AARP South
Carolina Membership Survey: Quality of Care Key findings
include the following: 89% of the participants say that the current
health care system needs change, with 52% believing that the system needs major
changes. 85% support ensuring access to affordable,
quality health care for all state residents. More than 80% of participants identify
controlling the cost of prescription drugs, improving the quality and safety of
medical care, and improving the quality of nursing home and long term care as
very or extremely important issues for them personally. 65% say they or a family member received care
in a hospital in the past 3 years. Problems they experienced included not
receiving legally required written information about how to get help when
medical needs were not being met, not having personal needs taken care of in a
timely fashion, and not being informed of medication side effects. Further, many
believe that doctors and nurses did not spend enough time with the patient.
72% say that having an advocate with them in
the hospital would make them much more comfortable.
A total of 1,080 AARP members age 50 and older responded to a mail survey during
September 9-October 7, 2008. For more information, please contact Joanne Binette
at 202-434-6303. (25 pages)
Root Cause Analysis: Are We Looking for Keys
Under the Lamp Post? www.npsf.org/paf/npsfp/fo/ by Albert W. WU, MD, MPH, Julius Cuong Pham, MD, PhD and Peter Pronovost, MD,
PhD
The Department of Public Health's infection surveillance and control
program cut by $215,000
The Health Care Quality and Cost Council cut by $700,000.
All current staff are being laid off (to read more about the changes
to the Quality and Cost Council, visit the HCFA blog at
http://blog.hcfama.org/?p=1941).
The Betsy Lehman Center for Patient Safety and Medical Error
Reduction cut by $150,000.
Dept. of Health &
Human Services
Center for Disease
Control and
Prevention:
Hand Hygiene Saves
Lives: Patient
Admission Video
This video teaches
two key points to
hospital patients
and visitors to help
prevent infections:
the importance of
practicing hand
hygiene while in the
hospital, and that
it is appropriate to
ask or remind their
healthcare providers
to practice hand
hygiene as well.
Modeled after the
video that airline
passengers are
required to view
prior to take-off on
a flight, this new
video is intended to
be shown to patients
upon admission to
the hospital. The
goal is that the
video will inform
patients at the
beginning of their
hospital stay about
what they can do to
help prevent
infections
throughout the
duration of their
stay. The video
begins with a brief
introduction on
healthcare-associated
infections. It is
narrated by a nurse
character named
Gayle who stresses
the importance of
hand hygiene for
both patients as
well as healthcare
providers.
www.cdc.gov/handhygiene/Patient_Admission_Video.html
Family awarded $340,000 in botched
surgery
The victim's family first filed their $3
million lawsuit in 2002. The case went
to trial three times. www.roanoke.com/news/roanoke/wb/144870
Hectic
shifts have nurses worried. Nurses and
patients alike say in a survey that low
staffing jeopardizes quality care in
Minnesota. The nurses' union is
proposing legislation to address
workloads.www.twincities.com/allheadlines/ci_7833721?nclick_check=1
Many Errors
by Medical Residents Caused by Teamwork
Breakdowns, Lack of Supervision. Press
Release, October 22, 2007. Agency for
Healthcare Research and Quality, Rockville,
MD.
http://www.ahrq.gov/news/press/pr2007/teambreakpr.htm
We're Not Your Enemy:
An Appeal from a Consumer
to Re-imagine Tort Reform
by
Susan S. Sheridan, MIM, MBA and
Martin J. Hatlie, JD Patient Safety &
Quality Healthcare July / August 2007
www.psqh.com/julaug07/tortreform.html
How to Size Up Your Hospital
Improved Public Databases Let People Compare Practices
and Outcomes; The Importance of Looking Past the Numbers
by Theo Francis
Hospital sanctioned $1.3 million
over lawsuit
"A
Parkersburg hospital has been
ordered to pay a $1.3 million
sanction in a medical
malpractice case for allegedly
violating court orders and other
misconduct..."
by
The Associated Press
No Minor Mistake: Doctor's
Error, Your Expense Preventable medical errors cost employers billions
of dollars a year. Now, some firms are standing up to
the medical establishment, saying they'll refuse to pay
for botched treatment and demanding high standards of
care and safety. by
Jeremy Smerd,
www.workforce.com/section/02/feature/24/97/66/index.html
Dr. Donald Berwick, the president and CEO of the
Institute for Healthcare Improvement, talks with Katie Couric about his
crusade to make hospitals safer for patients. Watch the video at
www.cbsnews.com/sections/i_video/main500251.shtml?id=2440764n
Patient
Safety Study | Nearly 250,000 deaths could have been prevented, report
says.
There were about 1.16 million reported incidents between 2003 and 2005,
by Julius A. Karash @ The Kansas City Star
Hospital simulators offer real learning opportunity
Health students
get chance to test skills
by
Liv Osby HEALTH WRITER,
losby@greenvillenews.com
"Lewis
Blackman was just 15 when he died after surgery at
the Medical University of South Carolina, one of
thousands of Americans who die as a result of
medical error every year.
On Wednesday, a
plaque in his memory was unveiled at a center in
Greenville that's part of a statewide program aimed
at improving patient safety, a program that will
bear his name.
The Greenville
Healthcare Simulation Center at Greenville Memorial
Hospital will give future health care professionals
a chance to learn on simulators before turning their
hand to live patients."
To read the full
article:
www.greenvilleonline.com/apps/pbcs.dll/article?AID=2007703150315
U.S. Department of
Justice · Office of Justice Programs Bureau of Justice Statistics Medical Malpractice Insurance Claims in Seven
States, 2000-2004
www.ojp.usdoj.gov/bjs/abstract/mmicss04.htm
Monitoring
malpractice
By discouraging lawsuits and
capping damages, Indiana’s
system either controls costs –
or it makes the injured suffer
even more by
Michael Schroeder,
The
Journal Gazette
www.fortwayne.com/mld/fortwayne/news/local/17047480.htm
Backfire at
Boeing: Misadventure in High-Performance
Health Care
How the
aerospace company's effort to institute
performance-based health care raised the ire
of workers and physicians and landed its
insurer in legal hot water.
www.workforce.com/section/02/feature/24/80/93/index.html
Medical 'dirty secret'
out in open
"For too long" hospitals
and dialysis centers
"have kept patient
infections a dirty
secret," said Lisa
McGiffert, director of
Consumer Union's Stop
Hospital Infections
campaign."
http://washingtontimes.com/national/20070308-115038-7792r.htm
"Physician Malpractice Database Includes Indiana :
Golden,
Colo.--HealthGrades, the nation’s leading
independent health care ratings company, has
compiled the first national database of physician
malpractice records available to the public.
Detailed information on medical malpractice
judgments, settlements and arbitration awards
against physicians in fifteen states is now
available on-line, at
www.healthgrades.com,
as part of HealthGrades’ physician quality reports
for consumers."
~
Source: Inside Indiana Business
www.insideindianabusiness.com/newsitem.asp?ID=22497
Girl's
death stirs debate over psychiatric meds:
Parents
of 4-year-old accused of intentionally
overmedicating daughter. http://www.msnbc.msn.com/id/17758170/
Veterans
hospitals received gold seal / Joint Commission awarded
certification after VA withheld info about poor care
by STELLA M. HOPKINS. For article contact at
704-358-5173 or via
email: shopkins@charlotteobserver.com
A HIDDEN SHAME:
Danger and death in Georgia's mental hospitals
1st annual report for the New Jersey Patient Safety Initiative provides a
summary of the 2005 activities of the Patient Safety Initiative and the reported
events/related RCAs for that year. The New Jersey reporting system is based on
the NQF "never events." This Patient Safety Initiative web site includes a
link to the report, newsletters and other materials. www.nj.gov/health/hcqo/ps
Transparency in Health Care: The
Time Has Come By The Commonweath Fund President Karen Davis, Ph.D., and Fund Senior
Program Officer Sara R. Collins
"One of the defining characteristics of U.S.
health care markets is their lack of transparency. More and better
information on the costs and quality of health services could
improve the system—by enabling providers to benchmark their
performance against their peers, allowing private insurers and
public programs to reward quality and efficiency, and helping
patients make informed choices about their care.
Transparency could also level the playing field.
The widespread practice of charging patients different prices for
the same care is inherently unequal, especially when the uninsured
are charged more than others."
Patient Safety
-
More than five years after the Institute of Medicine report, "To
Err Is Human," put patient safety on the agenda at health care
institutions nationwide, there have been significant
improvements in quality. But Paul M. Schyve's perspective this
month suggests that it is going to take real commitment to reach
the next, critical stage of improvement: a "patient safety
culture."
To read the Common Wealth Fund article:
www.cmwf.org/publications/publications_show.htm?doc_id=367238#issue
Virginia doctors cite
charitable immunity in malpractice suits
SC Bill would require more data from hospitals - Proposal
targets infections patients get while staying at S.C. facilities
By Roddie Burris www.thestate.com/mld/thestate/14368072.htm
No-Fault Compensation in New Zealand: Harmonizing Injury Compensation, Provider
Accountability, and Patient Safety (Health Affairs, Jan./Feb.
2006). In this Fund-supported study, former Harkness Fellows Marie Bismark
(2004-05) and Ron Paterson (2002-03) compare New Zealand's no-fault compensation
system for medical injuries to the malpractice approach in the United States.
The authors find New Zealand's Accident Compensation Corporation (ACC) is simple
for patients to navigate and produces more-timely decisions for a greater number
of patients. However, concerns about the program remain: 30 years after
implementation of the ACC, New Zealand's hospitals are no more or less safe than
those in other industrialized countries, the study finds.
Kaiser Permanente's Experience of Implementing an Electronic Medical Record: A
Qualitative Study (BMJ, Dec. 2005). As part of a research team
cofunded by the Garfield Foundation and the Fund, J. Tim Scott (Harkness Fellow
2002-03), based at the University of St. Andrews School of Management in
Scotland, interviewed doctors, managers, and office staff involved in selecting,
testing, and implementing an electronic health record (EHR) system at Kaiser
Permanente Hawaii. According to the study, the keys to successful EHR
implementation are a participatory selection process, maintaining flexibility in
roles and responsibilities, and decisive leadership at critical stages.
State orders lethal-bacteria reports: Hospitals, long-term care
centers must report C. diff cases
Thursday, December 29,2005 2005, by Joe Guillen, Plain Dealer Reporter
www.cleveland.com The Ohio Department of Health has ordered the state's hospitals and
long-term care facilities to submit weekly reports on cases of a potentially
deadly intestinal bacteria that has killed thousands of people in Canada and
Britain.
Bad med students, bad docs
by Elizabeth Weise, USA TODAY, 12/21/2005
Physicians disciplined by state medical boards were three times more likely
to have shown unprofessional behavior while in medical school than those
with no discipline records, a study in today's New England Journal of
Medicine finds. www.USAToday.com
Advising Patients
About Patient Safety: Current Initiatives Risk Shifting
Responsibility
In the Literature
In the wake of To Err Is Human,
the Institute of Medicine's ground-breaking report on patient
safety, federal agencies, health care quality organizations,
consumer advocacy groups, and others have created brochures to
educate patients about ways to avoid harm from medical errors. But
the advice contained in these materials—while well-intentioned—may
not always be effective or appropriate, concludes a Commonwealth
Fund-supported study. For their study, "Advising
Patients About Patient Safety: Current Initiatives Risk Shifting
Responsibility," (Joint Commission Journal on Quality and
Patient Safety, Sept. 2005) 2003–04 Harkness Fellow Vikki A.
Entwistle, M.Sc., Ph.D., formerly of the University of Aberdeen,
Scotland, and colleagues examined readily available educational
resources distributed by leading proponents of patient safety. The
team then chose five advisories for more detailed content analyses.
www.cmwf.org/publications/publications_show.htm?doc_id=297152&#doc297152doc297152
Making a difference out of her memory: The
disease that killed his daughter was discovered too late to properly fight
it. That spurred a Dunedin man to try to make sure it doesn't happen to
anyone else.
www.sptimes.com/2005/08/21/Tampabay/Making_a_difference_o.shtml
From
Governing’s August 2005 issue
Plague of Errors,
By John Buntin
Hospital infection rates are rising and killing 90,000 patients a year. Can the
states put a stop to it?
www.governing.com/articles/8med.htm
"Death rate
from medical errors still high, despite efforts at improvement"
While hospitals have made significant improvements in patient safety since a
landmark 2000 report on medical mistakes, as many as 98,000 Americans still
die each year from such errors. The death rate has not changed much despite
heightened efforts, and researchers say factors slowing things down include
the complexity of health care systems, a lack of leadership, a reluctance of
health care providers to admit errors and an insurance system that
reimburses errors.
USA TODAY (5/18)
www.usatoday.com/news/health/2005-05-17-medical-errors_x.htm
Greenville News May 9, 2005
"Hospitals work to stop spread of medical errors" By Liv Osby, HEALTH WRITER Fifteen-year-old Lewis Blackman went into a Charleston hospital for
minimally invasive surgery to correct a birth defect and bled to death four
days later after doctors and nurses failed to recognize the seriousness of
his condition. The former Sara Collins student is one of the thousands of
Americans who die every year because of medical errors, errors that are
edging up, according to new research. And this week the state Senate Medical
Affairs Committee will consider a bill named for the Columbia boy that is
designed to prevent errors like those that led to his death.
http://greenvilleonline.com/news/2005/05/08/2005050864059_plain.htm
Evidence Based Medicine: What it Means for Patients and Physicians
When used properly, evidence-based medicine can enhance the patient-physician
relationship and improve patient care.
www.healthpolitics.com/home.asp?op=evidencemedicine
"Medical Boards Let Physicians Practice Despite Drug Abuse"
By Cheryl W. Thompson
Over the past 20 years, John F. Pholeric Jr. struggled on and off with cocaine
addiction, cycled in and out of rehab and was convicted of a felony. During that
time, he also practiced medicine. To view the entire article, go to
www.washingtonpost.com/wp-dyn/articles/A39677-2005Apr9.html?referrer=emailarticle
The
State
Columbia, South Carolina
Sunday, Jun. 16, 2002, p. A1, A8-9
SPECIAL REPORT
Lewis Blackman, a healthy, gifted 15-year-old, underwent elective surgery at
MUSC. In one of the state's most modern hospitals, he bled to death over 30
hours while those caring for him missed signs that he was in grave peril.
www.thestate.com/mld/thestate/3481227.htm
AARP Bulletin, November 2004
Fatal Mistakes
http://www.aarp.org/bulletin/your
health/Articles/a2004-10-27-fatal_mistakes.html
Mo.
Malpractice Claims Fall But Premiums Rise
The number of medical malpractice claims filed and paid
is declining in Missouri, yet physicians' premiums are
rising, according to a report from the state Insurance
Department. New medical malpractice claims dropped 14
percent in 2003 to what the department said was a record
low, and total payouts to medical malpractice plaintiffs
fell to $93.5 million in 2003, a drop of about 21
percent from the previous year.
www.insurancejournal.com/news/midwest/2004/11/09/47543.htm
" The Dartmouth
Atlas project is a funded research effort of the faculty of the Center for
the Evaluative Clinical Sciences at Dartmouth Medical School. The Atlas project
brings together researchers in diverse disciplines - including epidemiology,
economics, and statistics - and focuses on the accurate description of how
medical resources are distributed and used in the United States."
News Articles Related to the Dartmouth Atlas:
www.dartmouthatlas.org/news.php
DATELINE SPECIAL:
How do medical mistakes happen? Dateline NBC investigates the tragedy that
happened to one family
www.msnbc.com/news/657566.asp
Campaign urges patients to ask questions
Patient involvement needed to avoid medical errorswww.msnbc.com/news/724175.asp
For the first time in California
history, patients would have access to doctors' complete records of malpractice
judgments and settlements under a sweeping policy change given preliminary
approval Saturday by the California Medical Board
www.msnbc.com/local/myoc/m181900.asp
Rules set for medical-error reporting.
Hospitals will be required to tell patients about mistakes
www.msnbc.com/news/593502.asp
"New device
may have prevented 2 hospital tragedies" by Abram Katz, New Haven Register
www.zwire.com/site/news.cfm?newsid=3106083&BRD=1281&PAG=461&dept_id=7573&rfi=8
"Information technologies that support better medical
decisions and free up healthcare participants for the human work of wellness and
healing."
www.healthcommons.org/Welcome.html
DISCLAIMER: The content provided on this web site
is for information purposes only. It is intended to be a resource for
educational material and is not designed to provide medical advice. Please
consult your health care provider regarding any medical issues you have relating
to symptoms, conditions, diseases, diagnosis, treatments and side-effects.
Copyright 2002, 2003, 2004, 2005, 2006,
2007, 2008, 2009
www.cnn.com/2008/HEALTH/07/17/ep.surgical.errors/index.html
"Bill
would open doctor complaints"