This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.
Continue reading “A Roadmap For Patient Safety and Quality Improvement”
Filed Under: Hospitals
Tagged: AHRQ, Armstrong Institute for Patient Safety and Quality, Hospitals, Patient Safety, Peter Pronovost, Quality
Mar 25, 2013
A little more than 13 years ago, the Institute of Medicine (IOM) released its seminal report on patient safety, To Err is Human.
You can say that again. We humans sure do err. It seems to be in our very nature. We err individually and in groups — with or without technology. We also do some incredible things together. Like flying jets across continents and building vast networks of communication and learning — and like devising and delivering nothing- short-of-miraculous health care that can embrace the ill and fragile among us, cure them, and send them back to their loved ones. Those same amazing, complex accomplishments, though, are at their core, human endeavors. As such, they are inherently vulnerable to our errors and mistakes. As we know, in high-stakes fields, like aviation and health care, those mistakes can compound into catastrophically horrible results.
The IOM report highlighted how the human error known in health care adds up to some mindboggling numbers of injured and dead patients—obviously a monstrous result that nobody intends.
The IOM safety report also didn’t just sound the alarm; it recommended a number of sensible things the nation should do to help manage human error. It included things like urging leaders to foster a national focus on patient safety, develop a public mandatory reporting system for medical errors, encourage complementary voluntary reporting systems, raise performance expectations and standards, and, importantly, promote a culture of safety in the health care workforce.
How are we doing with those sensible recommendations? Apparently to delay is human too.
Continue reading “Doctor, I’m Not Comfortable with That Order”
Filed Under: Hospitals, The Business of Health Care
Tagged: AHRQ, aviation industry, culture of safety, IOM, Medical errors, Michael Painter, Patient Safety, Patient Safety Organizations
Dec 6, 2012
Most tools used in medicine require knowledge and skills of both those who develop them and use them. Even tools that are themselves innocuous can lead to patient harm.
For example, while it is difficult to directly harm a patient with a stethoscope, patients can be harmed when improper use of the stethoscope leads to them having tests and/or treatments they do not need (or not having tests and treatments they do need). More directly harmful interventions, such as invasive tests and treatments, can harm patients through their use as well.
To this end, health information technology (HIT) can harm patients. The direct harm from computer use in the care of patients is minimal, but the indirect harm can potentially be extraordinary. HIT usage can, for example, store results in an electronic health record (EHR) incompletely or incorrectly. Clinical decision support may lead clinician astray or may distract them with unnecessary excessive information. Medical imaging may improperly render findings.
Search engines may lead clinicians or patients to incorrect information. The informatics professionals who oversee implementation of HIT may not follow best practices to maximize successful use and minimize negative consequences. All of these harms and more were well-documented in the Institute of Medicine (IOM) report published last year on HIT and patient safety .
One aspect of HIT safety was brought to our attention when a critical care physician at our medical center, Dr. Jeffery Gold, noted that clinical trainees were increasingly not seeing the big picture of a patient’s care due to information being “hidden in plain sight,” i.e., behind a myriad of computer screens and not easily aggregated into a single picture. This is especially problematic where he works, in the intensive care unit (ICU), where the generation of data is vast, i.e., found to average about 1300 data points per 24 hours . This led us to perform an experiment where physicians in training were provided a sample case and asked to review an ICU case for sign-out to another physician . Our results found that for 14 clinical issues, only an average of 41% of issues (range 16-68% for individual issues) were uncovered.
Continue reading “Improving Patient Safety Through Electronic Health Record Simulation”
Filed Under: Uncategorized
Tagged: AHRQ, EHR, EHR Simulation Research, HIT, Informatics, IOM, Jeffrey Gold, OHSU, Patient Safety, William Hersh
Oct 31, 2012
The flap greeting Mitt Romney’s cheerful admission that as president he’d defund Big Bird’s nesting place on public television could turn out to be good news for a federal agency promoting safe medical care that faces a similar extinction threat. But we won’t know till after the election whether the little-known agency benefited from Big Bird’s protective presence.
The stage was set for Romney’s Big Bird boast by a bill Republicans pushed through a House Appropriations subcommittee in July that slashed or eliminated budgets for a host of programs, including public television’s parent, the Corporation for Public Broadcasting. A committee statement at the time said the move was meant “to encourage CPB to operate exclusively on private funds.” That same bill completely abolished the Agency for Health Care Research and Quality (AHRQ).
Health policy wonks lamented that terminating the agency “would badly undermine important research on health care quality, disparities in care and patient safety,” as a member of AHRQ’s national advisory council put it. But hardly anyone else noticed.
The end of AHRQ didn’t even rate a separate mention in the committee’s lengthy press release. And while Politico reported that a Democratic subcommittee member called it “the only federal agency whose sole mission is to improve the quality, safety and cost efficiency of health care,” the subcommittee’s GOP chairman said, in effect, the death sentence was nothing personal. It was just a budget-balancing action and “not a reflection on anything.”
That’s where Big Bird waddles into the picture.
Continue reading “The Nefarious Big Bird- Health Care Connection”
Filed Under: Uncategorized
Tagged: 2012 Election, AHRQ, AHRQ Elimination, Big Bird, CPB, GOP, HHS, Michael Millenson, Mitt Romney, Politico, Presidential Debate
Oct 8, 2012
On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.
Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.
So we set out to change this. We developed a program that included a checklist of best practices, an intervention called CUSP [the Comprehensive Unit-based Safety Program] to help change culture and engage frontline clinicians, and performance measures so we could be accountable for results. It worked. We virtually eliminated these infections.
Then in 2003 through 2005, with funding from AHRQ, we partnered with the Michigan Health & Hospital Association. Within six months in over 100 ICUs, these infections were reduced by 66 percent. Over 65 percent of ICUs went one year without an infection; 25 percent went two years. The results were sustained, and the program saved lives and money, all from a $500,000 investment by AHRQ for two years.
Continue reading “Health Care’s Man on the Moon Moment?”
Filed Under: Hospitals
Tagged: AHRQ, central line-associated bloodstream infection, CUSP, ICU, Johns Hopkins, Medical errors, Michigan Health & Hospital Association, Patient Safety, Peter Pronovost, Preventable harm
Sep 12, 2012
It didn’t appear on the lightning strike map, but lightning did indeed strike a young medical student inside the Washington Convention Center right in front of about 1,500 amazed spectators on the first day of The Health Data Initiative Forum III: The Health Datapalooza. Everyone is fine—though our medical student may never be the same again.
Actually, this story began long before Datapalooza, of course. Fourth-year medical student, Craig Monsen, and his Johns Hopkins Medical School classmate, David Do, started collaborating on software applications soon after they met in first-year anatomy class. Craig graduated from Harvard with degrees in Engineering and Computer Science and David from University of Minnesota in Bioengineering.
They’re not quite Jobs and Wozniak—neither dropped out of anything—yet—although Craig, at least, is planning to skip or delay residency. You see, after seeing the Robert Wood Johnson Foundation (RWJF) Aligning Forces for Quality Developer Challenge last year—they got very serious about bringing to life their vision of new applications that could help patients and consumers make great health care decisions.
Continue reading “Lightning Strikes Datapalooza”
Filed Under: Health 2.0
Tagged: AHRQ, Aligning Forces initiative, Apps, Craig Monsen, Data, Innovation, John Lumpkin, RWJF, Startups, Symcat
Jun 6, 2012
By BOB WACHTER
Earlier this month, the National Quality Forum released its revised list of “Serious Reportable Events in Healthcare, 2011,” with four new events added to the list. While the NQF no longer refers to this list as “Never Events,” it doesn’t really matter, since everyone else does. And this shorthand has helped make this list, which will soon mark its tenth anniversary, a dominant force in the patient safety field.
The NQF was founded in 1999 at the recommendation of Al Gore’s Presidential Advisory Commission on healthcare quality. For its founding chair, the organization selected Ken Kizer, a no-nonsense, seasoned physician-administrator who had just done a spectacular job of transforming the VA system from the subject of scathing articles and movies into a model of high-quality healthcare, a veritable star in patient safety galaxy.
Kizer’s original charge at NQF was to develop a Good Housekeeping seal-equivalent for quality measures (“NQF-endorsed measures”). But soon after he arrived, Kizer added another item to the NQF’s wish list: the creation of a list of medical errors and harm that might ultimately be the subject of a nationwide state-based reporting system. As Kizer said at the time,
This is intended to be a list of things that just should not happen in health care today. For example, operating on the wrong body part [or] a mother dying during childbirth. That’s such a rare event today that it’s generally viewed as something that just shouldn’t happen. Now, there’s probably going to be an occasion now and then when it happens and everything was done right, but it’s so infrequent that it means you have to investigate it every time it occurs. So “never” has quotes around it in this case. Now, wrong-site surgery is a different story—that should never happen. There’s no way that you should take off the right leg when you’re supposed to do the left one. So in this case, never really means never.
Unsurprisingly, the items on the list quickly became known as “Never Events.” Twenty-seven of them were announced in 2002, and the list was expanded and revised four years later. (This primer, written by my colleague Sumant Ranji for our patient safety website, AHRQ Patient Safety Network, is the best description of the list and some of its policy implications.) Continue reading “Never Say Never (Events)”
Filed Under: Uncategorized
Tagged: AHRQ, Ken Kizer, National Quality Forum, Never Events
Jul 2, 2011
This week I had the occasion to be at UCLA for a very interesting meeting (more on that in a future post). As I arrived at LAX to return my rental car, I drove past a huge billboard at the corner of 96th Avenue and Airport Blvd (just across from the Renaissance Hotel) that made me do a double take. The billboard, said in gigantic white letters on a red background: “This year thousands of men will die from stubbornness.”
Naturally, my first thought was this: Why thousands? If men can die from stubbornness, aren’t they all doomed? If stubbornness is the proximate cause of death, we are looking at a wipe-out of society on a pretty imminent basis. The bad news: no more future generations. The good news: no one will hassle us women about buying too many shoes and all the top-paying private equity jobs will soon be available.
So figuring that I had misread this billboard, I actually made a U-turn and drove past it again (not sure what made me do it: alarm or wishful thinking). What I noticed on my second pass was the very fine print, which said, “Learn the preventative medical tests you need. AHRQ.gov.”
The billboard is apparently part of an U.S. Government Agency for Healthcare Research and Quality Department ad campaign targeted to get men to stop avoiding the doctor and to go and get the medical screening tests recommended each year, such as those for cholesterol, diabetes, high blood pressure, cancer and other illnesses. Continue reading “Stubborn”
Filed Under: The Insider's Guide To Health Care
Tagged: AHRQ, Lisa Suennen, prevention, Screening tests
Apr 20, 2011
First the good news—many are pushing the envelope on public reporting of health care information these days. For instance, last week the HHS/Health 2.0 Developer Challenge awarded honors to a new mobile app—using Hospital Compare data in new and innovative ways—try it. This application maps and provides some quality information as well as immediate ER waiting times for nearby hospitals. The idea of this app challenge, as you know, is to unleash moribund federal information, such as that sitting in the creaky Hospital Compare—to innovative types who will take it and create new—and, ideally, useful ways to present the information. That’s an exciting turn that makes altogether too much sense.
Then Wednesday, I had the good fortune to attend a very thoughtful AHRQ sponsored meeting on public reporting of care information for consumers. The meeting included a good mix of consumers, employers, regional alliance leaders, health professionals, researchers and others. Bill Roper provided the opening keynote. The messages ranged from overt optimism about the important role of public reporting in the drive toward sustainable high value care—to the sober assessment that although public reporting has matured (some)—we may also be reaching limits. As Steve Jencks commented—we’ve made progress—but let’s keep some perspective here—public reporting still needs some quick wins—it “isn’t quite covered in glory, just yet.”
Meredith Rosenthal, in her plenary presentation, observed that public reporting is essentially about to graduate from high school—sitting in the guidance counselor’s office trying to decide whether to go to college or trade school. Bob Galvin, in the closing session, added—that while public reporting is indeed in the guidance counselor’s office—and it clearly has a bright future—it’s a pretty confused student.
The problem? There seems to be near unanimous sentiment—at least in this group—that public reporting of quality and cost information is critically important to drive sustainable health care quality and value. Continue reading “Which Way Transparency Nirvana?”
Filed Under: Health 2.0
Tagged: AHRQ, Michael Painter, Transparency
Mar 28, 2011
- Calling all published and graduate student researchers who have used
Healthcare Cost and Utilization Project (HCUP) data!
- Nominations and applications accepted through July 16.
celebrate its 20th year of HCUP data, AHRQ will be honoring researchers
who have addressed healthcare research and policy issues using HCUP
data, software or tools.
AHRQ encourages published researchers
to apply in two areas: Scientific Contributions and Policy Impact. Graduate students can only apply for the scientific contribution
Award recipients will be honored at the AHRQ Annual
Meeting (September 27-29, in Bethesda, Maryland). They will have the
opportunity to present their research at a session during the
meeting. Transportation and accommodations will be provided.
and get more information here: http://www.hcup-us.ahrq.gov/hsra.jsp.
Filed Under: Healthcare Marketplace
Jun 15, 2010