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News Article
USA: Care quality, safety 'worse than expected' during Covid-19 pandemic
Patient Safety Learning posted a news article in News
A new CMS report reveals disparities in care quality and patient safety within US hospitals before and during the pandemic, finding "a large proportion of measures had worse than expected performance." CMS released its 2024 National Impact Assessment Feb. 28, which is released every three years and evaluates the measures used in 26 CMS quality and value-based incentive payment programs. This edition of the report compares quality measure scores pre-COVID-19 with hospitals' results in 2020 and 2021, the initial years of the COVID-19 public health emergency. Here are eight findings from the 72-page assessment: 1. During 2020 and 2021, a large proportion of measures had worse than expected performance, including significant worsening of key patient safety metrics. 2. Half or more of the performance measures in five priorities had worse results in 2021 than expected from the 2016–2019 baseline. Priorities with the highest proportions of worse-than-expected results in 2021 were wellness and prevention (69%), behavioural health (55%), safety (54%), chronic conditions (52%), and seamless care coordination (50%). 3. Specific to safety, standardised infection ratios worsened significantly in hospitals for central line–associated bloodstream infections (94% worse), MRSA (55% worse) and CAUTI (34% worse). Before the Covid-19 PHE (2015–2019), 34,455 fewer healthcare-associated infections (HAIs) were reported in acute care settings. 4. More than 35% of measures in two priorities had better results in 2021 than expected from 2016–2019 baseline trends. Those priorities are seamless care coordination (50%) and affordability and efficiency (38%). 5. Specific to affordability and efficiency, emergency department visits for home health patients fared 1.4 percentage points better, and acute care hospitalization in the first 60 days of home health in 2021 was 1.5 percentage points better. 6. Accountable entities with the highest proportions of worse than expected results in 2021 were clinicians (64%), accountable care organizations (54%), and acute care facilities (54%). 7. Wellness and prevention had the highest percentage of measures showing health equity disparities; notable examples include pneumococcal and influenza vaccinations among racial and ethnic groups. 8. Comparison racial and ethnic groups fared worse than the White reference group on 40 of 45 (88.9%) affordability and efficiency measures and 32 of 41 (78%) chronic conditions measures. For example, disparities were recorded for Black or African American patients in 32, or 71%, of the affordability and efficiency measures, mostly related to readmissions. Read full story Source: Becker Hospital Review, 29 February 2024 -
Content ArticleStrategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. This study aimed tov describe implementation of MEDS in routine clinical practice and associated outcomes. The study was conducted in five stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. The study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED
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Content ArticleThis US study in the journal Pediatrics analysed a national sample of paediatric hospitalisations to identify disparities in safety events. The authors used data from the 2019 Kids’ Inpatient Database and looked at the independent variables of race, ethnicity and the organisation paying for care (for example, private insurance company or Medicaid). The results showed disparities in safety events for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in hospitals.
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Content ArticleEarly-onset colon cancer (EOCC) is increasing in the US and disproportionately affects African-Americans. This analysis in the American Journal of Surgery aimed to compare EOCC survival among Black and White patients after matching relevant socio-demographic factors and stage. The authors found that Black patients with stage 3 EOCC are less likely to receive chemotherapy and have worse survival than White patients. They call for further research to identify potential factors driving this inequality.
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News ArticleA 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. Read full story Source: The Guardian, 14 February 2024
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Content ArticleSentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organisations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.
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News Article
USA: Best hospitals by specialty national rankings
Patient Safety Learning posted a news article in News
In 2023-2024, the US News Best Hospitals ranked hospitals in the USA in 15 adult specialties as well as recognised hospitals by state, metro and regional areas for their work in 21 more widely performed procedures and conditions. Of the nearly 5,000 hospitals analyzed and 30,000 physicians surveyed, only 164 hospitals ranked in at least one of the specialties. Read full story Source: US News -
Content ArticleECRI's Top 10 Health Technology Hazards for 2024 list identifies the potential sources of danger ECRI believe warrant the greatest attention this year and offers practical recommendations for reducing risks. Since its creation in 2008, this list has supported hospitals, health systems, ambulatory surgery centres and manufacturers in addressing risks that can impact patients and staff.
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Content ArticleIn his IHI Forum 2023 address, IHI President Emeritus and Senior Fellow Don Berwick explained why competitiveness does not lead to the best possible care. He shared his view on the limitations of free-market healthcare and his personal experience of how kindness can support our efforts to improve care.
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News ArticleA midwife in New York who reportedly gave 1,500 children homeopathic pellets rather than the vaccinations required by the state has been fined $300,000 by the state's health department. The midwife was identified as Jeanette Breen, who operates the Long Island-based Baldwin Midwifery. Ms Breen reportedly gave the pellets as an alternative to required vaccinations and then proceeded to falsify the children's immunisation records, according to the New York Department of Health. The midwife reportedly began giving the pellets during the Covid-19 pandemic, specifically during the 2019-2020 school year. The majority of the affected children live in Long Island, according to the Associated Press. The health department said that the false records have since been voided, and that the families will have to ensure their students are up-to-date with their shots before they can return to school. “Misrepresenting or falsifying vaccine records puts lives in jeopardy and undermines the system that exists to protect public health,” State Health Commissioner James McDonald said in a statement. Read full story Source: The Independent, 24 January 2024
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News Article
USA: ED boarding at crisis levels, Mass General says
Patient Safety Learning posted a news article in News
Boston-based Massachusetts General Hospital is requesting permission from the state to add more than 90 inpatient beds amid what it says is an "unprecedented capacity crisis." The hospital's emergency department has experienced critical levels of overcrowding nearly every day for the past six months, Massachusetts General said in a news release. The hospital boards between 50 to 80 ED patients every night who are waiting for a hospital bed to open. On 11 January, Massachusetts General had 103 patients boarding in the ED, representing one of the most crowded days in the hospital's more than 200-year history. "While hospital overcrowding has significantly affected patient care for many years, COVID-19 and the post-pandemic demand for care has escalated this challenge into a full-blown crisis – for patients seeking necessary emergency care, as well as for staff who are required to work under these increasingly stressful conditions," David F.M. Brown, president of Massachusetts General, said in a news release. Massachusetts General's request comes as hospitals across the state grapple with capacity issues, workforce shortages and a jump in respiratory illnesses this winter. On 9 January. the Massachusetts Department of Public Health issued a memo urging hospitals to expedite discharge planning amid the capacity crunch. Some health plans have also waived the need to obtain prior authorisation for short stays in post-acute care facilities. Read full story Source: Becker Hospital Review, 19 January 2024 -
News ArticleTo 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. Read full story Source: Betsy Lehman Center. 17 January 2024
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EventLearn from experts about Project PIVOT, a patient safety initiative led by Patients for Patient Safety (PFPS) US. According to a World Health Organization report, despite decades of patient safety improvement initiatives, approximately 134 million adverse safety events are still occurring each year. A recent report from the Office of the Inspector General revealed that 1 in in 4 Medicare patients experience avoidable adverse events - disproportionately impacting those communities who experience marginalization. A key emerging strategy to improve patient safety and equity is to incorporate patient-reported experiences and outcomes (PREs and PROs) into improvement efforts as illustrated by recent calls to action from the President’s Council of Advisors on Safety and Technology (PCAST), the WHO’s Global Patient Safety Action Plan, and in CMS’s proposed Patient Safety Structural Measure. Learn from Sue Sheridan, Martin Hatlie, and Suz Schrandt about Project PIVOT and other initiatives that are taking action to promote the implementation of patient-centered PROs and PREs to drive safer more equitable care. Register
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Content ArticleRacial and ethnic disparities in health are substantial and persistent in the USA. They occur from the earliest years of life, are perpetuated by societal structures and systems, and profoundly affect children’s health throughout their lives. This series of articles in The Lancet Child & Adolescent Health summarises evidence on racial and ethnic inequities in the quality of paediatric care, outlines priorities for future research to better understand and address these inequities and discusses policy solutions to advance child health equity in the USA. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence Policy solutions to eliminate racial and ethnic child health disparities in the USA
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News ArticleFewer Americans are dying of cancer, part of a decades-long trend that began in the 1990s as more people quit smoking and doctors screened earlier for certain cancers. However, the American Cancer Society warned that those gains are threatened by an increase in cancers among people younger than 55, in particular cervical and colorectal cancer, and by the continued disparities between white Americans and people of colour. “The continuous sharp increase in colorectal cancer in younger Americans is alarming,” said Dr Ahmedin Jemal, senior vice-president for surveillance and health equity science at the American Cancer Society. “We need to halt and reverse this trend by increasing uptake of screening, including awareness of non-invasive stool tests with follow-up care, in people 45-49 years, [old]” said Jemal. Read full story Source: The Guardian, 17 January 2024
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Content Article
FDA drug shortages database
Patient-Safety-Learning posted an article in Medication including labelling
Medication shortages can occur for many reasons, including manufacturing and quality problems, delays and discontinuations. This Food and Drug Administration (FDA) database provides information on drugs with a supply issue. Information is provided to the FDA by manufacturers. -
Content Article
Patient safety culture and quality: The missing link
Kumar posted an article in Safety culture programmes
There is a direct correlation between safety event management practices and care quality outcomes. The right safety management tools, supported by a shared perception and tolerance of risk, will help organisations go beyond reporting event data to improve safety culture. -
Content ArticleIn the USA, Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident doctor fatigue. However, compliance with ACGME WHRs is not universal. This study aimed to identify factors that influence resident doctors' decisions to take a post-call day (PCD) off in line with ACGME WHRs. The authors concluded that as most important influencer of residents’ decisions to take a PCD off was related to feedback from their supervisors, compliance with WHRs can be improved by focusing on the residency program’s safety culture.
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Content ArticlePatient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. The aim of this study from Eldridge et al. was to determine the change in the rate of adverse events in hospitalised patients. The study found that in the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.
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Content ArticleThe USA National Nurses United is proposing for minimum, mandated, nurse-to-patient staffing ratios to protect patients’ right to nursing care. Every patient deserves a single standard of high-quality care. The ratios, coupled with nurses’ powerful voice of advocacy secured in collective bargaining, protect patients from complications that arise from missed care such as medical errors, health care disparities, infections, and so much more.
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News ArticleMylissa Farmer’s pregnancy was doomed. But no one would help her end it. Over the course of a few days in August 2022, Farmer visited two hospitals in Missouri and Kansas, where doctors agreed that because the 41-year-old’s water had broken just 18 weeks into her pregnancy, there was no chance that she would give birth to a healthy baby. Continuing the pregnancy could risk Farmer’s health and life – yet the doctors could not act. Weeks earlier, the US supreme court had overturned Roe v Wade and abolished the national right to abortion. It was, legal counsel at one hospital determined, “too risky in this heated political environment to intervene”, according to legal filings. In immense pain and anguish, Farmer ultimately traveled several hours to Illinois, where abortion is legal. There, doctors were able to end her pregnancy. Farmer’s account is detailed in a legal complaint she filed against the hospitals, arguing that they broke a federal law that requires hospitals to treat patients in medical emergencies. In a first-of-its-kind investigation, the US government sided with Farmer and declared that the two hospitals had broken the law. The future of the government’s ability to invoke that law to protect women seeking emergency abortions is now in question. The law, the Emergency Medical Treatment and Labor Act (Emtala), is at the heart of the US supreme court’s latest blockbuster abortion case, which comes out of Idaho. Read full story Source: The Guardian, 9 January 2024
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Content ArticleThe maternal mortality rate (MMR) in the United States continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women. Keisha E. Montalmant and Anna K. Ettinger carried out a literature review to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. The review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women.
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Content ArticleThis article provides an overview of the proposed Patient Safety Structural Measure on the Centers for Medicare and Medicaid Services (CMS) list of Measures Under Consideration (MUC) 2023 and summarises the public comment submitted by Patient Safety Learning on this.
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Content ArticleThe US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included. See also our Medication error traps gallery
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Content ArticleThis observational cross-sectional study in the American Journal of Surgery aimed to quantify the association between US state trauma funding and both in-hospital mortality and transfers of injured patients. The authors concluded that Increased state trauma funding is associated with decreased adjusted in-hospital mortality and fewer interfacility transfers to a second acute care hospital.
