCC in the capsule around the breast implant from published literature. There have been reports in the literature of deaths from progression of the disease.  While the FDA continues to believe that occurrences of SCC in the capsule around the breast implant may be rare, the cause, incidence and risk factors remain unknown. 

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Source: US FDA, 8 March 2023

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USA: Predictable, preventable medical errors kill thousands yearly. Is it getting any better?

Two years ago, administrators and caregivers at St. Bernard Hospital in Chicago were stunned when they flunked a basic standard for patient safety.

"It was a real jolt," said Charles Holland, the hospital's president and CEO. "We thought we were doing patient safety and we thought we were doing it well."

But the Leapfrog Group, a nonprofit health care watchdog organisation, found the hospital fell short on documenting and having comprehensive approaches to hand-washing, medication safety systems and fall and infection prevention.

The wake-up call led Holland to hire a Patient Safety and Quality Officer and to use Leapfrog's criteria as a roadmap for improving patient safety.

It worked. In its latest annual review of hospital safety, released Wednesday, Leapfrog awarded the century-old charity hospital an A.

The fact that St. Bernard could turn around so quickly and so effectively without spending a fortune in the process shows that patient safety is an attainable goal, said Leah Binder, Leapfrog's president and CEO.

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Source: USA Today, 3 May 2023

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USA: Patients needing home IV nutrition fear dangerous shortages

CVS Health confirmed last year it was closing half its Coram home infusion branches and firing about 2,000 nurses, dietitians and pharmacists.

Their patients with life-threatening digestive disorders depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins and electrolytes typically are pumped through a catheter into a large vein near the heart.

A day later Optum Rx, another big supplier, announced its own consolidation. Suddenly, thousands were scrambling for their complex essential drugs and nutrients.

“With this kind of disruption, patients can’t get through on the phones. They panic,” said Cynthia Reddick, a senior nutritionist laid off last summer in the CVS restructuring.

“It was very difficult. Many emails, many phone calls, acting as a liaison between my doctor and the company,” said Elizabeth Fisher Smith, a 32-year-old public health instructor in New York, whose Coram branch closed. A rare medical disorder has forced her to rely on PN for survival since 2017. “It added to my mental burden,” she said

Home and outpatient infusions in the USA are a growing business, as new drugs for chronic illness expand treatment options and enable patients, providers and insurers to avoid hospitalisation. 

But while reimbursement for expensive new drugs has attracted corporations and private equity, the industry is constrained by a lack of nurses and pharmacists. The less profitable parts of the business — and the vulnerable patients they serve — are at risk. This includes the 30,000-plus Americans who rely on parenteral nutrition — including premature infants, post-surgery patients and those with damaged bowels because of genetic defects.

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Source: The Washington Post, 6 February 2023

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USA: Patients from minority groups face longer wait times for vital lung cancer treatment

Patients from minority groups are facing longer wait times for potentially life-saving lung cancer treatment compared to their white counterparts, according to a study.

Experts warn that disparities can have real consequences – the earlier treatment is initiated, the better the health outcomes for patients.

Researchers at the University of Virginia (UVA) Cancer Centre reviewed data from more than 222,700 patients with non-small cell lung cancer across the US.

The findings, published in the scientific journal Health Equity, showed that the mean time for radiation initiation was 61.7 days. Broken down by ethnicity, white patients had to wait only 60.9 days, while Black patients had a wait time of 65.9 days, meanwhile for Asian patients, it was 71.9 days.

A single-week delay in treatment could lead to a 3.2% and 1.6% increase in the risk of death for patients with stage I and stage II non-small cell lung cancer, respectively.

“Our results suggest that non-white lung cancer patients have delayed time to cancer treatment compared with white patients, and this is not limited to a particular type of treatment facility,” said senior researcher Rajesh Balkrishnan, PhD, of UVA Cancer Center and the University of Virginia School of Medicine’s Department of Public Health Sciences.

“Collaboration among providers and community stakeholders and organisations is much needed to increase accessibility and patient knowledge of cancer and to overcome existing disparities in timely care for lung cancer patients.”

Scientists cite multiple reasons for the racial disparities, including health insurance – non-white patients are more likely to be uninsured, face greater socioeconomic barriers to care and may be perceived by doctors as being at risk for not following through with treatment plans.

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Source: The Independent, 26 October 2022

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USA: Patient Safety Awareness Week

Patient Safety Awareness Week, an annual recognition event in the USA that occurs in March, is intended to encourage everyone to learn more about health care safety.

During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce.

Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done.

IHI works with partners around the world to improve the safety of health care for patients, caregivers, and the health care workforce.

Learn more about IHI's work to advance patient and workforce safety.

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USA: Over 400 patients mistakenly told they may have cancer due to software glitch

Grail, a company that developed blood tests to detect cancer, mistakenly sent approximately 400 customers letters saying they might be positive for the disease, The New York Times has reported.

Grail's Galleri test uses blood to detect cancer signals shared by 50 types of cancers and is available only by prescription, according to the report. Grail said in a statement that one of its vendors sent hundreds of letters with incorrect test results due to a "software configuration issue." 

"No patient health information has been disclosed or breached due to this issue, and no patient harm or adverse events have been reported," Grail's statement said.

The issue was not caused by incorrect test results, according to the company. More than half of people who received the erroneous letter had not yet had their blood drawn for the test. PWNHealth said in a statement that the system it uses to send template messages to people had a "misconfiguration." 

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Source: Becker's Hospital Review, 4 June 2023

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USA: OBGYNs reacting to Roe Vs Wade fear for patient safety and health

Reproductive health doctors are reacting to the Supreme Court's decision to overturn Roe vs Wade, the 1973 case that allowed people to seek abortions with limited government intervention.

On Friday, Justice Samuel Alito delivered his opinion on the case Dobbs vs Jackson Women's Health, saying he favoured the state of Mississippi in the case. Now, Roe vs Wade, which allowed abortion until about 24 weeks of pregnancy, is overruled, and individual states have the power to decide their residents' abortion rights.

OBGYNs who provide abortion care and family-planning services told Insider they worry for their patients' health and safety, and the future of all reproductive healthcare including miscarriages, fertility treatments, and birth control.

"This decision made by the SCOTUS is one that completely obliterates freedom from reproductive justice and women's health directly," Dr. Jessica Shepherd, a Texas-based gynecologist and Chief Medical Officer at Verywell Health, told Insider.

Dr. Stephanie Ros, a Florida-based OBGYN, says she fears most for working-class abortion seekers.

"I'm not worried about my wealthy patients – they will have the means to go 'visit an aunt' in Europe or elsewhere, and access abortion care if they so desire. I'm terrified for my middle class and poor patients, who don't have the means to pick up and travel on a moment's notice, and who often don't have access to medical care to even discover they're pregnant until later than their wealthy counterparts." 

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Source: Insider, 24 June 2022

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USA: Number of health systems allegedly denying care to indebted patients grows

Recently Minneapolis-based Allina Health was highlighted by The New York Times for pulling back from its policy of denying nonemergency care to some indebted patients. However, a recent investigation showed it is not the only health system to allegedly have engaged in the practice.

According to KFF Health News, about 20% of US nationwide hospitals in a random sample pursued similar policies of care denial.

The Lown Institute went further, naming major health systems including Rochester, Minn.-based  Mayo Clinic, St. Louis-based Ascension, Indianapolis-based Indiana University Health, Livonia, Mich.-based Trinity Health and Los Angeles-based Cedars-Sinai as operating facilities where the practice is followed.

IU Health, Ascension, Trinity Health and Cedars-Sinai denied they have such practices.

"We do not restrict medically necessary non-emergency care for patients with unpaid bills," an Ascension spokesperson said.

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Source: Becker Hospital Review, 26 June 2023

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USA: My emergency patients wait hours — or days — for a hospital bed


It has been well-documented that Covid-19 took a devastating toll on emergency departments nationwide, revealing and exploiting the fragility of our acute-care system. Less has been written, however, about the side effects of hospitals’ attempts to recover from that era — one of the most serious of which is the proliferation of boarding.

As hospitals scramble to regain their footing (and their profit margins), the financial incentive structure that undergirds US medicine has gone into overdrive. Inpatient beds that might previously have been reserved for patients who require essential care but generate very little money for the hospital, are increasingly allocated for patients undergoing more lucrative procedures.

The consequences of this systemic failure cannot be overstated. Four hours is supposed to be the maximum time spent boarding in an emergency department, but recent data shows that hospitals in the US are failing to meet that goal when occupancy is high (which it routinely is).

"On any given shift, hallways in the emergency department are lined with patients on stretchers. Boarding leads to a cascade of harms — including ambulances diverted to hospitals far from patients’ homes, patients charged for beds they haven’t yet occupied and overwhelmed emergency medicine personnel leaving the field because of burnout," says Hashem Zikry, an emergency medicine physician and a scholar in the National Clinician Scholars Program at UCLA.

Many narratives around boarding focus on the patients themselves, shaming some for inappropriately using the emergency department. Proposed solutions include pushing patients to urgent-care centers or modifying “patient flow.” But the issues with boarding cannot be addressed with such minor tweaks.

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Source: The Washington Post, 28 February 2024

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USA: Mississippi prison delayed woman’s cancer diagnosis until it was terminal, lawsuit says

A Mississippi prison denied medical treatment to an incarcerated woman with breast cancer, allowing her condition to go undiagnosed for years until it spread to other parts of her body and became terminal, according to a lawsuit filed on Wednesday.

Susie Balfour, 62, alleges that Mississippi department of corrections (MDOC) medical officials were aware she might have cancer as early as May 2018, but did not conduct a biopsy until November 2021, one month before she was released from prison. It was not until January 2022, after she left an MDOC facility, that a University of Mississippi Medical Center doctor diagnosed her with stage four breast cancer, according to her federal complaint.

Her lawsuit and medical records paint a picture of a prison healthcare system that deliberately delayed life-saving healthcare and for years repeatedly failed to conduct follow-up appointments that the MDOC’s contracted clinicians recommended.

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Source: The Guardian, 14 February 2024

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USA: Massachusetts will designate hospital “Levels of Maternal Care” to improve health outcomes for higher-risk patients

To help patients with high-risk pregnancies receive care at hospitals that are staffed and equipped to deliver care appropriate to their needs, the Department of Public Health will require licensed birthing hospitals to use a system called Levels of Maternal Care. The system classifies hospitals based on their capacity to meet the needs of patients with a range of potential complications during childbirth.

The impetus is the rising levels of severe maternal morbidity, large racial disparities in outcomes, and concerns that higher-risk patients who deliver in hospitals that over-estimate the level of care they are able to provide are more likely to experience complications.

Levels of care describe a hospital’s physical facilities, capabilities and staffing, indicating its ability to serve people giving birth across a range of medical needs. For example, Level 1 is appropriate for low-risk patients with uncomplicated pregnancies, including twins and labor after cesarean delivery. To that group, Level II adds patients with poorly controlled asthma or hypertension and other higher-risk conditions. Subsequent levels include patients at increasingly high risk of complications, up to Level IV, which is appropriate for patients with severe cardiac disease, those who need organ transplant and others.

Established by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in 2015, the classification system is one tool used by states across the country to improve maternal health and birthing outcomes.

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Source: Betsy Lehman Center. 17 January 2024

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USA: Lawsuit alleges Strattice “pig skin” mesh is defective, resulting in need for hernia revision surgery

A hernia mesh lawsuit recently filed by a Washington woman alleges that a Strattice “pig skin” mesh product used during her hernia repair was defective and failed, resulting in the need for two additional revision surgeries.

The Strattice Reconstructive Tissue Matrix is a hernia repair mesh introduced in 2008, which is constructed from porcine, or pig skin. The mesh is then preserved in a phosphate buffered aqueous solution. It is marketed as a cross-linked graft device, which is intended to chemically link the proteins in the tissue together. However, a growing number of lawsuits allege that the design actually increases the risk of foreign body responses, infections and other complications.

Hundreds of injuries and several deaths have been linked to the Strattice hernia mesh made from pig skin, according to the lawsuit.

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Source: About Lawsuits.com, 20 January 2023

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USA: Lack of information, not mistrust, the biggest barrier to Black women’s participation in clinical trials

A new report by US healthcare communications agency GCI Health found that Black women aren't avoiding clinical trials due to mistrust. The reasons for their underrepresentation are “more layered and nuanced.”

The report is based on a recent summer survey with 500 responses from Black women across the USA. It reveals that, while the majority (80%) are "open" to participating in a clinical trial, 73% have never been asked to do so.

While it's commonly believed that Black women are unwilling to participate in trials due to mistrust of the healthcare and biopharma systems, GCI's survey responses unveiled a more complex perspective.

The data suggest “that access to information is the largest barrier to participation, rather than mistrust in the medical establishment, as commonly believed,” GCI Health’s report found.

“We often hear that Black women are missing from clinical research because they are ‘hard-to-reach’ or reluctant to participate due to mistrust of the medical establishment,” said Kianta Key, group senior vice president and head of identity experience at GCI Health, in a press release. “In talking with women, we heard something more layered and nuanced that deserved exploration.”

“Our industry has a responsibility to reverse years of underrepresentation in clinical trials and do more to support better healthcare outcomes for Black women,” said Kristin Cahill, global CEO of GCI Group, in the release.

“Equity is critical to ensure new treatments and health interventions work for everyone. This research helps get us closer to understanding what needs to be done to make positive changes that will save lives and create healthier communities.”

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Source: Fierce Pharma, 14 November 2023

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USA: Job burnout threatens health care workforce

The U.S. is facing high levels of burnout among health care workers, which could lead to serious shortcomings in patient care, a new report from the U.S. Surgeon General has found.

Burnout among health care workers was a serious problem even before the COVID-19 pandemic, but the stress caused by the ongoing pandemic has made things much worse, said Surgeon General Dr. Vivek Murthy.

“The pandemic has accelerated the mental health and burnout crisis that is now affecting not only health workers, but the communities they serve,” Murthy said.

“Already, Americans are feeling the impact of staffing shortages across the health system in hospitals, primary care clinics, and public health departments. As the burnout and mental health crisis among health workers worsens, this will affect the public’s ability to get routine preventive care, emergency care, and medical procedures. It will make it harder for our nation to ensure we are ready for the next public health emergency. Health disparities will worsen as those who have always been marginalized suffer more in a world where care is scarce. Costs will continue to rise.”

The report calls for several steps to address the burdens on health care workers. These include:

  • Protecting the health, safety, and well-being of all health workers by ensuring they have proper equipment, training, and are protected against workplace violence.
  • Eliminating punitive policies for seeking mental health and substance abuse care.
  • Reducing administrative and documentation burdens and improving health information technology and payment models.
  • Prioritising health worker well-being on an organizational level—this includes providing competitive wages, paid sick and family leave, rest breaks, educational debt support, and other steps to ease the burden on health workers.

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Source: BenefitsPro, 6 June 2022

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USA: It's not just doctors and nurses reporting burnout. Support staff are feeling stressed

The vast majority of front-line clinical support staff are reporting moderate to extreme burnout, and nearly two-thirds have considered quitting, a new US survey found.

"While much has been reported on doctor and nurse burnout, less attention has been paid to the front-line clinical support staff who have been working tirelessly throughout the COVID-19 pandemic to ensure high-quality patient care was maintained," Meg Aranow, senior vice president and platform evangelist for patient experience vendor Well Health, told Fierce Healthcare.

"We recognize the critical role clinical support staff play in provider organizations—this study further validates the cascading impact clinical support staff have on the patient experience and so many facets of our healthcare system," Aranow said.

Well Health surveyed 320 clinical support staff who are primarily responsible for communicating and coordinating with patients, mostly through phone calls, which can be time-consuming. According to the survey results, the patient-communication coordination process is overwhelming staff to the point of wanting to quit, with 82% saying that contacting and coordinating with patients about their appointments, follow-ups and health issues via phone, email, text or live chat is a direct cause of their burnout.

The survey found that 58% of clinical support staff believe their burnout has negatively affected a patient’s quality of care, and 60% report poor or ineffective patient communication has negatively affected a patient’s health outcomes.

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Source: Fierce Healthcare, 20 October 2021

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USA: Investigation spotlights rise of for-profit ethics boards in research

A US government watchdog called for greater federal oversight of ethics boards that sign off on scientific studies, finding that for-profit companies have taken an outsize role in approving certain research and questioning whether financial motivations could put human subjects at risk.

Federal regulations require that certain research on human subjects — including those testing the safety of new drugs — first get approval from a registered institutional research board. These boards, which are made up of at least five members and can include researchers and academics, are designed to make sure that a study poses as little risk as possible and that participants have enough information to give consent.

While the majority of these boards are affiliated with universities, a small number have no affiliation with institutions conducting research. But according to a new report from the U.S. Government Accountability Office (GAO), these independent boards now account for the largest share of reviews of studies involving new drugs and biologics.

The GAO found that federal agencies overseeing the ethics panels inspect relatively few of them and lack ways to evaluate how well they protect people participating in research.

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Source: The Washington Post, 16 February 2023

 

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USA: House Bill establishes Federal Agency dedicated to patient safety

Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions.

Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic.

The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm.

A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. 

“We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.”

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Source: Business Wire, 8 December 2022

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USA: Hospitals' safety culture gap

Healthcare workers' perceptions of safety at their organisations is improving, though a gap still remains between senior leaders and front-line workers, according to a Press Ganey report.

Press Ganey surveyed more than 1 million employees from 200 health systems in the USA in 2023. The poll included 19 questions related to safety culture across three domains: prevention and reporting, pride and reputation, and resources and teamwork.

Three takeaways:

  1. Staff safety culture scores have risen from an all-time low of 3.96 (out of 5) in 2021 to 4.01 in 2023. This increase was largely driven by improvements around staff members' perceptions of resources and teamwork, including views on adequate unit staffing. "While these improvements are encouraging, there's still a lot of work to do," Press Ganey said. "Pre-pandemic rates were never the desired end state, and it’s important to note that nearly half (48.5%) of employees still have a low perception of safety culture." 
  2. Senior management reported the highest perceptions of safety culture at 4.53, while registered nurses and advanced practice providers reported the second- and third-lowest at 3.95 and 3.92, respectively. Security team members had the lowest perceptions of safety at 3.91.
  3. large gap was also seen between senior leaders and registered nurses regarding perceptions of workplace violence protections. Senior management gave their organizations a 4.30 out of 5 for having strong security measures in place to prevent violence, compared to just 3.36 for nurses. 

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Source: Becker's Hospital Review, 3 April 2024

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USA: Hospital acquired infections are down post-COVID, but other risks remain for patients

Hospital-acquired infections, which became substantially more common during the pandemic, have returned to pre-pandemic levels, according to a new report from a US patient safety watchdog group. It's key to note, researchers say, that infection rates before March 2020 were nothing to celebrate.

On top of that moderately good news, the Leapfrog Group found other metrics that measure patient safety and satisfaction have fallen significantly, likely because of hospital staffing shortages and other pandemic-era challenges.

"We're encouraged and relieved to see that infections are rapidly decreasing in hospitals following the spike during the pandemic, but we remain very concerned about a number of major problems in hospitals," said Leah Binder, president and CEO of Leapfrog, an independent, national nonprofit founded by large employers and other purchasers.

Patient surveys following hospital visits found declines in experiences for the second year in a row in all states. Particularly significant drops were reported in “communication about medicines” and “responsiveness of hospital staff." Preventable errors have been linked to these problems.

"Hospitals need to take a hard look at what they are unnecessarily continuing post-pandemic that are not helping patients," Binder said.

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Source: USA Today News, 6 November 2023

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USA: Healthcare leaders, staff differ on safety culture views

US clinical and nonclinical healthcare workers have an upward-trending perception of safety culture, but physicians and leaders do not agree, according to a Press Ganey report.

Press Ganey, a US company that focuses on patient satisfaction surveys, found in its annual safety culture trends report that senior management perceptions of all safety culture metrics are lower. Overall safety scores are down 0.04 points, prevention and reporting decreased 0.02 points, pride and reputation declined 0.05 points, and resources and teamwork are down 0.04 points. 

The report analysed 2022 data from 813,900 healthcare workers across 194 systems and 3,279 facilities.

"Senior management safety culture scores are typically higher than those of operational management, suggesting a more positive perspective among those at the highest levels of provider organizations," the report said. "Yet the continued downward trajectory of senior management scores stands out as significant." 

Among physicians, pride and reputation fell 0.12 points. Their perceptions of overall safety declined 0.06 points, prevention and reporting is down 0.03 points, and resources and teamwork is down 0.05 points. 

Other healthcare employees had higher perceptions of these metrics except for pride and reputation. Also, "fewer employees today say they would recommend their organization for care than in previous years," Press Ganey found. 

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Source: Becker's Hospital Review, 21 March 2023

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USA: Four-year-old accidentally given vasectomy

A family in Texas is suing a Houston-based doctor after their 4-year-old on son underwent an "unintended vasectomy" during a surgery.

The child was reportedly in the hospital for a hernia surgery at the time of the incident, according to Randy Sorrels, the family's personal injury attorney. He told Fox4 that part of the procedure involved work near the child's groin.

The attorney claimed the surgeon "cut the wrong piece of anatomy."

“The surgeon, we think, cut accidentally the vas deferens, one of the tubes that carries reproductive semen in it. It could affect this young man for the rest of his life,” Mr Sorrels told the broadcaster.

The surgeon who operated on the boy has no history of malpractice and has otherwise never received any negative reports on their work.

Mistakes like the one made on the toddler are generally very rare due to safety precautions built into the surgery process.

“It’s not a common mistake at all,” Mr Sorrels said. “Before a doctor transects or cuts any part of the anatomy, they are supposed to positively identify what that anatomy is and then cut. Here, the doctor failed to accurately identify the anatomy that needed to be cut. Unfortunately, cut his vas deferens. That wasn’t found out until it was sent in for pathology.”

The attorney said his and the family’s top concern is for the boy’s health. They are considering options for reversing the procedure, but the attorney noted that doing so would require the boy to undergo more surgery.

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Source: The Independent, 15 June 2022

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USA: Former nurse found guilty in accidental injection death of 75-year-old patient

RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country.

Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip.

Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.

Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare.

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Source: OPB, 26 March 2022

See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?

 

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