patient safety quality healthcare

New Sentinel Event Alert Focuses on Preventing Patient Suicide

The Joint Commission released a new Sentinel Event Alert last week, aimed at helping healthcare providers to better identify and treat patients at risk for suicide. Over 1,000 patient suicides were recorded in The Joint Commission Sentinel Event Database between 2010 and 2014.

According to SEA 56, the most common cause to the patient suicides during this time frame is linked to inadequate assessment, especially psychiatric assessment. The Joint Commission recommends that healthcare facilities create a standardized process of suicide ideation screening. This could be done by simply adding the question “Are you having suicidal thoughts or have you had suicidal thoughts in the past?” to the waiting room questionnaire. Ensure that the questionnaire is reviewed before the patient leaves the facility and if necessary, refer the patient for further screening.

Additionally, healthcare providers should check the patient’s background for potential suicide risk factors, including:

  • Previous suicide attempts
  • History of alcohol and drug abuse
  • Mental or emotional disorders (e.g., depression or bipolar disorder)
  • History of trauma or loss (e.g., abuse as a child, family history of suicide, economic hardship)
  • Serious illness, physical or chronic pain or impairment
  • Social isolation or a pattern of aggressive or antisocial behavior
  • Recent discharge from inpatient psychiatric care (e.g., patients may be at higher risk during the first year after discharge)


This alert replaces previous SEA’s 46 and 7.

For more information on this Sentinel Event Alert, click here.

Hospitals are beginning to rethink opioid prescribing practices

For the last several years, there has been a startling mortality trend emerging in the United States: Each year, middle-aged white Americans are dying at a faster clip than any of their counterparts in different age groups, ethnicities, or countries.

It's a trend that was startling, in part, because researchers couldn't explain why it was happening, particularly since death rates for other groups have been declining. However, in November, new research from two Nobel Prize winning Princeton economists found that the increasing number of deaths among whites 45?54 was linked to substance abuse, including heroin and prescription opioids.

According to the CDC, the rate of opioid overdose deaths between 1999 and 2013 was highest among those ages 45-54 (10.6 per 100,000). Furthermore, opioid overdose deaths increased sevenfold among adults 55-64 to 7.5 per 100,000 in 2013, and deaths among non-Hispanic whites have increased more than four times from 1.6 per 100,000 in 1999 to 6.8 per 100,000 in 2013.

This is an excerpt from the monthly healthcare safety resource Patient Safety Monitor Insider. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

Bribery on Two Continents: Olympus Corp. to Pay $646 million settlement

On March 1, the Department of Justice (DOJ) charged Olympus Corp. with paying millions of dollars in kickbacks to hospitals and doctors to buy its products. The company, which owns 85% of the U.S. endoscope market, has agreed to pay $646 million to resolve the criminal charges and civil charges brought against it. The sum is the largest total amount paid in U.S. history for violations involving the Anti-Kickback Statute by a medical device company.

“Olympus Corp. of the Americas’ and its subsidiaries’ greed-fueled kickback scheme threatened the impartiality of medical decision-making and the financial integrity of Medicare and Medicaid,” said Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services in a statement.

The DOJ says that by using kickbacks, Olympus’ U.S. division (OCA) made over $600 million in sales and $230 million in profits. The company admits to the charges, which include:

  • Holding up a $50,000 research grant until a hospital signed a deal to purchase Olympus equipment
  • Giving a doctor with a major role in a New York medical center’s buying decisions free use of $400,000 in equipment for his private practice.
  • Paying off doctors with hot air balloon rides, winery tours, spa treatments, lavish meals and rounds of golf at an Olympus sponsored forum.
  • Paying for a trip for three doctors to travel to Japan in 2007 as a quid pro quo for their hospital’s decision to switch from a competitor to Olympus.
  • Giving a hospital a $5,000 grant to facilitate a $750,000 sale.
  • Giving a week-long, paid vacation in Japan to the physician president of a professional organization and his spouse for three years in a row. The president was also paid a $10,000 honorarium to give a single lecture during each trip.

“The Department of Justice has longstanding concerns about improper financial relationships between medical device manufacturers and the health care providers who prescribe or use their products,” said Principal Deputy Assistant Attorney General Mizer.  “Such relationships can improperly influence a provider’s judgment about a patient’s health care needs, result in the use of inferior or overpriced equipment, and drive up health care costs for everybody.”

The OCA division’s settlement is split between $312.4 million for criminal penalties and an additional $310.8 million to settle civil claims under the federal and various state False Claims Acts. Mizer said in addition to yielding a substantial recovery for taxpayers, the settlement will send a clear message that these types of abusive arrangements will not be tolerated.  

Charges for Olympus’ Latin American Division

It's worth noting that $22.8 million of the fine is being paid by Olympus’ Latin American (OLA) division to resolve a separate criminal charge after paying providers at government-owned facilities to buy Olympus products.”

Between 2006 and 2011, OLA spent nearly $3 million in cash, money transfers, personal grants, personal travel and free or heavily discounted equipment to get providers at government-owned facilities to buy Olympus products. OLA admits it delivered this illicit kickbacks benefits to pre-selected practitioners at “training centers,” nominally set up to educate and train doctors. In total, OLA actions earned them $7.5 million in profits.

Olympus has come under fire in recent months by the Food and Drug Administration and the Senate after it was revealed that their duodenoscopes were linked to dozens of infection outbreaks and 21 deaths since 2012. A report  by the Washington Post found that the company knew its scopes had a flaw that prevented them from being disinfected properly, but concealed the dangers from hospitals for two years.

“OLA’s illegal tactics in Central and South America mirrored Olympus’s conduct in the United States.  The FCPA resolution announced today demonstrates the department’s commitment to ensuring the integrity of the health-care equipment market, regardless whether the illegal bribes occur in the U.S. or abroad,” said Principal Deputy Assistant Attorney General Bitkower. 

As part of the settlement Olympus has signed a new corporate integrity agreement with the Department of Health and Human Services. The program requirements include:

  • Compliance responsibilities for OCA management and the board of directors
  • A health care compliance code of conduct that includes certain standards
  • Training and education that includes specified standards
  • Requirements for consulting arrangements, grants and charitable contributions, management of field assets and review of travel expenses
  • A risk assessment and mitigation process
  • New review procedures for testing the compliance program

“For years, Olympus Corporation of the Americas (OCA) and Olympus Latin America (OLA) dropped the compliance ball and failed to have in place policies and practices that would have prevented the substantial kickbacks and bribes they paid,” said U.S. Attorney Paul Fishman. “It is appropriate that they be punished for that. At the same time, the deferred prosecution agreement takes into account the companies’ cooperation and commitment to fully functional corporate compliance.”

Medical Device Vulnerabilities High on CIO's List of Worries

By Scott Mace, HealthLeaders Media

This article originally appeared in HealthLeaders Media.

As HIMSS gets underway, the healthcare IT world is still shaking from last month's audacious privacy breach at a California hospital. Hollywood Presbyterian Hospital paid a $17,000 ransom to a criminal enterprise that broke into the hospital's system, encrypted data, and demanded an even larger payment.

While the concept of "ransomware" is not new, the very public ransom payment by Hollywood Presbyterian once again ratchets up the pressure in healthcare executive suites and boardrooms to do something different, and soon, to protect healthcare's digital assets.

As these things usually go, we may not learn exactly how the ransomware crooks found their way into Hollywood Presbyterian's systems and data. Perhaps to guard against further intrusions, or as a bulwark against lawsuits, enterprises tend not to divulge publicly just what the root cause of breaches are.

With that in mind, I spoke last week with a CIO who is sounding the alarm about an attack vector which, to my knowledge, has not yet been publicly blamed for any major breach in a US healthcare system, but has to be on the list of culprits. 

Aaron Miri is chief information officer of the 100-bed Walnut Hill Medical Center in Dallas, Texas. "I came out of the telecom space," he says. "Healthcare is probably 10, 15, 20 years behind the finance, telecom, and other industries, and rapidly catching up, but very much behind.

"Medical devices are one of the top issues for CIOs, due to the fact that the rules of the road apply differently to hospitals than they do to the medical device manufacturers, the EMR vendors, and to all the different verticals within healthcare that make up the continuum of healthcare."

The issue, Miri says, is that too many medical device manufacturers do not meet the definition of a covered entity as defined by HIPAA. Where a covered entity such as Walnut Hill has to abide by all of HIPAA's provisions to encrypt data at rest or in transit, the non-covered-entity device manufacturers can avoid placing basic security provisions in their equipment—provisions such as specific, secure logins.

"Those medical devices and those devices out there in the field are absolutely a risk point, because they have to touch a corporate network in some form or fashion to translate that data back to your EMR or whatever application is ingesting that," Miri says. 

At this point, I noted the lack of specific callouts to unsecured medical devices as a root problem on the HHS Office of Civil Rights' notorious "wall of shame" of HIPAA breaches.

Miri's response took the form of an example. "In one of my previous lives, we had a newborn hearing test [device] that goes into the newborn's ear, [and] was plugged in, via a serial cable, to a vendor-provided laptop," he says.

"That was all considered a standalone solution. But it was really a laptop connected to this medical device, all supported by the vendor. But it could not be encrypted for latency purposes. So we had to do all sorts of mitigating factors around it to make sure that, because it wasn't encrypted, that we accepted the risk, that we understood what the risk was, and so forth and so on. We had a business associate agreement with that vendor, and so that vendor dealt with the whole kit and caboodle, the whole solution. However, that was a risk point."

Sure enough, Miri says, "we did have an issue that we had to report to the OCR, because that laptop ended up stolen. These things happen all the time; however, given the nature of how clinical devices are somewhat a hodgepodge of laptops, computers, and/or a medical device, it may not qualify as a standalone device that must be reported."

A Big, Big, Big Problem

Windows XP is also a continuing headache in too many medical devices, Miri says. "I just saw one the other day in the UK, where a Windows XP device that was actually a lab instrument was infected with malware and had inadvertently infected an entire NHS hospital."

Another example Miri cites is medication-dispensing machines. "In my previous life, I had three brand-new medicine-dispensing machines shipped to me, brand new, still in the shrinkwrap," he says. "We put them into a brand new unit we had just built. We turned them on. We plugged them in the network. Immediately, my systems started going haywire. Sure enough, these things came infected from the factory with malware, because their underlying operating system was Windows XP. This was just a year and a half ago.

"Based on my conversations with other CIOs, [we] don't even know what's happening because of how unmanaged these devices are." He likens these devices to "little pockets of individual freedom floating out there that must attach to your network because the FDA mandates it must do so, without any ability to get your arms around the product, because they play by a different set of rules. So it's a big, big, big problem."

In Washington, groups such as CHIME and HIMSS are calling for tougher rules on medical device manufacturers, but Miri notes that responsibility for solving the problem is divided by between the FDA, the FTC, and the HHS Office of Civil Rights. "Who is the true sheriff of the road?" he asks. "Anybody who knows anything about government knows that once you have multiple agencies playing, they seem to get in each other's way."

The White House has a cybersecurity coordinator, but Miri says there is an effort to augment this with, effectively, a national chief information security officer, to stop the finger-pointing among agencies. A provision in the Cybersecurity Information Sharing Act of 2015, signed into law by President Obama in December, may help put such a czar in place.

"Some action is better than no action, but there is still no mandate, and I am still able to go buy medical devices on the market without any encryption, or without following the same rules that I am forced to go by as a covered entity," Miri says.

For now, CIOs such as Miri will have to rely upon a protective superstructure of security software, overlaid upon their computer networks, to try to detect intrusions, and limit the amount of damage that a rogue device can do upon a network. Miri relies on commercial solutions from vendors such as Imprivata to manage important aspects such as single sign-on, user access controls, and auditing.

"Especially when it comes to IT, I'm competing for every dollar I need to spend against a dollar that could be spent on a new bed or a new instrument, so if I cannot show ROI, you can bet your bottom dollar the CFO is going to give me any money to spend."

"So beyond the convenience and quality and safety factors of being able to audit, track, and disseminate what's going on with my community, I am able to show time saved. I am able to show a maximization of the time spent at the bedside with the patient."

Miri described other techniques that are making a difference, including virtual desktop interfaces (VDI) which provide further control of desktops. But I came away from our conversation believing it is high time that we crack down on those devices that represent one of the most vulnerable attack vendors of healthcare IT today.

It's not difficult to believe that if we do not act much more aggressively, a lot more ransoms shall be demanded by cyber criminals. At this crucial time in healthcare, it's the last thing any of us need.

Scott Mace is the senior technology editor at HealthLeaders Media.

AHRQ releases new tool to reduce CAUTI

Building on its Comprehensive Unit-based Safety Program (CUSP), the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) recently released a new toolkit aimed at reducing catheter-associated urinary tract infections (CAUTI) in hospitals.

Released in October 2015, the toolkit consists of three modules: implementation, sustainability, and resources. Hospitals can use principles of the CUSP program that have been successful in reducing central line-associated bloodstream infections (CLABSI) to reduce CAUTI rates in high-risk areas of the facility.

This is an excerpt from the monthly healthcare safety resource Patient Safety Monitor Journal. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

FDA: Top Three Duodenoscope Makers Release Updated Instructions

On February 19, the Food and Drug Administration (FDA) announced that reprocessing instructions for Pentax duodenoscopes had been validated and approved by the agency.  The announcement means that scopes from the three major manufactures, Olympus, Fujifilm, and Pentax, are now safe to use with their updated instructions.

Five months ago, the FDA issued safety warning against the three companies, stating that a design flaw prevented their scopes from being cleaned properly and were an infection risk. A later Senate investigation revealed that dirty scopes were the direct cause of 25 infection outbreaks since 2012

Pentax was the final company to have its updated reprocessing instructions validated by the FDA, with instructions for Fujifilm scopes and modifications to Olympus scopes approved in January.

Click here to read the FDA’s full safety communication on Pentax’s reprocessing instructions for the ED-3490TK Video Duodenoscope.

Nurse Renewal Rooms Benefit Patients, Too

By Jennifer Thew, HealthLeaders Media

This article originally appeared in HealthLeaders Media.

Hoping to counter stress and compassion fatigue, one hospital has created private spaces for its nurses to process their emotions before returning to their patients, refocused. At least one study links better nursing environments to better patient outcomes.

Crying at work is traditionally frowned upon, but I'm going to put myself out on a limb and admit I've done it. And, if you're being completely honest, you've done it, too.

After a code, a patient's death, a scolding from a physician, or a day when nothing seems to go right, many of us have sought solace in the nearest linen closet, locker room, or bathroom stall and let the tears flow.

In fact, just last week, this photo of an ED physician grieving the loss of a patient, popped-up in my Facebook feed, courtesy of an ED nurse friend. When someone who isn't a healthcare professional commented that it's unreasonable to expect healthcare workers to jump back into their shifts after a patient's death as if nothing happened, my friend replied, "We do it every day."

But, this 'rub some dirt on it and get back into the game' mentality might not be serving our profession well.

A study published in 2011 found that in a sample of 182 oncology nurses, one-third demonstrated emotional exhaustion and reported low rates of personal accomplishment, one-quarter reported depersonalization, and a 50% reported levels of emotional distress.

"Compassion fatigue is a huge issue for us all in bedside nursing, and we as leaders need to look into and address that," says Jacklynn Lesniak, RN, MS, BSN, senior vice president of patient care services and chief nursing officer at Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, IL.

One way CTCA Midwestern is tackling this issue is by giving RNs the time, tools, and space to process their feelings in the comfort of nurse-designed renewal rooms.

Disconnect to Reconnect
Jillianne Shriver, RN, BSN, HN-BC, team lead for the inpatient medical oncology unit at CTCA Midwestern, was inspired to develop the concept for the organization's renewal rooms after learning various types of relaxation techniques, during a three-week training on holistic nursing.

Those techniques included aromatherapy, journaling, and meditation. Though many of these interventions don't take very long—Shriver says benefits can be seen in as little as five minutes—finding the time and place to practice them during a busy shift can be challenging.

"I decided that I really wanted somewhere for the nurses to take that time to renew, rejuvenate, and recharge," she says. "To step out of whatever situation they may be in, whether that be a stressful or busy day, and have five to 15 minutes to themselves to be able to focus, ground themselves, take a deep breath, and then step back into practice."

Shriver began the project in May 2013 by reclaiming a storage space in which to she established the first renewal room. In it she placed a massage chair and tools for aromatherapy, music therapy, and journaling. There is also a sand garden, small waterfall, inspirational books, a Tibetan singing bowl, and a yoga mat.

"The environment I wanted to create is a private space," Shriver says. "We ask that they go in by themselves."

Before entering, nurses must let their charge nurse know they need to use the room and must turn over their phones, pagers, or other communications devices. The door is locked to ensure no one can interrupt them during their five to 15 minutes away.

"That way there's not any distractions, and they can really take that moment to focus on themselves," Shriver says. "In nursing, we have a wide variety of emotions, and they're able to go in there and express those emotions in a quiet, safe place."

A Much Needed Intervention
Aware of the aforementioned study on oncology nurses' experiences of burnout, Shriver wanted to make sure the room was serving its purpose. So she asked nurses to rate their anxiety levels on a Likert scale before and after using the room. After three months, it became clear it was a much-needed intervention.

"We logged that the room was utilized over 422 times in three months," she says. "After reviewing the surveys, 96% of the nurses reported that they had a decreased level of anxiety and they felt much better after they left the room."

In addition, Shriver says there was often a line of nurses waiting to use the room and the nurses shared some of their personal experiences using the room.

"I had a nurse say that after a patient crisis, her heart was racing and she shouldn't catch her breath," Shriver says. "So she went to the renewal room to cry it out. After that she was able to be present for all of her patients at that time."

She presented her findings to nursing leadership, which in turn supported the addition of renewal rooms in the construction plans for the organization's new inpatient tower that opened in November 2015.

"As the chief nursing officer, I was able to advocate for the staff through the building process and say to the board of directors, 'We really need this space in the new building.'"


Lesniak says there are now five renewal rooms in the organization—one on each unit in the inpatient tower, one in the surgical department, and one in the outpatient care area.

Benefits of a Holistic Environment
The renewal rooms are part of CTCA Midwestern's larger commitment to providing a holistic environment for both staff and patients, says Lesniak.

"One of our goals is to be a premier provider of nursing care and to establish that in an environment of healing and hope," she says. "Normally you look at an environment of healing and hope as being very patient-centric, which at CTCA is foundational to our model. But we took it a step further and [looked] at how it affects our nursing staff."

This includes supporting nurses in obtaining specialty certification in holistic nursing. Lesniak says there are currently 36 nurses who have achieved the holistic nursing specialty certification.

Developing a holistic work environment is more than something that is just nice to do for the nurses. Lesniak says helping nurses stay connected to their mind, body, emotions, and spirit, can benefit organizations and patients as well.

"As CNOs, something we're facing is the recruitment and retention of great talent," she says. "Holistic nursing and things like the renewal room and other methodologies of ensuring our bedside staff can take care of themselves are a huge strategy to help with recruitment and retention of our bedside nurses in the country."

New research by Linda H. Aiken, RN, PhD, FAAN, FRCN, at the University of Pennsylvania supports the idea that happy nurses equal happy (and healthy) patients. The study found patients who had surgery at hospitals with better nursing environments, including Magnet designation (which CTCA Midwestern has achieved), and above-average staffing levels, have better outcomes at the same or lower costs than other hospitals. 

And in healthcare, no matter how you get there, better patient outcomes is what it's all about.

"We really want our nurses to empower themselves by realizing the importance of their practice of self-care," Shiver says, "because when nurses take care of themselves, they can better serve their patients, the patients' families, and their communities."

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. 

Read more...

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.

Read more...

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.”



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