patient safety quality healthcare

Patient Safety Experts Highlight Key Concerns for 2016

For many healthcare facilities, a new year means new goals. As we say goodbye to 2015, patient safety experts from around the country share their focus areas for the coming year.

Improving EHR systems

After spending the last several years implementing, launching, and optimizing a system-wide electronic medical record (EMR) system, Henry Ford Health System (HFHS) is looking to leverage EMRs to transform care delivery, according to Mary Voutt-Goos, director of patient safety and clinical care design at HFHS in Detroit. In 2016, the five-hospital system is planning to transition its award-winning "No Harm Campaign," in place since 2008, to "Harm 2.0," which will offer real-time harm measurement and predictive analytics to identify patient risk.

Continue reading this article in this month’s issue of Patient Safety Monitor website. Subscribers to Patient Safety Monitor Journal have free access to this article.

CMS Announces Standardized Quality Measures

CMS and America’s Health Insurance Plans (AHIP) released seven quality measures yesterday that aim to reduce the cost of measuring clinical quality while supporting multi-payer alignment on core measures for physician quality programs.  The new measure sets will improve informed consumer decision-making, reduce variability in measure selection, collection burden, and cost, according to CMS.

“In the U.S. healthcare system, where we are moving to measure and pay for quality, patients and care providers, deserve a uniform approach to measure quality,” said CMS Acting Administrator Andy Slavitt in a release. “This agreement will reduce unnecessary burden for physicians and accelerate the country’s movement to better quality.”

The core measures are in the following seven sets:

  • Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PSMHs), and Primary Care
  • Cardiology
  • Gastroenterology
  • HIV and Hepatitis C
  • Medical Oncology
  • Obstetrics and Gynecology
  • Orthopedics

This first set of measures were developed by CMS, AHIP, and other healthcare system participants as part of a new broad Core Quality Measures Collaborative. The Collaborative plans on releasing additional measure sets over time. Commercial payers will begin using the measures as soon as possible, according to CMS.

PSQH Applies for BPA Worldwide Business Publication Membership

Danvers, MA February 2016 – Patient Safety & Quality Healthcare ( has applied for business publication membership in BPA Worldwide. The magazine is published by BLR (Danvers, MA).

BPA Worldwide will track circulation for Patient Safety & Quality Healthcare (PSQH) based on business/distribution, demographics and geographic coverage. The magazine will have 12 months to complete its initial circulation audit.

“We are pleased that Patient Safety & Quality Healthcare has applied for membership in BPA Worldwide,” said BPA President and CEO Glenn Hansen. “We applaud the publisher for providing advertisers and prospects with the solid assurance of an independent circulation audit conducted according to our world-respected, uncompromising standards. With a BPA audit, media buyers can be confident that circulation claims are accurate, and that they have the verified data that they need to assess a publication’s effectiveness in serving its market.”

Patient Safety & Quality Healthcare is known throughout the industry for its in-depth frontline reporting of successful patient safety and healthcare improvement programs,” said Elizabeth Petersen, Executive Vice President of BLR’s healthcare division. “We’re pleased to continue to serve this important market.”

Patient Safety & Quality Healthcare brings patient safety and quality improvement stakeholders together. Subscribers include patient safety officers, quality improvement executives, risk managers, infection control managers, executive nurses, pharmacy directors, and other clinical executives. Subscribers are encouraged and challenged to break free of their established work silos to look for new solutions and performance breakthroughs. Each issue of PSQH includes industry news, topical columns and departments, case studies of successful implementation of patient safety/quality improvement programs, and information from prominent industry associations and sponsoring organizations. The editorial content is written by industry experts and practitioners, and carefully edited by the PSQH editorial team.

About BPA Worldwide. BPA Worldwide is the business of providing assurance. For 80+ years as a not-for-profit assurance service provider, BPAWW was originally created by advertisers, advertising agencies and the media industry to audit audience claims used in the buying and selling of advertising. Today, in addition to auditing audience claims, through its iCompli service, BPAWW verifies compliance to defined government, industry, and organizational standards as well as adherence to privacy, data protection and sustainability guidelines and best practices. With more than 3,600 clients in over 20 countries, BPAWW is a trusted resource for compliance and assessment services. Its latest offering, Ad iCompli, measures and scores online ad campaign performance for business and consumer marketers.

For more information on BPAWW and its services, please visit

About BLR. BLR®—Business & Legal Resources helps U.S. businesses simplify compliance with state and federal legal requirements and helps them become more successful. They accomplish this by offering authoritative content and practical, easy-to-use tools. Through their expert in-house editors and exclusive attorney network, they provide the most comprehensive, reliable state-specific information available—and do it in all 50 states. Their award-winning information products—including training programs, events, Web portals, reports, and subscription services—give businesses of all sizes and industries the best tools available at affordable prices.

Patient Safety News Roundup

CMS penalizes 758 hospitals for patient safety infractions

The CMS has fined 758 hospitals across the country for high rates of patient safety incidents including infections, sepsis, and hip fractures.

More than half of the hospitals that were fined in 2015 also received fines the previous year, according to Kaiser Health News. Hospitals will pay a total of $364 million in penalties.

The federal penalties have been a divisive issue, splitting patient safety advocates that argue the fines are not large enough to make sustainable gains in preventing patient harm, against providers, who say hospitals are unfairly punished for falling below certain thresholds, even when they have made significant strides in reducing adverse events.

One thing is for certain: Medicare fines don't discriminate based on reputation. Stanford Health Care, Denver Health Medical Center, Mount Sinai Hospital Medical Center, and Mayo Clinic hospitals were among the providers fined this year.

Continue reading this article on the Patient Safety Monitorwebsite. Subscribers have free access to this article in the February issue.

New Tool Simplifies the Process of Patient Safety Improvement

A new tool offers a straightforward approach to improvement

A new tool endorsed by the National Patient Safety Foundation aims to streamline patient safety and quality improvement efforts using a simple, evidence-based model.

"The Healthcare Adventures Graphic Gameplan for Patient Safety," released in October 2015, offers a standardized approach both leaders and clinicians can use to address gaps in patient safety. A multidisciplinary group that partnered patient safety experts with human development and organizational behavior experts created the tool and released it for free with the hope that some hospitals would be able to apply the same principles to initiatives within their facility.

Patient Safety Monitor Journal spoke with one of the guide's authors, Jay Vogt, an organizational and human development consultant and founder of Peoplesworth in Concord, Massachusetts, about the tool and how hospitals can use it to improve patient safety interventions and address cultural barriers.

Continue reading this articleon the Patient Safety Monitorwebsite. Subscribers have free access to this article in the February issue.

Study: Poor Communication Leads to Malpractice, Death

Poor communication in healthcare has tangible, measurable effects. A new study released by CRICO Strategies found that communications failures were a factor in 30% of malpractice cases between 2009 to 2013, including 1,744 deaths. The reports estimate that both the deaths and $1.7 billion in malpractice costs could have been avoided with better communication between patients and physicians. 

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CDC’s Core Elements of Hospital Antimicrobial Stewardship Programs

Just over a year after President Barack Obama issued an executive order calling for federal agencies to combat antibiotic resistance, The Joint Commission has released proposed standards that would require a broad range of healthcare providers to implement a structured, evidence-based antimicrobial stewardship program.

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JAMA: Nurses Key to Surviving Surgery

A study released in The Journal of the American Medical Association has found that surgical patients in hospitals with better nursing environments receive better care without drastically increasing costs. Researchers found the rate of 30-day mortality rates for postoperative patients was 4.8% at hospitals with more than 1.5 nurses per bed (NPB), while facilities with less than one NPB had mortality rates of 5.8%. The difference was most noticeable for patients in the highest risk quintile, with a mortality rate of 17.2% at magnet hospitals compared to 19.9% at control hospitals.

 “It wasn’t just the number of nurses that made the difference. Magnet status hospitals recognized for having excellent nursing programs and cultures do better,” said study author Linda Aiken, PhD, RN, in a release.

While there are numerous studies showing the benefits of a large nursing staff, the costs of hiring new staff has been an impediment for many facilities. Despite this, it was shown that better staffed hospitals actually paid less ($163) overall per patient than understaffed hospitals.

 “A surprising finding was that better nurse staffing throughout the hospital does not have to be more costly,” Aiken said. “Indeed, we found that magnet hospitals achieved lower mortality at the same or lower costs by admitting 40% fewer patients to intensive care units and shortening length of hospital stay.”

Nominations Open for Sherman Award for Excellence in Patient Engagement, an online community dedicated to sharing best practices in patient and family engagement, is now accepting nominations for the 2016 John Q. Sherman Award for Excellence in Patient Engagement.

Established in 2014, the Sherman Award is dedicated to recognizing innovative work that has resulted in better, safer care and improved outcomes by engaging patients and families in their care. The award—a partnership between, the National Patient Safety Foundation’s (NPSF) Lucian Leape Institute, and Standard Register Healthcare—will be conferred at NPSF’s 18th annual Patient Safety Congress in Scottsdale, Arizona, on May 24, 2016. The winner will receive an all-expenses-paid trip to Scottsdale for the congress.

“Increasing attention on engaging patients and their personal support networks signals a true shift in healthcare,” said Mark O’Leary, chair of’s advisory board and president of Standard Register Healthcare. “Each project represents an organization’s commitment to creating deep and lasting relationships by engaging and activating patients and families across the continuum of care. We hope showcasing these outstanding projects and caregivers will inspire more patient and family-centered practices.”

Named for John Q. Sherman (1882-1939), founder of Standard Register and philanthropist, the award is given to a program focused on enhancing patient and family engagement. Programs will be judged on patient and family involvement in project design and implementation, measurable results, sustainability, and reproducibility of the project.

“Patient and family engagement is essential to the delivery of safe and appropriate health care,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO of NPSF and president of the NPSF Lucian Leape Institute. “We are pleased to collaborate with to recognize those who have put successful practices into place to partner with patients, and this award is a wonderful way to share what they have learned.”

Nominations will be accepted through March 11. Work must have occurred between January 1, 2014, and January 31, 2016. The official nomination form and full details about criteria for the John Q. Sherman Award are available at

Olympus Recalls Duodenoscopes, FDA Approves New Model

Olympus Corp., the largest seller of duodenoscopes in the U.S., last week recalled all of its TJF-Q180V model scopes. The move came just one day after a Senate committee report linked Olympus products to 142 antibiotic-resistant infection (ARI) cases.

Duodenoscopes are flexible cameras inserted into a patient’s mouth or digestive tract to diagnose a number of cancers and are used in over 700,000 procedures annually. Recent investigations found a flaw in the scope’s design made it nearly impossible to fully disinfect—exposing patients to ARIs and resulting in 25 outbreaks in four countries over the last three years. Last year, 141 patients in Los Angeles were infected and three died from ARIs attributed to dirty scopes.

Olympus voluntarily issued the recall after the Food and Drug Administration (FDA) cleared the company’s new safety modifications to the existing model. Olympus will replace the elevator channel sealing mechanism at the tip of the scope with a new mechanism that should reduce the risk of fluid leakage in the channel, according to the report.

Olympus will begin replacing the scopes next month. There are approximately 4,400 scopes currently in use and Olympus hopes to have them all replaced or modified by August 2016. Until the scopes are replaced, healthcare facilities may continue using the unmodified TJF-Q180V models, but are urged to meticulously follow the manufacturer’s reprocessing instructions.

Editor’s note: This article was adapted from Accreditation & Quality Advisor

FDA Releases Cybersecurity Recommendations for Medical Device Manufacturers

Cybersecurity threats to medical devices are a growing concern. The FDA took a proactive step last week and released draft guidance last week encouraging medical device manufacturers to address certain cybersecurity risks to keep patients safe.

Manufacturers should look beyond the initial security measures implemented in a medical device and consider additional safety measures throughout a particular device’s whole lifecycle, according to the report.

“All medical devices that use software and are connected to hospital and healthcare organizations’ networks have vulnerabilities—some we can proactively protect against, while others require vigilant monitoring and timely remediation,” said Suzanne Schwartz, MD, MBA, associate director for science and strategic partnerships and acting director of emergency preparedness/operations and medical countermeasures in the FDA’s Center for Devices and Radiological Health, in a press release.

The guidance stresses the need for proactively planning and assessing cybersecurity vulnerabilities, information sharing between the public and manufacturers, as well as creating a cybersecurity risk management program that includes:

  • Applying the 2014 NIST voluntary Framework for Improving Critical Infrastructure Cybersecurity
  • Monitoring cybersecurity information sources to identify any vulnerabilities
  • Understanding, assessing, and detecting the presence of possible vulnerability
  • Defining essential clinical performance to identify, protect, respond and recover from a cybersecurity threat
  • Adopting a threat disclosure policy and practice
  • Implementing measures that identify cybersecurity risk early and before an incident occurs

C.diff Infection Raises Hospital Costs by 40% per Case

By Alexandra Pecci, for HealthLeaders Media

Treating Clostridium difficile adds about $7,285 in hospital costs per patient, not including readmissions, research finds.

It can be difficult to quantify the exact economic burden of C. diff on hospitals and the health system as a whole. But a recent study puts a dollar amount on the cost of C. diff, that number is not only big, but also likely underestimated.

Published in the November issue of the American Journal of Infection Control, the study found that C. diff-associated diarrhea (CDAD) increases hospital costs by 40% per case and puts those infected at high risk for longer hospital stays and readmissions.

Read more...

FDA validates revised reprocessing instructions for Model ED-530XT duodenoscopes

FUJIFILM Medical Systems issued revised reprocessing instructions late last month for Model ED-530XT duodenoscopes, according to a safety communication issued by the FDA. The instructions require exacting pre-cleaning, manual cleaning, and high-level disinfection procedures.

While these revised reprocessing instructions are for Model ED-530XT duodenoscopes, the FDA is encouraging healthcare facilities that use Fuji’s 250 and 450 duodenoscope models, to use the revised reprocessing instructions until the revised instructions for those models are final.

Key changes to the reprocessing procedure for Fuji’s ED-530EXT duodenoscope:

  • Pre-cleaning
    • During immersion of the scope tip in detergent solution, move the forceps elevator back and forth and aspirate detergent solution while the forceps is raised and while lowered.
  • Manual cleaning
    • Additional brushing of the distal tip, forceps elevator and elevator recess first using the existing Fujifilm valve cylinder cleaning brush (Model WB11002FW2) and then using the new disposable (Model WB1318DE) cleaning brush.
    • Additional flushing of detergent and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered.
    • Additional flushing steps and increased channel flushing volumes of detergent and rinse water
  • Manual high-level disinfection
    • Additional flushing of disinfectant and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered. Additional raising and lowering of the elevator while immersed in disinfectant solution and rinse water.
    • Additional flushing steps and increased flushing volumes of disinfectant and rinse water through the duodenoscope’s internal channels.


    In October, the FDA ordered the top three manufacturers of duodenoscopes, Olympus America, Inc., Fujifilm Medical Systems, USA, Inc., and Hoya Corp. to submit plans outlining how they were going to conduct studies to understand how the duodenoscopes are being reprocessed in healthcare settings.

    For more information visit the FDA website.

Study: Discharge notes are often written grades above patient reading levels

A study published in The American Journal of Surgery found that low literacy rates can drive up the number of hospital readmissions. Of the 497 patients studied, researchers found that only 24% had the reading skills necessary to understand their discharge instructions, with 65% reading a lower grade level than what their notes were written in.

“Even if patients believe they understand what occurred during their hospitalization and the instructions they are to follow upon dismissal, they can become confused after they leave the hospital environment as their memory can be clouded by medications they were administered, the stress of hospitalization, and, particularly, within our patient population, traumatic brain injuries such as concussions,” senior study author Martin Zielinski, MD, told Reuters.

The study also found that 65% of 30-day readmissions were for patients who didn’t have the literacy skills to understand their discharge notes. Researchers recommend writing dismissal notes at a sixth-grade level to ensure patient comprehension.

Massachusetts medical board proposes rules on simultaneous surgeries

Surgeons in the state of Massachusetts will have to document each time they enter and leave the operating room according to a new regulation approved by the Massachusetts Board of Registration in Medicine, according to a recent report in The Boston Globe.

Patients rarely know if they are sharing their surgeon with another patient, and the lack of documentation about the surgeon’s whereabouts during a procedure leaves some wondering if their doctor actually performed the entire procedure, according to the report.

Additionally, the primary surgeon will need to identify the backup doctor in the event the primary surgeon needs to leave the operating room during the procedure.

Other rules approved by the board last week include:

  • Doctors will be required to report other physicians who are impaired by alcohol or drugs while on duty
  • Online physician profiles have been expanded to include out-of-state malpractice judgments and settlements involving Massachusetts doctors

The approved rules need approval by various state agencies by the end of March before they can go into effect.



ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine