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Patient Safety News


Being a Joint Commission certified agency, SNI Staffing provides regular updates for nurses and its clients regarding health quality initiatives. This area contains collection of links to National Patient Safety initiatives, articles and updates to support medication safety and infection control.


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The links in this area will let you leave SNI web site. The linked sites are not under the control of SNI and SNI is not responsible in any way for the contents of any linked site or any link contained in a linked site, or any changes or updates to such sites. SNI is providing these links to you only as an educational tool, and inclusions of any link does not imply endorsement by SNI of the site.  

Patient Safety Links and Articles


-Healthcare safety video produced by Quantros.

-The Institute for Safe Medication Practices (ISMP) offers a wide range of resources and information to help healthcare practitioners in a variety of healthcare settings prevent errors and ensure that medications are used safely. All of the ISMP tools listed below are free, downloadable, and easy to use.

-During 2001-2005, HCIF developed and implemented the Regional Medication Safety Program, a collaborative patient safety effort among 65 hospitals in the Philadelphia region. This program was designed to enhance the quality of care provided to patients through the systematic implementation of attainable medication safety goals under a cohesive program.

-The Partnership for Patient Care (PPC) is a collaboration with Independence Blue Cross which began in 2006 to accelerate the adoption of evidence-based clinical practices by pooling the resources, knowledge, and efforts of healthcare providers. This unique collaboration between payer and providers has been recognized as a national model.

-The Institute for Healthcare Improvement has partnered with JAMA to facilitate the transition of science into practice through the series Author in the Room®. In this series, the author of a study published in JAMA with the potential to change clinical practice will talk with clinicians during a conference call, facilitated by clinical experts in implementing changes in practice

-Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.
The commonly used expression "missing the forest for the trees" is a shorthand summary of the concept of situational awareness—the degree to which a clinician's perception matches reality. Situational awareness requires that clinicians can perceive the information they need, comprehend the importance of this information, and forecast the implications of this information (i.e., adverse consequences that might happen). Nurses' role in patient safety is largely dependent on maintaining situational awareness, and this study used direct observation of intensive care unit (ICU) nurses in three hospitals to assess the degree to which monitoring devices and other information displays supported each phase of situational awareness. The authors found that the design of bedside information displays often impaired nurses' ability to gather critical patient data, particularly around medications, resulting in the potential to harm situational awareness. The authors make recommendations, based on human factors engineering principles, to improve the quality of information displays in the ICU


-FierceHealthcare reports about recent patient privacy breaches at hospitals across the nation.

-HealthLeaders Media reports that hospitals that have been given incentives to collaborate with one another can significantly reduce surgical complications, according to a recent study.

-Reuters reports that new research indicates doctors tend to prescribe drugs that pharmaceutical companies promote to them and patients end up paying more, but not always getting the most suitable medicines.

-Modern Healthcare reports that a collaborative effort between The Joint Commission and select hospitals and health systems has resulted in improved patient handoffs and better communication among providers.

-Healthcare IT News reports that patients at five-star rated hospitals had a 72 percent lower risk of dying when compared with patients at one-star-rated hospitals, according to a new study by HealthGrades.

-The Bloomberg News reports that patients with advanced incurable cancer still are routinely tested for additional types of malignancies, causing anxiety and with no benefit for most.

-Modern Healthcare reports about a newly-published white paper that offers a four-pillar framework intended to move health care toward the elimination of health care-associated infections.

-A New York Times physician columnist discusses the importance of the “lost art” of a physical exam.

-NPR reports about a computerized tracking system that can virtually eliminate the problem of lost sponges during surgery.

-HealthLeaders Media reports about the success of bar code scanning in reducing patient medication errors.

-HealthLeaders Media reports about newly-issued guidelines from the Institute for Healthcare Improvement about managing serious clinical adverse events.

-Becker’s ASC Review reports about how basic hand hygiene can help your staff fight health care-acquired infections.

-HealthLeaders Media reports that Geisinger Health System researchers have concluded that organizing multi-discipline teams of providers to deliver timely, coordinated, and personalized care in a hospital could save thousands of lives a year.

-Healthcare Finance News reports that a newly-released report from the American Hospital Association elaborates about how hospitals can support patient-centered medical homes. 

-The Fiscal Times reports that systematic telephone outreach by trained nurses to patients at high risk of serious health problems engages patients and “almost immediately” lowers health care costs.

-The Associated Press reports that hospital care has improved considerably, especially for the treatment of pneumonia, children’s asthma, and heart attack, according to the newly-released Joint Commission report.

-HealthLeaders Media reports about a recently-published commentary that discusses the “disastrous cascade” that can result when patients are assigned to the wrong level of care, and the subsequent use of rapid response teams.

-The Associated Press reports that quality of care is up at the nation’s hospitals, according to a newly-released report from The Joint Commission.

-The Nursing Spectrum reports that reminder systems that help hospital staff to remember to remove catheters reduce the rate of catheter-associated urinary tract infections by 52 percent.


Medpage Today and the New York Times report about a newly-released report card from the publisher of Consumer Reports, for coronary artery bypass graft outcomes for about 20 percent of the nation’s hospitals.

In a related article, a New England Journal of Medicine Perspective columnist refers to the voluntary release of ratings as “a watershed event in health care accountability.”

The Public Opinion reports that patient care is improving at area hospitals, according to the newly-released analysis from the Pennsylvania Health Care Quality Alliance.

WHYY reports about Lankenau Hospital’s new CT scanner that exposes patients to only about half of the radiation compared to older scanners. 

The Boston Globe highlights a newly-released study that evidences the differences between what doctors say and what patients hear.

The New York Times reports about efforts in some hospitals to go beyond hiring interpreters and translating paperwork, to adopting practices intended to improve care for a diverse patient population.

HealthLeaders Media reports about five new technologies that make surgery safer.

WPXI reports about a patient who had a severe allergic reaction after a local pharmacy filled her prescription with a similarly named drug, instead of the one prescribed.

The Erie Times-News reports about how local hospitals are listed in the state’s recently-released urinary-tract infection report.

The Centre Daily Times offers tips to consumers from Mount Nittany Medical Center to help determine if a visit to the hospital is the best thing for the patient they’re visiting, and for other hospital patients.

The New York Times reports that efforts to stop deadly mix-ups of interchangeable medical tubes face resistance and obstacles at the Food and Drug Administration.

Medical News Today reports about new research that points to unequal health care as the cause of higher death rates from colorectal cancer among African Americans.

USA Today reports to consumers about what every patient should ask, and tell, their doctor.

Healthcare Finance News reports that a recently-released study has found that church-owned health systems demonstrate significantly better, more efficient care than for-profit health systems.

Reuters reports that the information leaflets pharmacies give to customers with their prescriptions vary widely in content, and may often be difficult for people to read and understand, according to a new study.

The Pittsburgh Business Times reports, “Excela Westmoreland Hospital has targeted central line infections in the intensive care unit as part of a national patient safety project funded by the Agency for Healthcare Research and Quality.” HAP cited.

Healthcare Finance News reports that hospitals differ in their MRSA detection and treatment policies, but most follow national recommendations, according to a new study.

The Nursing Spectrum reports that, according to a new study, hospital-acquired infections are the leading cause of preventable mortality among pediatric patients.

Healthcare IT News reports that the Department of Health and Human Services has withdrawn its final breach notification rule for unsecured protected health information and intends to publish a new final rule during the coming months.

A Wall Street Journal columnist discusses the cost-effectiveness of the two most common screening methods for colon cancer.

The Pittsburgh Post-Gazette reports about a study done by Allegheny General Hospital emergency staff of patients transported via medical helicopter, which showed that the percentage of patients with MRSA from another health care facility was the same as those coming from non-health care sites.

The Bucks Local News reports about St. Mary Medical Center’s partnership with Gilda’s Club Delaware Valley to provide a holistic approach to patient-centered cancer care.

The Technology Review reports about a Cambridge, Massachusetts-based start-up that’s developing a way to diagnosis infectious disease by reading the DNA sequence of pathogens, often within a day.

The Washington Post reports about breastfeeding mix-ups that sometimes occur in hospitals.

The Wall Street Journal reports that insured Americans are using fewer medical services as they begin to pick up a greater share of the costs.

WPVI-TV reports that the personal information for about 21,000 patients from a local hospital was stolen after an employee broke company protocol and downloaded the information to his laptop.

U.S. News & World Report reports that several hospitals across the country are pioneering the concept of accountable care organizations.

Healthcare Finance News reports that the Agency for Healthcare Research and Quality has released its annual health care state-by-state quality report.

Medical News Today reports about newly-released findings from a Commonwealth Fund study identifying barriers that are preventing national health care from moving toward more integrated and accountable delivery models.

HealthLeaders Media highlights the proposed rule that modifies the current HIPAA privacy, security, and enforcement rules.

The Pittsburgh Post-Gazette reports about a local film created to help encourage more diverse participation in medical trials.

The Associated Press reports that the Pennsylvania Patient Safety Authority has issued a new report outlining incidents of disruptive behavior by health care workers in Pennsylvania hospitals.

The Patriot-News reports about the risks of radiation from CT scans, x-rays, and other common diagnostic tests.

The Washington Post reports that new survey results indicate deadly, “yet easily preventable,” bloodstream infections continue to plague American hospitals because administrators fail to commit resources and attention to the problem.

HealthLeaders Media reports about a new analysis of malpractice data that may offer valuable insight into future hospital patient safety initiatives.

The New York Times reports that thousands of patients need surgery to fix failed artificial knees and hips, but additional operations can be avoided by adhering to several simple procedures.

Reuters reports about the continuing debate about how best to reduce the amount of radiation American patients receive from medical testing.

The Associated Press reports that a new federal study finds many same-day surgery centers have serious problems with infection control.

The Pittsburgh Tribune-Review reports that central-line bloodstream infections declined 18 percent in western Pennsylvania, and is below the national average, according to a newly-released report from the Centers for Disease Control and Prevention.

A New York Times physician columnist elaborates about why preventable serious adverse events aren’t always preventable.

Code of Ethics for Nurses

WHO Guidelines on Hand Hygiene in Health Care

National Patient Safety Goals on Labeling Medications and Multidrug-Resistant Organisms 

HealthLeaders Media reports that a new study indicates patients admitted to a hospital during a weekend are half as likely to get same-day procedures they need than if admitted during a weekday. 

Health Day News reports about a study that indicates approximately 25 percent of all MRI and CT scans are inappropriately recommended by doctors.

Modern Healthcare reports that pneumonia and sepsis caused by hospital-acquired infections killed 48,000 people and increased health care costs by $8.1 billion during 2006, according to a newly-published study.

In a related article, a Wall Street Journal columnist also reports about the story.

HealthLeaders Media reports about ways to improve handoffs at your hospital.

WPVI-TV reports about how some Philadelphia hospitals fared in the newest hospital data available from Consumer Reports. 

USA Today reports that top surgeon Atul Gawande is urging medical teams nationwide to use a “safe surgery checklist” to avoid preventable errors.

The Joint Commission’s fourth annual report (pdf) about hospital quality and patient safety was released earlier this week. The report, using data from 2009, focuses on 31 performance measures for heart attack, heart failure, pneumonia, surgery, and children’s asthma by accredited hospitals. The data indicates that more than 95 percent of the accredited organizations have achieved in excess of 90 percent performance on some measures.

The Philadelphia Inquirer reports about data from the Pennsylvania Department of Health about potentially deadly bloodstream infections reported by Pennsylvania’s hospitals.

The Portland Business Journal prints the national press release distributed by the Department of Health.

HealthLeaders Media reports seven tips to comply with new HIPAA security rules effective February 17.

The Associated Press reports that health officials are trying to rekindle interest in protection against this new influenza strain that, despite plummeting cases, still is threatening lives, even as they reassess just how much more vaccine needs to be shipped.


A Pittsburgh Post-Gazette opinion written by the CEO of the Pittsburgh Regional Health Initiative elaborates about why we need a federal safety agency for patients.

HealthDay News reports that family doctors now are taking more time consulting with adult patients, seeing them more often, and improving the quality of visits, a new study suggests.

The Daily American reports about proper hand washing and other good habits intended to eliminate bacteria. Somerset Hospital cited.

The Pittsburgh Tribune-Review reports that Jefferson Regional Medical Center’s efforts to switch to electronic medical records have some doctors concerned about patient safety.

The Reporter elaborates about several initiatives at Doylestown Hospital that impact patient safety and the environment, and the hospital’s recent receipt of a Trailblazer Award from the EPA.

A Tribune-Democrat editorial discusses the Pennsylvania Health Care Cost Containment Council’s recent report, adding that the community is “comfortable with what we see from local hospitals.”

The Tribune Democrat reports that local hospital administrators say the Pennsylvania Health Care Cost Containment Council reports provide inspiration and direction to do better.

Healthcare IT News reports that a new Rand study is one of the first to link the use of electronic health records in community-based medical practices with higher quality of care.

A Washington Post physician columnist elaborates about his own experience as a patient “being caught in a web of excessive and unnecessary medical testing.”

WPXI reports about an internal investigation into improper sterilization procedures recently discovered at a local hospital.

HealthLeaders Media reports that, in an effort to increase focus on patient-centered care, some hospitals are creating patient advisory boards or committees.

The New York Times reports about the advantages of patient advocates, who can help research treatment options, sort out insurance claims, and open doors to specialists.

A New York Times columnist advises that the Joint Commission plans to unveil a pilot project aimed hand-washing at prominent hospital systems throughout the country.

The Wall Street Journal reports that different ways of analyzing the outcomes of medical clinical trials can lead to sharply divergent results.

The Wall Street Journal reports about hospital “rapid response” programs that empower patient families.

A Wall Street Journal columnist reports about a newly-created company, CareFusion, which will focus on resolving “the top two challenges which hospitals around the world face.”

ModernHealthcare reports that Aetna is strengthening its focus on patient safety with new online information and tighter payment policies for hospital errors.

The New York Times elaborates about a diabetes case as an example of how setting guidelines that are good for every patient “can get messy.”

The Daily Local News offers consumer advice about how to make your hospital stay a safe one.

Healthcare Finance News reports about a new team approach model for preventive health care for older adults that can improve health and quality of life, decrease emergency department visits, and lower hospital admission rates.

Hearst Newspapers reports that experts estimate a staggering 98,000 people die from preventable medical errors each year.

A Philadelphia Inquirer op-ed states that in-hospital falls are serious business these days.

A Patriot-News opinion stresses that “rural” shouldn’t mean less when it comes to health care.

The New York Times reports that the American Medical Association is studying a proposal that doctors hang up their lab coats for good because of the germs they accumulate.

The Philadelphia Inquirer reports about the healing power of patient gardens.

The Patriot-News reports about the “patient-centered care” provided at the newly-opened Penn State Hershey Cancer Institute. .

Healthcare IT News reports that Bridges to Excellence has launched five new reward programs for physicians to assess improvements in the diagnosis, treatment, and management of chronic conditions.

The American Medical News reports about hospitals being forced to cut back on infection control programs.

A Wall Street Journal columnist advises hospitals are losing the resources they need to enhance their continuing infection control efforts.

World now at the start of 2009 influenza pandemic- The World Health Organization today raised its alert level for the 2009 H1N1 flu, indicating that the virus has spread as anticipated to become a pandemic. “Today’s decision by the WHO was expected and doesn’t change what we have been doing here in the United States to prepare for and respond to this public health challenge,” said Health and Human Services Secretary Kathleen Sebelius. “…What this declaration does do is remind the world that flu viruses like H1N1 need to be taken seriously. Although we have not seen large numbers of severe cases in this country so far, things could possibly be very different in the fall, especially if things change in the Southern Hemisphere, and we need to start preparing now in order to be ready for a possible H1N1 immunization campaign starting in late September.” Nearly 30,000 cases of the novel flu virus have been confirmed in 74 countries, including more than 13,200 cases and 27 deaths in the U.S.

WHYY reports that nursing homes in eastern Pennsylvania must now report the secondary infections that patients acquire when they’re treated for other conditions.

HealthLeaders Media reports that the health care industry has made a concerted effort to focus more on patient safety, according to newly-released study results.

HealthLeaders Media reports that the Joint Commission has revised its National Patient Safety Goals

U.S. health officials troubled by new flu pattern- The new influenza strain circulating around most of the United States is putting a worrying number of young adults and children into the hospital and hitting more schools than usual, U.S. health officials said on Monday. The H1N1 swine flu virus killed a vice principal at a New York City school over the weekend and has spread to 48 states. While it appears to be mild, it is affecting a disproportionate number of children, teenagers and young adults.


Recommendations for Implementing Prevention and Monitoring Strategies Recommendations for preventing and monitoring Clostridium difficile infection (CDI) are summarized below. They are designed to assist acute care hospitals in prioritizing and implementing their CDI prevention efforts. Each recommendation includes a ranking for the strength and the quality of evidence supporting it.
Definitions of the levels of evidence (I-III) and grades of recommendation (A-E) are provided at the end of the "Major Recommendations" field. Definition A CDI case is defined as a case of diarrhea or toxic megacolon without other known etiology that meets 1 or more of the following criteria: (1) the stool sample yields a positive result of a laboratory assay for C. difficile toxin A and/or B, or a toxin-producing C. difficile organism is detected in the stool sample by culture or other means; (2) pseudomembranous colitis is seen on endoscopic examination or surgery; and (3) pseudomembranous colitis is seen on histopathological examination.


The Centers for Disease Control and Prevention last night issued updated guidance to help clinicians identify and care for patients with H1N1 flu. The agency recommends testing and antiviral treatment be prioritized for people with severe respiratory illness and at highest risk of complications from seasonal flu. This includes children under age 5, pregnant women, people with chronic medical conditions and weakened immune systems, and people age 65 and older. At least 403 cases of H1N1 flu virus have been reported in 38 states, including 35 patients who have been hospitalized. Americans who develop flu-like symptoms should see a health care provider if they have severe illness or are at high-risk for flu complications, according to the latest CDC guidance for the public.

Reuters reports that mobile phones used by hospital workers may be a source of hospital-acquired infections.

The New York Times reports that pharmacies around the country offering no-charge antibiotics are sending the wrong message to consumers, and could worsen the problem of drug resistance.

Modern Medicine reports that most medication errors in primary care are prescribing errors, and pharmacists are the most likely to intercept the mistakes.

AHA is Accepting Applications for the 2009-2010 Patient Safety Leadership Fellowship. Space is available for the 2009-2010 Patient Safety Leadership Fellowship, co-sponsored by AHA and the National Patient Safety Foundation. The Fellowship program is a year long learning experience focused on improving organizational approach on patient safety. Fellows gain new skills, tools, and leadership capacity to engage staff, senior leaders and clinicians in creating cultures of safety and providing highly reliable care. Visit or call (312) 422-2933 for more details.

The Philadelphia Inquirer reports that cancer centers, long focused on simply keeping patients alive, are now enhancing services to help patients watch for new cancers and manage treatment-related symptoms.

A New York Times columnist states, “To get diagnoses and treatment plans right, we need doctors who know us over time, and who have the time to know us.”

The American Organization of Nurse Executives (AONE) announced the recipients of its 2009 distinguished leadership awards, which will be presented during the organization’s annual meeting in April. Ann Van Slyck, RN, a pioneer in variable billing for nursing services based on patient acuity, will receive the Lifetime Achievement Award. Donna Sullivan Havens, RN, a professor in the school of nursing at the University of North Carolina at Chapel Hill, will receive the Nurse Researcher Award. Lucian Leape, M.D., a renowned patient safety leader and adjunct professor of health policy at the Harvard School of Public Health, will receive the Honorary Member Award. For more on the awards, visit AONE is an AHA subsidiary.

Modern Healthcare reports that investor-owned hospitals lagged a bit behind the national hospital average on the second set of Hospital Compare quality data that was recently released.

The Wall Street Journal reports that recent outbreaks of hepatitis have encouraged efforts to improve unsafe injection practices in doctors’ offices, outpatient clinics, and long-term care facilities. Unsafe injection practices are one of the leading causes of infections in doctors' offices, outpatient clinics and long-term-care facilities, according to the Centers for Disease Control and Prevention. Although most health-care workers are aware of the dangers of reusing needles, other injection guidelines aren't always followed, including disposing of syringes after each use. Contaminated shots can lead to transmission of such diseases as hepatitis and HIV, along with other viral and bacterial infections. Read more.

A Seattle Times guest columnist comments about how to reduce multi-drug-resistant hospital-associated infections, adding that “…recommended infection control practices do not make a difference unless they are followed.”

WITF reports, in print and audio, about the decrease in hospital-acquired infections in Pennsylvania, according to the newly-released Pennsylvania Health Care Cost Containment Council report. In a related article, the Central Penn Business Journal also reports about the decrease.

The following news sources report about PHC4’s report, citing local hospitals: the Patriot-News, the Valley Independent, WFMZ-TV (in print and video), and WHYY Radio (in print and audio).

A Philadelphia Inquirer editorial gives credit to Pennsylvania’s hospital executives and medical staffs for “taking to heart” the need to cut infections.

The Associated Press reports about “software glitches” that caused patients at Veterans Affairs health centers nationwide to receive incorrect doses of drugs, delayed treatments, and may have exposed them to other medical errors.

The Philadelphia Business Journal reports about the convenience and growth of retail clinics, despite the medical community’s concerns about the quality of care being provided. The Philadelphia region has about two dozen convenient-care clinics, operated by industry leaders MinuteClinic, which is owned by CVS Corp., or Conshohocken-based Take Care Health Systems, which is owned by Walgreens and just opened its first Philadelphia-area health centers last month. Physician organizations including the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics raised concerns about the spread of such health-care providers in a study by the Rand Corp. Read more.

The New York Times examines whether or not informed consent for cancer treatment should include a discussion with the patient about hospital outcome disparities.

MSNBC reports that Holy Spirit Hospital and UPMC Presbyterian Shadyside are among four hospitals recognized for reducing medical errors and improving patient outcomes in the nation’s first patient safety contest.

A Wall Street Journal opinion warns of “the bacteria that could kill you” on hospital scrubs.



USA Today reports about the federal government’s new nursing home performance ratings, noting that for-profit homes seem more likely to provide inferior care than their non-profit rivals.

In a related article, the Associated Press reports that nursing homes are concerned about the new rating system, and questioning its validity.

A U.S. News & World Report columnist discusses on a new online hospital rating site,, commenting, “It's great -- if you want to compare hospitals in umpteen ways that have limited value.”

The Wall Street Journal reports about wide variations in the drug safety information provided to consumers when prescriptions are filled.

The New York Times reports about how hard it can be for states to close or “shrink” hospitals, even when there is evidence they are providing costly and below-average care.

The Wall Street Journal examines the overwhelming “flood of safety information” consumers are receiving about their medications, warning they may forget the benefits if they focus only on the risks.

"After a series of prescription-medication scares in recent years, consumers are receiving a flood of safety information about the drugs they take -- so much that it risks scaring some people.
Too much information about drug safety -- disseminated through media, online alerts from consumer watchdog groups and even by the Food and Drug Administration itself -- might overwhelm patients and raise undue alarm, some medical professionals caution. Consumers may forget about the benefits of a medication if they focus only on risk. And the health consequences associated with stopping a medication, particularly for a chronic condition, may be far worse than the possibility of a side effect." Read More

Some Advice On Hospitals That Just Might Save Your Life Or Someone Else's. A Bulletin columnist discusses medical mistakes, and offers advice about “…what to ask and what to insist on while staying in a hospital.

State Associations Offered Opportunities to Work with Hospitals on National Projects

Central Line-Associated Bloodstream Infections—The Agency for Healthcare Research and Quality (AHRQ) has provided a grant to the AHA’s Health Research and Trust that would support ten hospitals in ten states to work with the Centers for Disease Control and Prevention, Johns Hopkins Quality and Safety Research Center, and the Michigan Health & Hospital Association Keystone Center to replicate the work that was done in Michigan hospitals’ intensive care units to reduce the occurrence of central line-associated bloodstream infections. Almost simultaneously, Hopkins received two philanthropic gifts that would allow for more states to participate in the project. The project requires the implementation of the Johns Hopkins Comprehensive Unit Based Safety Program (CUSP) to improve teamwork about physicians and nurses, and to implement interventions to reduce central line-associated bloodstream infections. Given the work that already has been done throughout Pennsylvania to reduce central line-associated bloodstream infections through a variety of initiatives, HAP is interested in learning whether there are at least ten hospitals that would want to participate in this project. The project does have broader implications as it relates to fostering teamwork and collaboration to address patient safety in intensive care units. Please contact HAP’s Lynn Leighton at (717) 561-5308 by November 30 to indicate preliminary interest in having one or more of your hospital’s intensive care units participate in the project.

Preventing Re-Hospitalization/Readmission—The Commonwealth Fund has provided a grant to the Institute for Healthcare Improvement (IHI) to work with at least eight states to develop a project aimed at reducing preventable re-hospitalizations. Through the 9th Scope of Work, Quality Insights of Pennsylvania has initiated a project aimed at reducing re-hospitalization in Westmoreland County. The design of the project in Pennsylvania would be lead by Steve Jenckes, a consultant working on this project with IHI. HAP is seeking to understand what level of interest might exist among Pennsylvania hospitals with working on such a statewide project. Please contact HAP’s Lynn Leighton at (717) 561-5308 by November 30 to indicate preliminary interest in designing and participating in the re-hospitalization project.

The Bucks County Courier Times reports that most Bucks and eastern Montgomery County hospitals and surgical centers use colored wristbands for patients with conditions such as allergies. But the color schemes and their corresponding medical messages often vary depending on the hospital, which can pose a potential safety risk, medical experts say. This situation will change soon, as they will adopt the standardized patient wristband color coding system that other hospitals are adopting statewide. Read more.

AHRQ issues final rule for patient safety organizations

The Agency for Healthcare Research and Quality issued a final rule outlining the requirements for becoming a Patient Safety Organization and how the agency will enforce confidentiality protections. Though the AHRQ finalized much of the proposed rule, it made changes to certain provisions and added new requirements, including broadening the list of excluded entities and increasing flexibility in how PSOs can store patient safety work product and how component PSOs maintain separation between themselves and their parent organizations. “Hospitals have eagerly awaited this opportunity to share information with each other in a reliable way so that they can learn what factors underlie patient safety events and look for ways to make care safer,” said Nancy Foster, AHA vice president for patient safety policy. PSOs voluntarily collect, aggregate and analyze patient safety data from providers to improve health care quality. The rule takes effect Jan. 19, 2009.

The Seattle Times reports about how hospitals “unleased a MRSA epidemic,” and hospitals’ “resistance” to detection programs. UPMC Shadyside Hospital cited. In a related article, the Seattle Times reports that, “A growing number of consumer advocates...have vowed that if the U.S. hospital system will not heal itself, they will do it.”

The Wall Street Journal reports that an FDA advisory panel will consider three proposed antibiotics designed to treat serious skin infections, including some caused by MRSA.

Workers Get Health Care at the Office As Costs Rise, Some Employers Focus on Preventive Services; Relying on the On-Site Clinic

Even as employers push a greater share of rising medical costs on to workers, a growing number of companies also are providing services like free check-ups, screening exams and prescription drugs that potentially can save employees hundreds of dollars a year. Companies say the programs also will save them money in the long run. Although a few employers have long offered on-site clinics, the trend is gathering steam as more companies expect to reduce their overall health-care spending by focusing more attention on preventing illness, including complications from such conditions as hypertension and diabetes. Companies also expect employees will be more productive if they don't have to leave the workplace to seek medical treatment. Read more in the article by M.P. MCQUEEN.

New Antibiotics Take Aim at Staph's Rise (Nov 17 2008)

A Food and Drug Administration advisory panel this week will consider three proposed antibiotics designed to treat serious skin infections, including some caused by a type of staph bacterium resistant to many antibiotics. The bacterium -- methicillin-resistant staph aureus, or MRSA -- has sparked concern as the super bug has moved into community settings like schools and locker rooms in recent years after once being largely confined to hospital settings. But it's not clear if any of the three drugs will reach the bar for FDA approval because of safety concerns or questions about how well the drugs work compared with other available medications. On Wednesday the panel is expected to vote on Theravance Inc.'s telavancin and Targanta Therapeutics Corp.'s oritavancin before considering iclaprim by Swiss biotech company Arpida Ltd. Thursday. Read more in the article By JENNIFER CORBETT DOOREN.

HealthDay News reports that chronically ill patients in the United States spend more out-of-pocket money, skip needed care, and report more medical errors than patients in seven other industrialized countries. Patients in the United States are also more likely to report poorly coordinated care that puts them at risk and wastes their time, Schoen said. And they're significantly more likely to report prescription and diagnostic test errors. Read more.

U.S. trails other nations in chronic illness care.

Washington (Reuters) - Chronically ill Americans are more likely to forgo medical care because of high costs or experience medical errors than patients in other affluent countries, according to a study released on Thursday.

The researchers questioned 7,500 adults in Australia, Canada, France, Germany, Netherlands, New Zealand, Britain and the United States. Each had at least one of seven chronic conditions: high blood pressure, heart disease, lung disease, diabetes, cancer, arthritis and depression. Read more in article by Will Dunham.

The Washington Post reports that people who get flu shots may also benefit from a reduction in their risk of developing a blood clot. The benefit appeared stronger in those under the age of 52, according to research that was presented Sunday at the American Heart Association's annual scientific sessions, in New Orleans. The findings, the first to demonstrate such an effect, may help explain why the flu shot lessens the risk of cardiovascular events in people with coronary artery disease, but the real current value of the data may lie in it convincing more people to get their annual shot. Read more.

Healthcare IT News reports that the Leapfrog Group soon will launch its new hospital incentives and reward program, touted as more comprehensive and easier to use for both hospitals and payers.

WA voters allow terminal patients to self-administer lethal drugs

Washington state voters Tuesday approved a measure permitting terminally ill adults to request and self-administer lethal medications prescribed by a physician. Under the measure, approved by 59% of voters, a physician with primary responsibility for the patient’s care must determine that the patient has an incurable disease expected to cause death within six months, that the request is voluntary, and that the patient is competent and making an informed decision. A second physician would have to confirm the determination. The measure does not require a health care provider or facility to provide a prescription for lethal medication. Washington State Hospital Association President Leo Greenawalt said, "Hospitals in Washington State are working together to improve end-of-life care and access to palliative care. The passage of Initiative 1000 makes this work even more important. We are also renewing our efforts to get Washingtonians to discuss their end-of-life wishes with their families, and put their wishes in writing."

MI voters approve marijuana use for medicinal purposes

Voters in Michigan Tuesday approved an initiative permitting the use and cultivation of marijuana for medical conditions. Under the ballot measure, residents with certain debilitating medical conditions, such as cancer, AIDS and Alzheimer’s disease, will be able to register with the state Department of Community Health to obtain a specified amount of marijuana from a physician or grow marijuana plants for medicinal use. Michigan joins a dozen other states that permit the medical use and cultivation of marijuana. A spokesperson for the Michigan Health & Hospital Association said, “While immediate next steps are still being determined, it is likely we will be working with our member hospitals, physicians and the appropriate state agencies to address certain concerns about the language of this proposal as passed.”

IHI and JAMA Announce Author and Article for November 19th: Call Rita Redberg, MD, MSc, author of "Frequency of Stress Testing to Document Ischemia Prior to Elective PCI"

(IHI) and the Journal of the American Medical Association (JAMA) Wednesday, November 19, 2008, from 2:00 - 3:00 PM Eastern Time for “Author in the Room,” an interactive conference call aimed at closing the gap between knowledge – what is published in an article - and action – how much of this knowledge is put into practice to improve care. The call will help readers consider the implications of the study results for improving their practice. To read more and access the article, please visit: IHI website.

Registration: There is no fee for this innovative initiative but enrollment is required. Enrollment grants you one telephone connection and unlimited participation at your site. Please note there are limited lines available for this call so early enrollment is encouraged. A free audio recording of the call will be posted to the "Archive" tab of the program web pages after the call. To enroll for the November 19, 2008, "Author in the Room" call, please visit: IHI website.

The Central Penn Business Journal reports about hospitals’ efforts to make patient experiences as pleasant as possible.

Outcome-Driven Patient Safety Projects Recognized

Four hospitals that achieved outstanding, quantifiable patient safety improvements were recognized at this week’s (10/26/08) 2008 Annual Meeting of the Delaware Valley Healthcare Council of HAP. Finalist Crozer-Chester Medical Center reduced by nearly half the “door-to-balloon time” between arrival and angioplasty for emergency heart attack patients. Finalist Mercy Catholic Medical Center reduced by 83 percent the rate of deep vein thrombosis not present on admission. Finalist Springfield Hospital exceeded 95 percent composite compliance on eight evidence-based medicine initiatives. The 2008 Award Recipient, Albert Einstein Healthcare Network, applied the concept of bundles to the medication delivery cycle. The initiative reduced medication order entry errors by nearly 40 percent. Dispensing and high-alert medication errors dropped by more than 60 percent. To recognize this achievement, The Health Care Improvement Foundation awarded Einstein a grant of $5,000 to help support future efforts to improve patient safety.

HealthDay News reports that, regardless of declines in either mental or physical health, most senior citizens don’t change their outlook on their end-of-life care when the time comes.

USA Today reports that a majority of patients are satisfied with the care they receive during a hospital stay, but many report being unsatisfied with communication and pain control.

Hospitals Seek to Limit Use of Transfusions. New Efforts to Recycle Blood and Treat Anemia Are Aimed at Cutting Costs and Risks.

Amid rising blood costs and mounting safety concerns about transfusions, hospitals are adopting stricter measures to manage their blood supplies.
A growing number of hospitals are developing guidelines for when transfusions are necessary, and they are making sure doctors are in compliance. Institutions also are increasingly checking patients for anemia before surgery and treating them with iron or red-blood-cell-boosting drugs to cut down on transfusions in the operating room.

Patients are feeling the impact. Some hospitals are eliminating the practice of having patients donate their own blood weeks before surgery, which can trigger anemia. Instead, they are recycling patients' own blood by collecting it in the operating room for immediate re-infusion during or after surgery. And in intensive-care units, nurses are sharply reducing the amount of blood they draw daily from patients for testing, which can make patients so anemic they require a transfusion. Read more.

A New York Times’ blog advises that, “A simple Sharpie pen is emerging as an effective tool to prevent surgical errors and infections.

Surgeons typically use marking pens to ensure they operate on the correct part of a patient’s body. But one concern is that the germs from the pen could pose a risk for infection. As a result, many hospitals use sterile pens once and throw them away, a practice that costs thousands of dollars a year.

Infection control experts from the University of Alberta decided to study pens used to mark up surgical patients. They compared a one-use sterile surgical pen to a standard Sharpie — the brand name for a line of no-smudge permanent markers favored by everyone from autograph-writing football stars to President Bush.

In a controlled experiment, the tips of both kinds of pens were heavily contaminated with four types of bacteria that can cause surgical site infections, including two germ types that are resistant to antibiotics. The researchers recapped the markers and allowed them to sit for 24 hours. Read more.

How Doctors Can Avoid Perilous Patient ‘Hand Offs’

As the medical community debates the merits of the 80-hour limit on residents’ work weeks, one challenge that’s drawn attention is the patient “hand off.” Because residents work shorter hours, patients are more frequently transferred from one doctor who’s leaving a shift to another who’s starting, creating opportunities for miscommunication. So physicians at Johns Hopkins Hospital have developed a list of good surgical sign-out practices, published in the current issue of the Archives of Surgery. Read more of this post by Sarah Rubenstein.

One Big Antibiotic Dose Fights MRSA, Study Says

Powerful antibiotic drugs are normally injected once a day -- a problem for patients who contract infections in hospital wards and are sent home. Many don't finish their treatment. But a new study found that an experimental antibiotic may work just as well when given in one gigantic dose, marking progress in the treatment of drug-resistant infections, including an often-fatal bacteria known as MRSA. The research was conducted by Targanta Therapeutics Corp., a Cambridge, Mass., company that has applied to sell the antibiotic, oritavancin, in the U.S. "So many of the patients we treat are noncompliant with medication," said Lala Dunbar, a doctor at the Medical Center of Louisiana in New Orleans, who participated in the study and has advised Targanta. A full dose of antibiotic is meant to destroy infections. But taking only part of a dose -- which happens in patients, often poor or elderly, who stop taking medication partway through -- can end up breeding drug-resistant strains of bacteria inside the body. One such infection, known as methicillin-resistant Staphylococcus aureus, or MRSA, has caused much concern. About 94,000 people caught serious cases of MRSA and 19,000 died from it in 2005, according to latest estimates from the Centers for Disease Control and Prevention. Read more of WSJ article by Keith J. Winstein.

What Zero Looks Like: Eliminating Hospital-Acquired Infections

As much as public awareness of the problem has grown, most patients might still be surprised to learn that infections contracted during a hospital stay are a significant cause of death in the US. Medical professionals already know this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection. Read more in article posted on Institute for Healthcare Improvement.

5 Million Lives Campaign Invites You to National Network Day

Welcome to the 5 Million Lives Campaign, the next wave of an ever-growing mobilization to transform US health care, led by the Institute for Healthcare Improvement (IHI) and many committed partners and hospitals. If you’ve been enrolled in the 100,000 Lives Campaign, you’ll find some of the information in these Frequently Asked Questions (FAQs) familiar. However, we invite you to become acquainted with the new aims and additional interventions of the 5 Million Lives Campaign. Read more.

HealthDay News reports that the death rate at top-ranked U.S. hospitals is 70 percent lower than at the lowest-ranked hospitals, evidence of wide variations in the quality of patient care.

Legislative Updates

Prohibition of Excessive OvertimeHouse Bill 834 was approved by the House and the Senate, and the Governor is expected to sign the bill. Sponsored by Representative Dan Surra (D-Clearfield) the bill states that a health care facility (including hospitals and nursing homes) may not require certain employees to work in excess of an agreed to, predetermined, and regularly scheduled daily work shift. The bill includes a provision, sought by HAP, permitting the use of mandatory overtime in situations of “unexpected absences discovered at or before the commencement of a scheduled shift, which could not be prudently planned for by an employer, and which would significantly affect patient safety.” The effective date is July 1, 2009. HAP will provide hospitals and health systems with additional information on this new requirement.

Preventable Serious Adverse Events—The Senate did not vote on House Bill 2098, sponsored by Representative Tony DeLuca (D-Allegheny), which prohibits health care providers from billing for certain preventable events.

Child Death Review Program—Senate Bill 684, sponsored by Senator Lisa Baker (R-Luzerne), was approved by the House and Senate. The bill requires the Department of Health to establish the Public Health Child Death Review Program, which shall facilitate state and local multiagency, multidisciplinary teams to examine the circumstances surrounding deaths in the Commonwealth for the purpose of promoting safety and reducing child fatalities. The bill goes to the Governor for approval.


October 27—The Joint Commission 2009 Standards Update and National Patient Safety Goals (Harrisburg)


The New York Times reports that, toward improving infection control in hospitals, the nation’s top epidemiological societies issued guidelines to help lower infection rates.

PA bill would end required overtime by health workers

A new bill working its way through the Pennsylvania legislature would ban the state's hospitals, ambulatory surgery centers and long-term-care providers from demanding nurses and other clinical workers to work overtime.
The bill, which has passed both chambers of the state's legislature, includes clinical workers who aren't considered supervisors in union contracts, and those who earn hourly wages and those who are temporary workers. On the other hand, it excludes doctors, physician assistants and dentists, as well as other jobs not directly related to care such as clerical and maintenance functions.
The rules aren't without exceptions, included to mollify the Hospital & Healthsystem Association of Pennsylvania. The measure includes language which allows healthcare employers to require overtime under certain specific circumstances, including unforeseeable declared emergencies, unforeseen or extraordinary events (read disasters, terrorism or the like) that impact their staffing needs or big vacancies that substantially affect patient safety. (The bill specifically notes that chronic short-staffing won't cut it as an excuse for mandating overtime.)

To learn more about this bill read this Modern Healthcare article (Registration required)


Bill barring mandatory overtime for nurses headed to Rendell

Legislation banning mandatory overtime for nurses in Pennsylvania is headed to Gov. Ed Rendell, who has indicated he will sign it into law, the bill’s sponsor said Wednesday.
House Majority Administrator Dan Surra’s measure would prohibit private and public health-care facilities from mandating that nurses and other direct patient-care workers work overtime except in specific emergencies or when unforeseen staffing shortages could compromise patient safety.
“If a nurse has been forced to work 12, 14, 16 hours in a row, that nurse should have the right to say ‘no more – I’m concerned about the quality of care I’m delivering to my patients and the quality of my life’ and the hospital must agree, barring a major emergency,” Surra, D-Elk, said. “This is just plain common sense. These men and women are monitoring patients, dispensing medicine and making literal life or death decisions – decisions that should not be clouded by lack of rest. I was proud to introduce this bill, and I’m proud to see it finally about to become law.”
The bill would allow nurses to voluntarily work overtime, but would prohibit hospitals from disciplining or firing nurses who refuse to work overtime, Surra said.
“In other states that have already taken action, the ban on mandatory overtime has not caused staffing emergencies or a health-care crisis,” Surra said. “In fact, more nurses are entering the profession, performing well, and are more confident about their ability to provide the best care possible for their patients.”

Source: Pittsburgh Business Journal (Subscription required)

HealthDay News reports that, in a new state ranking of palliative care, only Vermont, Montana, and, New Hampshire get an A, while Oklahoma, Alabama, and Mississippi get an F, with the rest somewhere in between.


Patient Safety Authority Issues Long-Term Care Infection Reporting Requirements; DOH Offers Mini-Grants

The Pennsylvania Patient Safety Authority (PSA) and Department of Health (DOH) published in the Pennsylvania Bulletin a final notice to nursing facilities on health care-associated infection reporting requirements under Act 52. The notice summarizes the comments that were received as a result of the initial notice published in May 2008. The notice contains information on the reporting system that will be used, as well as information on upcoming training opportunities. The notice also provides an updated list of reportable health care-associated infections (HAIs). Nursing facilities must begin mandatory reporting on April 1, 2009.
To support identification, reporting, and prevention of health care-associated infections in nursing homes, DOH is making available mini-grants of up to $1,000 per nursing care facility (pdf) to support accurate identification and reporting of health care-associated infections. Mini-grant awards are to support infection control and surveillance education (i.e., trainings, presentations, conference sessions, forums, workshops, etc.) and related materials and expenses. DOH’s 2008–2009 Nursing Home Mini-Grant Award Guidelines for Infection Control & Surveillance Training (pdf) are available online. To become a registered “non-procurement vendor” under this program, facilities must submit an IRS Form W-9 (pdf). Applications must be submitted to DOH no later than November 26. Additional information is available from DOH at (717) 425-5422.


GAO: 23 states require hospitals to publicly report on infections

Twenty-three states require hospitals to publicly report on health care-associated infections, including three that collect data on methicillin-resistant staph infections, according to a report released today by the Government Accountability Office. Most of the states focus on a few measures developed or endorsed by the Centers for Disease Control and Prevention, and use the CDC’s National Healthcare Safety Network to collect data. In comments to GAO included in the report, AHA expressed concern that the HAI data collected through NHSN does not provide a valid comparative assessment of hospital performance, noting that the data submitted are not validated and hospitals vary in how they collect it. In addition to states, GAO reviewed 14 diverse hospitals and health systems with MRSA reduction initiatives. All of them routinely tested for MRSA, but used varying testing methods, tested different patient populations, and needed varying levels of funding and staff to implement their initiatives.


Act 52 will mandate nursing facilities to report health care-associated infections (HAIs) to the Department of Health (DOH), as well as the Patient Safety Authority during 2009. On Friday, October 3, the Department of Health announced the availability of mini-grants to nursing facilities of up to $1,000 per nursing facility to support accurate identification and reporting of HAIs. The mini-grants are to support infection control and surveillance education (i.e., trainings, presentations, conferences, workshops, etc.) and related materials and expenses. Information about the mini-grants, including the guidelines, is available at the DOH message board and listed below:

Applications must be completed, mailed, and received by the HAI Prevention Section by November 26, 2008, to be eligible to receive an award. 

HealthDay News reports about recently-published recommendations stating newly-built hospitals should have all single rooms because they reduce infections and may reduce medication errors.

DOH and Patient Safety Authority Issue Final Notice about Infection Reporting

Contained in the September 20 Pennsylvania Bulletin, the Patient Safety Authority (PSA) and Department of Health (DOH) issued the final notice to nursing facilities about reporting requirements pertaining to health care-associated infections (Act 52). This final notice contains a summary of the comments that were received as a result of the initial notice that was published on May 31, 2008. The notice also contains information about the reporting system that will be used, as well as information about upcoming training opportunities during the near future. Special focus also should be given to the list of reportable health care-associated infections (HAIs), as the list has been revised. As a reminder, nursing facilities must begin mandatory reporting on April 1, 2009.

A Wall Street Journal opinion states a recent jury award of over $2.5 million from a medical malpractice lawsuit should send a warning to physicians, hospitals and hospital board members that medical errors are considered preventable.

Hospital Infections: Preventable and Unacceptable. On July 30, a jury awarded over $2.5 million to James Klotz and his wife Mary in a medical malpractice lawsuit against a heart surgeon, his group practice and St. Anthony's Medical Center in St. Louis, Mo. In 2004 Mr. Klotz, now 69, was rushed to the hospital with a heart attack and a pacemaker was surgically implanted. He developed a drug-resistant staph infection called methicillin-resistant Staphylococcus aureus (MRSA). It was so severe that he underwent 15 additional operations, spent 84 days in the hospital and lost his right leg, part of his left foot, a kidney and most of his hearing. Read the whole article by Betsy McCaughey.

The Health Care Improvement Foundation (HCIF) is an independent, not-for-profit corporation dedicated to building partnerships for better health care in Southeastern Pennsylvania. With a multi-dimensional focus on health care safety -– in patient care, environmental practices, and disaster preparedness -– HCIF brings together diverse organizations to achieve regional collaboration and improvement.

The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information.

The Joint Commission Sentinel Event Alert - Issue 35 - January 25, 2006

Cleveland’s Plain Dealer questions whether annual hospital rankings, like U.S. News & World Report’s best hospitals list, are beneficial to consumers.

Reuters reports that the U.S. fails on most measures of health care quality, with Americans waiting longer to see doctors and more likely to die of preventable or treatable illnesses than people in other industrialized countries.

The New York Times reports about a study that highlights the stark contrast between what the United States spends on its health system and the quality of care it delivers.

In a July 7 Advance for Nurses article, focus is made about how home health nurses are optimizing scheduling to deal with the rising fuel prices. The article, “Home Health Nursing at Any Cost,” addresses what home health nurses can do in terms of creative scheduling to optimize trips and mileage to care for their patients.

Results from a recent first annual survey of emergency medicine physicians show the current nursing shortage not only impacts nurses, but the physicians as well. The nursing shortage is impacting health care facilities across the nation. Emergency physicians are experiencing this additional stress, indicating the lack of competent nurses in emergency departments as being one of the leading causes of dissatisfaction. The national study, “Trends, Predictions, and Perceptions of Emergency Medicine Physicians,” was conducted during May, drew responses from 777 physicians, and was designed to solicit their perceptions of the state of emergency medicine.

The New York Times reports that advocates for nurses are lobbying for increased penalties for violent patients and urging that all incidents be reported.

Forbes reports that, while the next president would have likely targeted Medicare Advantage for cuts next year, the program may lose its most-favored health policy status even before the election.

The New York Times report that wireless systems used by many hospitals to keep track of medical equipment can cause potentially deadly breakdowns in lifesaving devices such as breathing and dialysis machines.

The San Francisco Chronicle examines how, each year, “thousands of Californians find themselves at odds with their health insurers over whether they, as patients, should get the treatment their doctors prescribed.”

The Wall Street Journal reports about the challenges to hospital medical-ethics teams, faced with an increasing number of life and death cases, complicated by life-prolonging technology, and legal liability.

The New York Times reports that the World Health Organization has issued its first guidelines aimed at reducing complications and deaths from operations.

HealthDay News reports that overcrowding and under-staffing can cause a breakdown in the control of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals.

Nursing Spectrum reports on Albert Einstein Healthcare Network’s award-winning SMASH program -- Stop MRSA Acquisition and Spread in our Hospitals.

Senate Finance Committee Chairman Max Baucus (D-MT) and Ranking Member Charles Grassley (R-IA) introduced companion legislation to H.R. 6252, a bill in the House that would delay and change the Medicare competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies. The Medicare DMEPOS Competitive Bidding Acquisition Reform Act would delay the program’s July 1 launch for 18 months, and require the Centers for Medicare & Medicaid Services to allow hospitals and other health care providers to supply certain DMEPOS items at the bid price without being required to become contractors.

In 2005, an estimated 22.2 million Americans had a current diagnosis of asthma with approximately 12.2 million of these individuals suffering at least one asthma attack in the previous year.1 Asthma, a chronic disease characterized by inflammation of the airways, restricts the passage of air into the lungs and leads to episodes of wheezing, coughing, chest tightness, and shortness of breath; severe asthma episodes can close off airways completely and may prevent vital organs from receiving oxygen.2 With proper outpatient care, the disease is largely controllable and hospitalization is preventable. However, differences in the prevalence of asthma and disparities in outpatient treatment result in rates of hospitalizations for asthma which vary by age, gender, race, and educational background, among other factors. Read more in this Report.

Healthcare IT News reports the Centers for Medicare & Medicaid Services has awarded nearly $25 million to hospitals nationwide in a pay-for-performance project that has resulted in a 15.8 percent boost in quality over three years.

The Pittsburgh Post-Gazette reports on national study results that reveal patients managed by critical care physicians were at greater risk of dying than patients managed by doctors who lacked that training.

The St. Louis Post-Dispatch reports that hospitalized children suffer too many infections and other preventable complications that extend their stays and cost millions, according to a study released by The Children’s Hospital of Philadelphia.

The Chicago Tribune reports that many hospitals have begun to implement programs that urge patients to speak up if they have concerns or don’t understand what nurses or doctors are doing.

The New York Times reports that race and place of residence can have a staggering impact on the course and quality of the medical treatment a patient receives.

The Associated Press reports on a $300 million initiative that will target 14 communities and regions nationwide, seeking to improve the quality of health care and eventually provide models for national health reform.

In a related story, the Patriot-News reports that Adams and York counties are among the communities selected for the national health care quality improvement effort.

HealthLeaders Media offers an audio interview with Carolyn Scanlan, President and CEO of The Hospital & Healthsystem Association of Pennsylvania, on how the state’s annual infection report is encouraging hospitals to work for improvement.

The Pittsburgh Post-Gazette reports on the latest addition to the Hospital Compare website -- a comparison of local hospitals on certain measures of patient satisfaction and clinical care.

The Bucks County Courier Times also reports on the new website addition.

The Associated Press reports that hospitals are increasingly turning to “undercover patients” to grade the health care experience being offered, and the AMA is giving consideration to endorsing the practice.

A Citizen’s Voice letter to the editor states that, “Reporting medical mistakes helps prevent lawsuits.”

The Wall Street Journal reports the federal government plans to identify some of the most troubled nursing homes in its public database, part of a trend toward giving consumers access to nursing home information online.

The Philadelphia Inquirer reports that federal inspectors have documented serious contamination concerns in one of the country’s premier childhood vaccine manufacturers.

The Wall Street Journal reports the Food and Drug Administration is under fire from Congress for gaps in its foreign drug facility inspections.

U.S. News & World Report highlights a congressional hearing during which experts discussed whether federal health officials are doing enough to protect patients from infections acquired in hospitals, clinics and doctor’s offices.

Baltimore Sun reports that the federal government isn’t doing enough to protect patients from getting infected at hospitals, endangering tens of thousands of lives and costing billions of dollars.

The Philadelphia Inquirer reports that an examination of hospital billing data indicates patients who were discharged after four or fewer days in the hospital were significantly more likely to die than those who remained in the hospital for five, six or more days.

U.S. News & World Report states that, with regard to the Pennsylvania Health Care Cost Containment Council’s hospital-acquired infections report, “Publishing a report such as this is a courageous act.”

The Patriot-News cautions the hospital-acquired infections report should not be used by consumers to judge or compare hospitals, since the reporting process is complicated and new, and some hospitals might not even be detecting or reporting all of their infections.

The Pittsburgh Business Times reports that hospitals and doctors are being driven to reduce infections picked up at their facilities, and the stepped-up infection monitoring and control will cost more, but how much more isn’t yet known.

A Patriot-News editorial states, “Far too many patients are still contracting infections during hospital stays in Pennsylvania. But for the first time there may be signs of progress.” 

The Associated Press reports on a safety alert issued by the Joint Commission advising more needs to be done to prevent medication errors in children, and calling on hospitals to utilize more stringent safety guidelines.

A Carlisle Sentinel editorial states “the 2006 statistics are out on how many people contracted infections in Pennsylvania hospitals...and this is good news,” adding that Pennsylvania is one in only five states to publish the data, and the only state collecting information in all areas of serious infection.

Upcoming events. April 22—Keys to Patient Safety: Ensuring Competent and Quality Contracted Services (Harrisburg)

The Morning Call reports that former patients and federal health officials recently came to the same conclusion in separate report cards on the overall quality of health care in Pennsylvania: It’s average.

The Patriot News reports that Pennsylvania hospitals might be getting better at counting and reporting infections and, according to a Pennsylvania Healthcare Cost Containment Council report hospitals might be getting better at preventing infection.

The following publications also reported on the newly-released data. HAP (including DVHC of HAP) cited in all articles.  Associated Press, Daily American, Philadelphia Business Journal, Philadelphia Inquirer, Pittsburgh Post-Gazette   

Educating patients and consumers about infection risk factors and prevention tips helps empower their decision-making and makes them active participants in their health care. This report is one of many tools available to help consumers and providers assess ongoing efforts to eliminate hospital-acquired infections and can help trigger discussions between patients and their doctors and nurses in making care decisions. Along with this report, patients can take advantage of other education resources developed by well-respected organizations, such as:

Pennsylvania Patient Safety Authority Issues New Advisory
The Pennsylvania Patient Safety Authority issued its latest Patient Safety Advisory (pdf), which covers diagnostic ionizing radiation and pregnancy; medication assessment and falls risk; timely treatment of stroke symptoms; preventing the retention of foreign objects; and pneumatic tube safety. The advisory also includes a feature about “meaningful engagement in patient safety improvement” and “getting boards on board” with patient safety, written by authority chair Ana Pujols-McKee, M.D. HAP is working with the authority on a state-specific initiative in this area.

The Morning Call reports that for the first time, it takes only a couple of mouse clicks to access information about how Pennsylvania hospitals stack up against each other.

The Wall Street Journal reports that, in a bid to save costs and stem a rising tide of medical waste, hospitals are recycling a growing number of medical devices labeled as single-use, from scissors and scrubs to the sharp blades surgeons use to saw through bones.

The Associated Press reports that the Government Accountability Office is investigating whether the Food and Drug Administration’s review process cleared two blockbuster medications without sufficient proof of their safety or effectiveness.

The Philadelphia Inquirer reports that reducing complications a high priority nationwide, and area health care providers are working to identify where problems occur, and taking steps to prevent them.

The Wall Street Journal reports that hospitals are taking steps to prevent errors in the use of high-alert medications that, when given in the wrong dose or used incorrectly, have the highest risk of seriously harming or even killing a patient.

Congressman Tim Murphy Cosponsors Bill to Stall Medicaid Regs. U.S. House Commerce Committee Chairman John Dingell (D-MI) and Representative Tim Murphy (R-PA) have introduced H.R. 5613, supported by HAP, which would prevent the Centers for Medicare & Medicaid Services (CMS) from moving forward with seven Medicaid regulations before April 2009. The rules affect payments for graduate medical education, rehabilitation services, hospital clinic services, safety net providers, and case management services. In addition, the bill would halt CMS action on state provider tax laws and appeals filed through the Department of Health and Human Services. Some of the regulations have moratoria imposed by Congress that will expire on May 25.

HCAHPS Patient Experience Data Set for March 28 Release. On March 28, the Centers for Medicare & Medicaid Services (CMS) will release survey results about patients’ experience of care, known as HCAHPS, on the Hospital Compare website. This will include survey information from patient discharges from October 2006 through June 2007; care dimensions measured include communication, responsiveness, impressions of the hospital environment, pain management, discharge information, and overall care. The HCAHPS survey used to capture this information is different from traditional patient satisfaction surveys in that it asks how often different aspects of care were provided. Additionally, CMS has moved Medicare payment and volume data, which is now displayed on a separate Medicare website, to Hospital Compare. Hospitals may view their own HCAHPS data and see how it compares to state and national averages on the QualityNet website. Hospitals should anticipate media inquiries about their HCAHPS data as well as the payment data. Additional information will be sent to members early next week.

DPW to Issue New Funds for Hospital OB, Nenonatal Services. HAP was successful in gaining additional funding for hospital obstetrical and neonatal services in the current state fiscal year. The Department of Public Welfare (DPW) is providing public notice of its intent to establish a one-time additional class of disproportionate share hospital (DSH) payments for certain qualifying hospitals based on obstetrical and neonatal intensive care cases. A total of 73 hospitals qualify for these funds; information was sent to those hospitals in HAP Memo 08-34. DPW expects to make the state share payment by the end of April. Once federal approval has been received, the federal share will be made. Ensuring access to appropriate prenatal, obstetrics, and postpartum services is an essential investment in Pennsylvania’s future. HAP has worked with Senator Jane Orie (R-Allegheny) and Representative Kathy Manderino (D-Philadelphia) on legislation addressing access to obstetrical and neonatal intensive care services. Senate Bill 966 and House Bill 1514, the Access to Obstetrical and Neonatal Care Act, provide additional payments to qualifying hospitals that have a high volume or percentage of Medicaid cases. While these bills were not enacted into law, DPW agreed to follow the basic requirements in these bills to provide additional funding to eligible hospitals. The current budget provides approximately $11 million in state and federal funds for this purpose. HAP is seeking action on S.B. 966 and H.B. 1514, and requesting $33 million in state and federal funds for fiscal year 2008–2009.

Study: Physician Self-Referral Decisions Influenced by Payment Status. A study published this week in Health Affairs has found that “physicians at physician-owned facilities are more likely than other physicians to refer well-insured patients to their facilities and route Medicaid patients to hospital outpatient clinics.” The study analyzed more than one million discharge abstracts from hospital outpatient departments and ASCs located in the Pittsburgh and Philadelphia metropolitan areas. The study concluded, “The worry is that physician-owned facilities will siphon off profit centers that have traditionally cross-subsidized care for uninsured and Medicaid patients, as well as unprofitable services such as burn treatment. The findings from this paper are consistent with that fear.” As HAP has noted in response to previous reports about non-general acute care hospitals, these facilities typically do not take those patients who cannot pay, treat far fewer Medicaid patients than do acute care hospitals, and do not treat patients with complex conditions. The result is that community hospitals take in and treat the sickest and most needy patients.
HAP will continue to press for equitable requirements for licensed health care facilities, regardless of ownership or setting. HAP’s advocacy will continue to emphasize that facilities that are providing the same or similar services should adhere to the same or similar standards of licensure, public reporting, reimbursement, and provision of care to the uninsured, Medicaid, and other publicly-supported patients.

PHCQA Launches Hospital Quality Website. The Pennsylvania Health Care Quality Alliance (PHCQA) this week launched a new website that compiles hospital quality data from existing data sources to help promote quality and transparency in health care. The PHCQA website, a cooperative effort of hospital, physician, health insurance, and government leaders, includes hospital-specific process and performance measures associated with treatment of heart attacks, heart failure, and pneumonia. PHCQA is using data that is already publicly available through the Centers for Medicare & Medicaid Services (CMS) and Pennsylvania Health Care Cost Containment Council (PHC4) websites. Details were sent to members in HAP Memo 08-31.

HHS Secretary Visits PA, Outlines Health IT Initiative. Health and Human Services (HHS) Secretary Michael Leavitt this week convened a meeting of health care stakeholders in Philadelphia, hosted by Thomas Jefferson University Hospital, and last week he convened a similar meeting in Pittsburgh, hosted by the Jewish Healthcare Foundation. In both meetings, Leavitt discussed the need to create a more coherent health care system through the effective use of health information technology (IT) and greater transparency of health care costs and quality. Leavitt outlined a new Medicare health IT demonstration project, Connecting to Better Health Care, that will reward physician practices for using CCHIT-certified electronic medical records, electronically reporting basic quality measures, and for demonstrating improvement in those measures over time. At the Pittsburgh meeting, Leavitt formally designated the Pittsburgh Regional Health Initiative as one of the 14 initial HHS Chartered Value Exchanges (CVE) and challenged them to consider pursuing the demonstration project. At the Philadelphia meeting, Leavitt generated stakeholder interest in pursuing both CVE designation and the demonstration project. David Nash, M.D., of Jefferson Medical College, was charged by Leavitt with continuing discussions in southeastern Pennsylvania and also coordinating with efforts in southwestern Pennsylvania.

Providers Urged to Participate in MCPSS Survey. The Centers for Medicare & Medicaid Services (CMS) is conducting its annual Medicare Contractor Provider Satisfaction Survey (MCPSS) by contacting a sample of Medicare providers. The survey is designed to garner quantifiable data on provider satisfaction levels with key services provided by the Medicare fee-for-service contractors (FFS) who process and pay more than $280 billion in Medicare claims each year. Providers selected to participate in the survey are being contacted by the survey contractor, Westat. CMS is encouraging providers contacted by Westat to complete the survey. According to CMS, the results of the study will “help us improve the services we provide you and be used by CMS as an additional measure to evaluate performance of Medicare Administrative Contractors (MACs) and support process improvement efforts.” Westat will contact selected providers by telephone in the coming weeks to encourage their participation. MCPSS results will be available to contractors and the public in July 2008.

The New York Times reports that patients treated in hospitals on weekends have inferior outcomes when compared to those receiving care on weekdays.

The Associated Press reports on a published list of 131 nursing homes nationwide with poor inspection records, released by the Centers for Medicare & Medicaid Services.

Forbes’ special series of articles, pictures and video entitled, “How Safe Are America’s Hospitals?” reports on patient safety, infections and specialty hospitals.

The Philadelphia Inquirer reports that reducing complications a high priority nationwide, and area health care providers are working to identify where problems occur, and taking steps to prevent them.

The Pittsburgh Post-Gazette also reports on the Forbes series, stating that one in 200 patients who spend one night or more in a hospital will die from a medical error, and one in 16 will pick up an infection.

The New York Times reports that some cases of carbon monoxide might be caught if doctors began routinely testing emergency room patients for exposure.

The Associated Press reports that the new way to push for patient safety is to not pay hospitals for the extra costs associated with preventable hospital errors.

The New York Times reports that new research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers, and even in-house beauticians.

The San Francisco Chronicle reports that entire classes of mainstay antibiotics are being threatened with obsolescence, and bugs far more dangerous than staph are evolving in ominous ways.

The Des Moines Register reports that doctors agree medical errors should be reported to their hospitals, but a significant number admit they don't always report their own.

USA Today reports that hospitals are attacking potentially fatal bacterial infections by marrying a series of proven medical treatments.

A New York Times op-ed states that most doctors are afraid to take responsibility for medical errors, but studies have shown that physicians’ apologies may protect against litigation.


The New York Times reports that in nearly a third of cases of sudden cardiac arrest in the hospital, the staff takes too long to respond, increasing the risk of brain damage and death, a new study finds.


USA Today reports that the first major study of how quickly hospitals respond to in-house cardiac arrests found delays in almost a third of cases.


The Centre Daily Times reports that state Rep. Kerry Benninghoff has introduced a bill that would add methicillin-resistant Staphylococcus aureus, or MRSA, to the list of reportable diseases in Pennsylvania.


Click to access more Patient and Medication Safety Articles from 2007 archives

Click to access more Patient and Medication Safety Articles from 2006 archives


JCAHO Certified Advanced Registered Nurse Practitioner