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Senate
Passes Patient Safety Bill JCAHO
Releases 2005 Patient Safety Goals Family
Physicians Eager to Adopt EHR, AAFP Survey Says HealthGrades
Study Finds 195,000 Medical Error Deaths in U.S., IOM Author Questions
Numbers AMA
To Seek Comment for New Physician Performance Measures AHRQ
to Hold Chronic Care Conference Sept. 10-11 AHA
Seeking ‘Quest for Quality’ Applicants by Oct. 15 Senate Passes Patient Safety
Bill A Senate bill designed to improve patient safety through
collecting and reporting medical error data passed by a voice vote after
a yearlong delay. The bill now must be reconciled with a similar bill
that the House of Representatives passed in March 2003. “Under this bill, doctors and other health care
providers will be able to report their mistakes without the threat of
punishment, and their patients will be much better off for it,”
said Sen. Jim Jeffords (I-Vt.), the primary sponsor of the bill. Senate bill 720, the Patient Safety and Quality Improvement
Act, calls for the establishment Patient Safety Organizations (PSO): private
or public organizations tasked with analyzing reported patient safety
data and developing strategic guidance to give back to providers on how
to improve patient safety and the quality of care. Highlights of the Senate bill include: The
Senate Committee on Health, Education, Labor and Pensions (HELP) unanimously
passed the patient safety bill in July 2003 but disagreements over evidentiary
privileges blocked the bill for almost a year. Sen. Judd Gregg (R-N.H.),
chairman of the HELP committee, said in a statement that bill passed July
22 after bipartisan negotiations. JCAHO Releases 2005 Patient
Safety Goals The Joint Commission on Accreditation of Healthcare Organizations
has released its 2005 National Patient Safety Goals for each of its accreditation
programs and its disease-specific care certification program. The goals
and associated requirements, apply to the nearly 16,000 Joint Commission-accredited
and certified health care organizations and programs. The 2005 National Patient Safety Goals are specific to
the various types of health care settings accredited and certified by
the Joint Commission. These include ambulatory care and surgery centers,
office-based surgery, assisted living facilities, behavioral health care
settings, critical access hospitals, disease-specific care programs, home
health care, hospitals, nursing homes, and laboratories. “The 2005 National Patient Safety Goals extend our
expectations of accredited organizations in providing safe, high quality
care,” JCAHO President Dennis S. O’Leary, MD, said. The goals establish succinct, evidence-based requirements
related to critical aspects of care, addressing, for example, the accuracy
of patient identification, effectiveness of communication among caregivers,
safety in the use of infusion pumps, reduction of the risk of health care-associated
infections, reconciliation of medications across the continuum of care,
reduction of the risk of patients falls, and protection against pneumonia
in older adults. The National Patient Safety Goals are reviewed and revised
annually by the Sentinel Event Advisory Group. The goals are largely,
but not exclusively, based on information from the Joint Commission’s
Sentinel Event Database. For more info, www.jcaho.org. Family Physicians Eager to
Adopt EHR, AAFP Survey Says A member survey conducted by the American Academy of Family
Physicians found that nearly 40% of the respondents have either completely
converted to electronic health record systems or are in the process of
making the transition in their practices. The survey polled 788 AAFP members in 21 constituent chapters.
Of the 310 respondents that have EHRs, 73% indicated that their EHR systems
improved the health of their patients in part by reducing prescribing
errors and enhancing patient communication. The survey also found that
49% of AAFP members wanted to purchase an EHR—15% of those within
one year, 16% within two years and 18% after two years—with only
7% of the respondents indicating they had no plans to purchase an EHR. AAFP hopes to have 50% of its active members using EHRs
by the end of next year. HealthGrades Study Finds 195,000
Medical Error Deaths in U.S., IOM Author Questions Numbers An average of 195,000 people in the U.S. died due to potentially
preventable, in-hospital medical errors in each of the years 2000, 2001
and 2002, according to a study of 37 million patient records that was
released by HealthGrades. The HealthGrades study applied the mortality and economic
impact models developed by Dr. Chunliu Zhan and Dr. Marlene R. Miller
in a research study published in the Journal of the American Medical Association
in October of 2003. The Zhan and Miller study supported the Institute
of Medicine’s (IOM) 1999 report conclusion, which found that medical
errors caused up to 98,000 deaths annually and should be considered a
national epidemic. The HealthGrades study finds nearly double the number
of deaths from medical errors found by the 1999 IOM report “To Err
is Human,” with an associated cost of more than $6 billion per year. The IOM study extrapolated national findings based on
data from three states; the Zhan and Miller study looked at 7.5 million
patient records from 28 states over one year; and HealthGrades looked
at three years of Medicare data in all 50 states and D.C. This Medicare
population represented approximately 45% of all hospital admissions (excluding
obstetric patients) in the U.S. from 2000 to 2002. “The HealthGrades study shows that the IOM report
may have underestimated the number of deaths due to medical errors, and,
moreover, that there is little evidence that patient safety has improved
in the last five years,” said Dr. Samantha Collier, HealthGrades’
vice president of medical affairs. “The equivalent of 390 jumbo
jets full of people are dying each year due to likely preventable, in-hospital
medical errors, making this one of the leading killers in the U.S.”
HealthGrades examined 16 of the 20 patient-safety indicators
defined by the Agency for Healthcare Research and Quality—from bedsores
to post-operative sepsis—omitting four obstetrics-related incidents
not represented in the Medicare data used in the study. Of these sixteen,
the mortality associated with two, failure to rescue and death in low
risk hospital admissions, accounted for the majority of deaths that were
associated with these patient safety incidents. These two categories of
patients were not evaluated in the IOM or JAMA analyses, accounting for
the variation in the number of annual deaths attributable to medical errors.
However, the magnitude of the problem is evident in all three studies.
But Forbes magazine’s website reported
that Dr. Lucian Leape, adjunct professor of health policy at the Harvard
School of Public Health and one of the authors of the 1999 IOM report,
questioned the numbers. He argued that failure to rescue is not an accepted
standard in calculating deaths in Medical errors, and that the nature
of Medicare patients would increase the mortality rate. “Medicare patients have a higher adverse event rate
because they have a lot more treatments, they’re sicker, they have
multiple diseases, so the mortality rate, the error rate, all these things
are higher,” Leape said in the Forbes article. AMA To Seek Comment for New
Physician Performance Measures The American Medical Association-convened Physician Consortium
for Performance Improvement is beginning a 30-day public comment period
for the recently developed physician clinical performance measures for
community-acquired pneumonia. Both the measures and the comment response
form are available at www.ama-assn.org/go/quality. The public comment period extends from Aug. 2 –
Sept. 3. AHRQ to Hold Chronic Care Conference
Sept. 10-11 The Agency for Healthcare Research and Quality is co-sponsoring
a two-day multidisciplinary research dissemination conference with the
University of Missouri-Columbia Nursing Outreach and Distance Education
program on Sept. 10-11 in Columbia, MO. The conference, “A National Conference on Transferring
Geriatric Research into Practice: Improving Chronic Care Quality,”
will focus on improving chronic care quality in long-term, home, and community
care settings. Featured speakers include Rosaly Correa-de-Araujo MD,
PhD, AHRQ senior advisor for women’s health and Arlene Bierman MD,
chair of the Ontario Women’s Health Council Chair at the University
of Toronto’s St. Michael’s Hospital. For more info, www.muhealth.org/~nursing/node/conference/chroniccare04.html.
AHA Seeking ‘Quest for
Quality’ Applicants by Oct. 15 Applications are now available for the 2005 American Hospital
Association McKesson The AHA McKesson Quest for Quality Prize seeks to raise
awareness of the need for an organizational commitment to highly reliable,
exceptional quality, patient-centered care; reward successful efforts
to create and improve systems that improve quality of care; inspire organizations
to broaden their framework for quality improvement efforts through systematic
integration and alignment throughout the organization; and communicate
successful programs and strategies to the hospital field. The award is supported by grants from McKesson and the
McKesson Foundation. The award winner will receive $75,000 and two finalists
will receive $12,500 each. Other hospitals may be recognized with Citations
of Merit. Applications and information on the prize are available
at www.aha.org/questforquality, by calling 312-422-2700, or by writing
the Office of the Secretary, American Hospital Association, One North
Franklin, Chicago, IL 60606. Applications are due Oct. 15.  Home :: Inside AHQA :: For The Media :: Public Policy :: Advancing Quality :: Quality Connections :: SiteMap
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