The document provides a summary of sentinel event data reported in Utah from 2009. 101 sentinel events were reported in 2009, with 54 being surgical or procedural events. The most common type of event reported was related to retained foreign objects during surgical procedures. Initiatives are underway in Utah to address common safety issues identified in the data like retained foreign objects and to improve reporting and identification of sentinel events.
This presentation describes the historical basis for error reduction initiatives, published errors and rates of occurrence, prototype paper-based model vs software-based model, software-based model deployment, and results.
A SPECIAL S U P P L E H E N T TO THE HHTIHGS CENTEH REPOUT.docxbartholomeocoombs
A SPECIAL S U P P L E H E N T TO THE H/HTIHGS CENTEH REPOUT
ETY
i ! . : i, . - w , ; , • • ' • ' i l
POLICY DELIBERATIOI
VIRGINIA A. SHARPE
On the cover: Hospital, by Frank Moore,
1992. Oil on wood with frame and attach-
ments. 49" X 58" overall. Private Collection,
Italy. Courtesy Sperone Westwater, New
York.
This is the final report of a two-year Hastings Center research
project that was launched in response
to the landmark 1999 report from the
Institute of Medicine, To Err Is
Human, and the extraordinary atten-
tion that policymakers at the federal,
state, regulatory, and institutional lev-
els are devoting to patient safety. It
seeks to foster clearer and better dis-
cussion of the ethical concerns that
are integral to the development and
implementation of sound and effec-
tive policies to address the problem of
medical error. It is intended for poli-
cymakers, patient safety advocates,
health care administrators, clinicians,
lawyers, ethicists, educators, and oth-
ers involved in designing and main-
taining safety policies and practices
within health care institutions.
Among the topics discussed in the
report:
H the values, principles, and per-
ceived obligations underlying pa-
tient safety efforts;
• the historical and continuing
tensions between "individual" and
"system" accountability, between
error "reporting" to oversight agen-
cies and error "disclosure" to pa-
tients and families, and between
aggregate safety improvement and
the rights and welfare of individual
patients;
• the practical implications for
patient safety of defming "respon-
sibility" retrospectively, as praise or
blame for past events, or prospec-
tively, as it relates to professional
obligations and goals for the fu-
ture;
S the shortcomings of tort liabili-
ty as a means of building institu-
tional cultures of safety, learning
from error, supporting truth telling
as a professional obligation, or ad-
equately compensating patients
and families, contrasted with alter-
native models of dispute resolu-
tion, including mediation and no-
fault liability;
SB the needs of patients, families,
and clinicians affected by harmful
errors and how these needs may be
addressed within systems ap-
proaches to patient safety; and
SI the potential conflicts berween
the protection of patient privacy
required by the Health Insurance
Portability and Accountability Act
and efforts to use patient data for
the purposes of safety improve-
ment, and how these conflicts may
be resolved.
Although this report is the work of
the project's principal investigator,
not a statement of consensus, it draws
from the insights of the interdiscipli-
nary group of experts convened by
The Hastings Center to make sense of
the complex phenomenon of patient
safety reform. Working group mem-
bers brought their experience as peo-
ple who had suffered from devastat-
ing medical harms and as institution-
al leaders galvanized to reform by
tragic events in their own health care
institutions. They br.
This presentation describes the historical basis for error reduction initiatives, published errors and rates of occurrence, prototype paper-based model vs software-based model, software-based model deployment, and results.
A SPECIAL S U P P L E H E N T TO THE HHTIHGS CENTEH REPOUT.docxbartholomeocoombs
A SPECIAL S U P P L E H E N T TO THE H/HTIHGS CENTEH REPOUT
ETY
i ! . : i, . - w , ; , • • ' • ' i l
POLICY DELIBERATIOI
VIRGINIA A. SHARPE
On the cover: Hospital, by Frank Moore,
1992. Oil on wood with frame and attach-
ments. 49" X 58" overall. Private Collection,
Italy. Courtesy Sperone Westwater, New
York.
This is the final report of a two-year Hastings Center research
project that was launched in response
to the landmark 1999 report from the
Institute of Medicine, To Err Is
Human, and the extraordinary atten-
tion that policymakers at the federal,
state, regulatory, and institutional lev-
els are devoting to patient safety. It
seeks to foster clearer and better dis-
cussion of the ethical concerns that
are integral to the development and
implementation of sound and effec-
tive policies to address the problem of
medical error. It is intended for poli-
cymakers, patient safety advocates,
health care administrators, clinicians,
lawyers, ethicists, educators, and oth-
ers involved in designing and main-
taining safety policies and practices
within health care institutions.
Among the topics discussed in the
report:
H the values, principles, and per-
ceived obligations underlying pa-
tient safety efforts;
• the historical and continuing
tensions between "individual" and
"system" accountability, between
error "reporting" to oversight agen-
cies and error "disclosure" to pa-
tients and families, and between
aggregate safety improvement and
the rights and welfare of individual
patients;
• the practical implications for
patient safety of defming "respon-
sibility" retrospectively, as praise or
blame for past events, or prospec-
tively, as it relates to professional
obligations and goals for the fu-
ture;
S the shortcomings of tort liabili-
ty as a means of building institu-
tional cultures of safety, learning
from error, supporting truth telling
as a professional obligation, or ad-
equately compensating patients
and families, contrasted with alter-
native models of dispute resolu-
tion, including mediation and no-
fault liability;
SB the needs of patients, families,
and clinicians affected by harmful
errors and how these needs may be
addressed within systems ap-
proaches to patient safety; and
SI the potential conflicts berween
the protection of patient privacy
required by the Health Insurance
Portability and Accountability Act
and efforts to use patient data for
the purposes of safety improve-
ment, and how these conflicts may
be resolved.
Although this report is the work of
the project's principal investigator,
not a statement of consensus, it draws
from the insights of the interdiscipli-
nary group of experts convened by
The Hastings Center to make sense of
the complex phenomenon of patient
safety reform. Working group mem-
bers brought their experience as peo-
ple who had suffered from devastat-
ing medical harms and as institution-
al leaders galvanized to reform by
tragic events in their own health care
institutions. They br.
Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 447
Patient Safety and Patient Safety
Culture: Foundations of Excellent
Health Care Delivery
Primum non nocere. First do no harm.
Patient safety forms the founda-tion of healthcare delivery justas biological, physiological,and safety needs form the
foundation of Maslow’s hierarchy
(Maslow, 1954). Little else can be
accomplished if the patient does not
feel safe or is, in fact, not safe. But the
healthcare system is extremely com-
plex, and ensuring patient safety
requires the ongoing, focused efforts
of every member of the healthcare
team.
Patient safety moved to the fore-
front in health care with the release in
1999 of the Institute of Medicine (IOM)
landmark report, To Err is Human:
Building a Safer Health System, which
estimated that annually in the United
States, up to one million people were
injured and 98,000 died as a result of
medical errors (IOM, 2000). The re -
port caught the attention of the media,
and there were headlines across the
nation about the safety (or lack of safe-
ty) for patients in healthcare organiza-
tions. In 2013, James updated the esti-
mate of patient harms associated with
Beth Ulrich
Tamara Kear
Continuing Nursing
Education
Beth Ulrich, EdD, RN, FACHE, FAAN, is
Editor, the Nephrology Nursing Journal, and a
Professor, the University of Texas Health Science
Center at Houston School of Nursing. She is a Past
President of ANNA and a member of ANNA’s
Sand Dollar Chapter. She may be contacted direct-
ly via email at [email protected]
Tamara Kear, PhD, RN, CNS, CNN, is an
Assistant Professor of Nursing, Villanova
University, Villanova, PA, and a Nephrology
Nurse, Liberty Dialysis. She is on the Editorial
Board for the Nephrology Nursing Journal,
serves as the ANNA Research Committee chairper-
son, and is a member of ANNA’s Keystone Chapter.
Statements of Disclosure: Please refer to page
457.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 457.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of ex -
cellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.
In 1999, patient safety moved to the forefront of health care based upon astonishing sta-
tistics and a landmark report released by the Institute of Medicine (IOM). This report,
To Err.
The New Focus on Quality and OutcomesIntroductionIn 1999, the .docxoreo10
The New Focus on Quality and Outcomes
Introduction
In 1999, the Institute of Medicine (IOM) published a groundbreaking analysis of the impact of medical errors on the health care delivery system and the patients it serves. The analysis, published as "To Err is Human: Building a Safer Healthcare System," concluded that medical errors resulted in up to 98,000 patient deaths in American hospitals every year. This report hit the national press and participants in the health care system and the political system with the force of a large bomb. Since that time, hospitals and other health care entities have refocused their attention on quality, errors, and patient safety in an unprecedented way, urged on by public outcry and by federal and state efforts to compel improvements in the health care system. Such entities as the Institute for Healthcare Improvement (www.ihi.org) the National Quality Forum (www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have all emerged as champions of quality and safety initiatives, offering training, resources, access to best practices, and data collection strategies to move the cause of quality and safety for patients forward.
History
The IOM report had a huge impact on the discussion of quality and safety in the health care field. Aspects of quality care have always been present in hospitals, typically focused around the quality assurance or quality management departments. They historically collected data on department indicators and monitored them as part of accreditation. However, departmental data was typically focused on operational performance in the departments in question, and not a great deal was collected on issues of medical errors and near-misses. The litigious legal climate caused most hospitals to fear collecting and sharing data that could potentially be used against them in a legal action. However, the IOM report caused a national demand to know what health care institutions were doing to protect their patients from injury caused by errors. A climate of increased transparency has begun to emerge, although it is still a very long way from the concept of full openness on standardized reporting of indicators. The Centers for Medicare and Medicaid Services (CMS) weighed in with publication of their never-events, as explored further below.
Finally there has been an increased push for public reporting of data on individual hospital performance on selected indicators. While some progress has been made, there is a large range of indicators that is not yet publically reported, and medical errors are not publically reported at all at this point, although those with great potential to cause harm must be reported to their relevant state licensing agency.
What Is Happening Now
Out of all this push has come an increasing focus on patient safety as a critical aspect of health care quality. Hospitals and other health care institutions are experimenting with the creation of cultures of quality, wherein ...
Please follow instructions carefully. Thank you so kindly. Ass.docxmattjtoni51554
Please follow instructions carefully. Thank you so kindly.
Assignment 1 “Changes in Human Resource Management (HRM) and Employment Law" Please respond to the following: 1 and ½ half pages with references
· Based on the assigned chapters this week, identify three (3) key changes that have advanced HR and provide a justification to support your selection.
· From this week’s assigned reading, choose one (1) historical government HR regulation enacted and elaborate on how this new mandate affected all stakeholders involved. Recall stakeholders in any industry, and cover those directly involved and their communities.
Assignment 2 "Human Resources Activities and Relationships" Please respond to the following:
1 and ½ half pages with references
· Considering the services provided by a hospital HR department, how do most HR specialists deal with employee scarcity like nursing shortages when trying to hire the best professionals?
· What leadership and management skill sets are useful for retaining good employees and deferring employee turnover?
Assignment 3
Job Descriptions and Employee Training and Development" Please respond to the following:
2 pages with references
· Go to the Joint Commission’s Website located at http://www.jointcommission.org/standards_information/jcfaq.aspx. At “Standards FAQs,” select a field-related manual category from the drop-down list, type in “human resources” in the “Optional Keyword” box, and then click the “Go” button. Next, provide an example of how the Joint Commission has influenced a specific function of HR in a healthcare organization.
· Recommend a specific employee training method that you think would be most effective for a healthcare organization, and determine one advantage and one disadvantage of your chosen training method. Provide support for your rationale.
The New Focus on Quality and Outcomes
Introduction
In 1999, the Institute of Medicine (IOM) published a groundbreaking analysis of the impact of medical errors on the health care delivery system and the patients it serves. The analysis, published as "To Err is Human: Building a Safer Healthcare System," concluded that medical errors resulted in up to 98,000 patient deaths in American hospitals every year. This report hit the national press and participants in the health care system and the political system with the force of a large bomb. Since that time, hospitals and other health care entities have refocused their attention on quality, errors, and patient safety in an unprecedented way, urged on by public outcry and by federal and state efforts to compel improvements in the health care system. Such entities as the Institute for Healthcare Improvement (www.ihi.org) the National Quality Forum (www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have all emerged as champions of quality and safety initiatives, offering training, resources, access to best practices, and data collection strategies to move the cause of quality.
A proposal for classifying peristomal skin disorders: results of a multicente...Mario Antonini
The challenges of caring for abdominal ostomy disorders have grown over the years. Because the literature shows no evidence of a tool to classify peristomal skin disorders, a study group comprised of seven enterostomal therapy nurses and four surgeons sought to provide an objective, reproducible, standardized classification instrument. A prospective, observational study was conducted
among eight ostomy centers across Italy. The 339 patient participants (272 men, 67 women, average age 63 [25 to 85] years) were divided into two groups according to onset of complications (less than or greater than 1 year); 800 digital photographs were taken to enhance observation and blood samples were drawn for additional data. From the data obtained, a classification scheme was created
and subsequently tested using four non-study group experts. The resulting instrument facilitated lesion interpretation and detection, including topography. Thus far, this is the first validated classification attempt not based on assessments of lesions attributable to entirely different etiopathogenetic factors. Further research to refine the tool and to correlate the additional data obtained from blood samples with the classification system is underway.
November 1999I N S T I T U T E O F M E D I C I N E S.docxIlonaThornburg83
November 1999
I N S T I T U T E O F M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding the expense of additional care necessitated by the errors, lost income
and household productivity, and disability) of between $17 billion and $29
billion per year in hospitals nationwide. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
in terms of loss of
trust in the health
care system by pa
tients and dimin
ished satisfaction
by both patients
and health profes
sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatmen.
2 8 5L e a r n I n g o b j e c t I v e sC H A P T E R.docxlorainedeserre
2 8 5
L e a r n I n g o b j e c t I v e s
C H A P T E R 1 0
Q U A L I T Y M A N A G E M E N T I N
T H E P H Y S I C I A N P R A C T I C E
Quality and reliability are system properties.
—W. Edwards Deming
➤ Articulate the nature of performance management.
➤ Describe the approaches to performance improvement.
➤ Appreciate the impact of variation on performance.
➤ Discuss the components of the Triple Aim.
➤ Describe process improvement.
In t r o d u c t I o n
One of the most important issues to address in the medical practice is the quality and
safety of the care provided to patients. The Institute of Medicine (IOM 2001), a presti-
gious branch of the National Institutes of Health, stated in its landmark report Crossing the
Quality Chasm: A New Health System for the 21st Century, “In its current form, habits, and
environment, American health care is incapable of providing the public with the quality
health care it expects and deserves.”
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EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 4/16/2020 7:48 PM via SUNY CANTON
AN: 1839064 ; Wagner, Stephen L..; Fundamentals of Medical Practice Management
Account: s8846236.main.ehost
F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 8 6
Another historic IOM (2000) report, To Err Is Human: Building a Safer Health
System, indicated that a shocking number of people—an estimated 44,000 to 98,000 per
year—are harmed by the healthcare system. A more recent study found that this number
has increased since publication of the 2000 IOM report despite substantial efforts to
improve. Medical errors have now become the third leading cause of death in the United
States (Makary and Daniel 2016).
The complexity of medical service and the inconsistency with which these services
are delivered, not to mention the fragmented nature of the system, have led to a number
of quality concerns (Mosadeghrad 2014), including a lack of systematic approaches to care
delivery and quality improvement. Efforts to improve quality in the medical profession
have a long tradition of focusing on individual performance versus system performance.
Exhibit 10.1 illustrates the potential flaw in this thinking. The bell-shaped curve, P-1,
represents the overall performance of any given system. Curve P-2 illustrates an improved
system of performance where the median performance is moved from M-1 to M-2. If an
organization seeks to improve by only focusing on the low performers, it experiences only
a small improvement, shown as I-1. By improving th ...
Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 447
Patient Safety and Patient Safety
Culture: Foundations of Excellent
Health Care Delivery
Primum non nocere. First do no harm.
Patient safety forms the founda-tion of healthcare delivery justas biological, physiological,and safety needs form the
foundation of Maslow’s hierarchy
(Maslow, 1954). Little else can be
accomplished if the patient does not
feel safe or is, in fact, not safe. But the
healthcare system is extremely com-
plex, and ensuring patient safety
requires the ongoing, focused efforts
of every member of the healthcare
team.
Patient safety moved to the fore-
front in health care with the release in
1999 of the Institute of Medicine (IOM)
landmark report, To Err is Human:
Building a Safer Health System, which
estimated that annually in the United
States, up to one million people were
injured and 98,000 died as a result of
medical errors (IOM, 2000). The re -
port caught the attention of the media,
and there were headlines across the
nation about the safety (or lack of safe-
ty) for patients in healthcare organiza-
tions. In 2013, James updated the esti-
mate of patient harms associated with
Beth Ulrich
Tamara Kear
Continuing Nursing
Education
Beth Ulrich, EdD, RN, FACHE, FAAN, is
Editor, the Nephrology Nursing Journal, and a
Professor, the University of Texas Health Science
Center at Houston School of Nursing. She is a Past
President of ANNA and a member of ANNA’s
Sand Dollar Chapter. She may be contacted direct-
ly via email at [email protected]
Tamara Kear, PhD, RN, CNS, CNN, is an
Assistant Professor of Nursing, Villanova
University, Villanova, PA, and a Nephrology
Nurse, Liberty Dialysis. She is on the Editorial
Board for the Nephrology Nursing Journal,
serves as the ANNA Research Committee chairper-
son, and is a member of ANNA’s Keystone Chapter.
Statements of Disclosure: Please refer to page
457.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 457.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of ex -
cellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.
In 1999, patient safety moved to the forefront of health care based upon astonishing sta-
tistics and a landmark report released by the Institute of Medicine (IOM). This report,
To Err.
The New Focus on Quality and OutcomesIntroductionIn 1999, the .docxoreo10
The New Focus on Quality and Outcomes
Introduction
In 1999, the Institute of Medicine (IOM) published a groundbreaking analysis of the impact of medical errors on the health care delivery system and the patients it serves. The analysis, published as "To Err is Human: Building a Safer Healthcare System," concluded that medical errors resulted in up to 98,000 patient deaths in American hospitals every year. This report hit the national press and participants in the health care system and the political system with the force of a large bomb. Since that time, hospitals and other health care entities have refocused their attention on quality, errors, and patient safety in an unprecedented way, urged on by public outcry and by federal and state efforts to compel improvements in the health care system. Such entities as the Institute for Healthcare Improvement (www.ihi.org) the National Quality Forum (www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have all emerged as champions of quality and safety initiatives, offering training, resources, access to best practices, and data collection strategies to move the cause of quality and safety for patients forward.
History
The IOM report had a huge impact on the discussion of quality and safety in the health care field. Aspects of quality care have always been present in hospitals, typically focused around the quality assurance or quality management departments. They historically collected data on department indicators and monitored them as part of accreditation. However, departmental data was typically focused on operational performance in the departments in question, and not a great deal was collected on issues of medical errors and near-misses. The litigious legal climate caused most hospitals to fear collecting and sharing data that could potentially be used against them in a legal action. However, the IOM report caused a national demand to know what health care institutions were doing to protect their patients from injury caused by errors. A climate of increased transparency has begun to emerge, although it is still a very long way from the concept of full openness on standardized reporting of indicators. The Centers for Medicare and Medicaid Services (CMS) weighed in with publication of their never-events, as explored further below.
Finally there has been an increased push for public reporting of data on individual hospital performance on selected indicators. While some progress has been made, there is a large range of indicators that is not yet publically reported, and medical errors are not publically reported at all at this point, although those with great potential to cause harm must be reported to their relevant state licensing agency.
What Is Happening Now
Out of all this push has come an increasing focus on patient safety as a critical aspect of health care quality. Hospitals and other health care institutions are experimenting with the creation of cultures of quality, wherein ...
Please follow instructions carefully. Thank you so kindly. Ass.docxmattjtoni51554
Please follow instructions carefully. Thank you so kindly.
Assignment 1 “Changes in Human Resource Management (HRM) and Employment Law" Please respond to the following: 1 and ½ half pages with references
· Based on the assigned chapters this week, identify three (3) key changes that have advanced HR and provide a justification to support your selection.
· From this week’s assigned reading, choose one (1) historical government HR regulation enacted and elaborate on how this new mandate affected all stakeholders involved. Recall stakeholders in any industry, and cover those directly involved and their communities.
Assignment 2 "Human Resources Activities and Relationships" Please respond to the following:
1 and ½ half pages with references
· Considering the services provided by a hospital HR department, how do most HR specialists deal with employee scarcity like nursing shortages when trying to hire the best professionals?
· What leadership and management skill sets are useful for retaining good employees and deferring employee turnover?
Assignment 3
Job Descriptions and Employee Training and Development" Please respond to the following:
2 pages with references
· Go to the Joint Commission’s Website located at http://www.jointcommission.org/standards_information/jcfaq.aspx. At “Standards FAQs,” select a field-related manual category from the drop-down list, type in “human resources” in the “Optional Keyword” box, and then click the “Go” button. Next, provide an example of how the Joint Commission has influenced a specific function of HR in a healthcare organization.
· Recommend a specific employee training method that you think would be most effective for a healthcare organization, and determine one advantage and one disadvantage of your chosen training method. Provide support for your rationale.
The New Focus on Quality and Outcomes
Introduction
In 1999, the Institute of Medicine (IOM) published a groundbreaking analysis of the impact of medical errors on the health care delivery system and the patients it serves. The analysis, published as "To Err is Human: Building a Safer Healthcare System," concluded that medical errors resulted in up to 98,000 patient deaths in American hospitals every year. This report hit the national press and participants in the health care system and the political system with the force of a large bomb. Since that time, hospitals and other health care entities have refocused their attention on quality, errors, and patient safety in an unprecedented way, urged on by public outcry and by federal and state efforts to compel improvements in the health care system. Such entities as the Institute for Healthcare Improvement (www.ihi.org) the National Quality Forum (www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have all emerged as champions of quality and safety initiatives, offering training, resources, access to best practices, and data collection strategies to move the cause of quality.
A proposal for classifying peristomal skin disorders: results of a multicente...Mario Antonini
The challenges of caring for abdominal ostomy disorders have grown over the years. Because the literature shows no evidence of a tool to classify peristomal skin disorders, a study group comprised of seven enterostomal therapy nurses and four surgeons sought to provide an objective, reproducible, standardized classification instrument. A prospective, observational study was conducted
among eight ostomy centers across Italy. The 339 patient participants (272 men, 67 women, average age 63 [25 to 85] years) were divided into two groups according to onset of complications (less than or greater than 1 year); 800 digital photographs were taken to enhance observation and blood samples were drawn for additional data. From the data obtained, a classification scheme was created
and subsequently tested using four non-study group experts. The resulting instrument facilitated lesion interpretation and detection, including topography. Thus far, this is the first validated classification attempt not based on assessments of lesions attributable to entirely different etiopathogenetic factors. Further research to refine the tool and to correlate the additional data obtained from blood samples with the classification system is underway.
November 1999I N S T I T U T E O F M E D I C I N E S.docxIlonaThornburg83
November 1999
I N S T I T U T E O F M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding the expense of additional care necessitated by the errors, lost income
and household productivity, and disability) of between $17 billion and $29
billion per year in hospitals nationwide. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
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tients and dimin
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by both patients
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sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatmen.
2 8 5L e a r n I n g o b j e c t I v e sC H A P T E R.docxlorainedeserre
2 8 5
L e a r n I n g o b j e c t I v e s
C H A P T E R 1 0
Q U A L I T Y M A N A G E M E N T I N
T H E P H Y S I C I A N P R A C T I C E
Quality and reliability are system properties.
—W. Edwards Deming
➤ Articulate the nature of performance management.
➤ Describe the approaches to performance improvement.
➤ Appreciate the impact of variation on performance.
➤ Discuss the components of the Triple Aim.
➤ Describe process improvement.
In t r o d u c t I o n
One of the most important issues to address in the medical practice is the quality and
safety of the care provided to patients. The Institute of Medicine (IOM 2001), a presti-
gious branch of the National Institutes of Health, stated in its landmark report Crossing the
Quality Chasm: A New Health System for the 21st Century, “In its current form, habits, and
environment, American health care is incapable of providing the public with the quality
health care it expects and deserves.”
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EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 4/16/2020 7:48 PM via SUNY CANTON
AN: 1839064 ; Wagner, Stephen L..; Fundamentals of Medical Practice Management
Account: s8846236.main.ehost
F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 8 6
Another historic IOM (2000) report, To Err Is Human: Building a Safer Health
System, indicated that a shocking number of people—an estimated 44,000 to 98,000 per
year—are harmed by the healthcare system. A more recent study found that this number
has increased since publication of the 2000 IOM report despite substantial efforts to
improve. Medical errors have now become the third leading cause of death in the United
States (Makary and Daniel 2016).
The complexity of medical service and the inconsistency with which these services
are delivered, not to mention the fragmented nature of the system, have led to a number
of quality concerns (Mosadeghrad 2014), including a lack of systematic approaches to care
delivery and quality improvement. Efforts to improve quality in the medical profession
have a long tradition of focusing on individual performance versus system performance.
Exhibit 10.1 illustrates the potential flaw in this thinking. The bell-shaped curve, P-1,
represents the overall performance of any given system. Curve P-2 illustrates an improved
system of performance where the median performance is moved from M-1 to M-2. If an
organization seeks to improve by only focusing on the low performers, it experiences only
a small improvement, shown as I-1. By improving th ...
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. 2009 Utah Sentinel Events
Data Report
Identifying Opportunities for Improvement
A joint report from
March 2010
2. About this report
The purpose of this report is to provide information on the
sentinel event data collected from January-December 2009 by
the Utah Department of Health. Facilities participating in the
data collection include all Utah hospitals and ambulatory
surgical centers.
Included in this report is a historical overview of the collection
process, details of the data collection and the collaborative
efforts underway to address issues identified in the data.
3. Overview of sentinel event reporting in Utah
In 2001 the Utah Department of Health (UDOH), in response to the publication “To Err is
Human,” initiated a patient safety program in partnership with the Utah Hospitals & Health
Systems Association (UHA), Utah Medical Association (UMA), and HealthInsight, the Quality
Improvement Organization for Utah. Quality and risk managers representing the healthcare
sector collaborated as a learning group to better identify actual and potential events and to
develop system-wide, sustainable safeguards to prevent these events in the future. The
reporting system was deliberately designed to shift away from a traditional “focus of blame”
and instead encourage a “just” culture for collaborative system improvement.
Sentinel events by their nature, are rare events. Although sentinel events are not always
medical errors, they are indicators of system breakdown. Sentinel events can be devastating
experiences to patients, their families, and their healthcare providers. Identification of these
events across hospitals and ambulatory surgical centers provides opportunity for system-wide
learning and the development of industry-based improvement strategies.
Between October 2001 and April 2007, sentinel events, defined as unanticipated deaths, wrong
site surgeries, abductions, and loss of function that occur at a facility (hospital or ambulatory
surgical center) directly related to any clinical service were required to be reported to the Utah
Department of Health. During that time period there were eight general categories reported.
On average, between 30 and 40 events a year were identified and reported.
In an effort to improve reporting, the Sentinel Event Users Group (SEUG) now named the
Patient Safety Work Group (PSWG), comprised of representatives from UHA, UMA,
HealthInsight and UDOH, worked diligently to increase the types of events reported and the
ease of reporting these events. Consequently, an administrative rule change was implemented
mid-2007 to expand the type of events reported from eight general categories to 32 specific
categories. The motivation for such a change was to be able to compare the Utah experience
with national experiences and data. Additionally, in late 2008, the reporting process changed
from a faxed document and manual data entry done by the UDOH Patient Safety Director to a
secure, web-based reporting portal. This reporting change now supports individual facilities,
offering the ability to download all of their reports and to conduct internal trend analyses.
The primary goal of the Utah Patient Safety Program is to create a robust surveillance system
capturing the incidence of sentinel events occurring in hospitals and ambulatory care centers.
This has been a work-in-progress and as the system has improved, the number of events
reported has increased. When comparing Utah’s voluntary program to Minnesota’s mandated
data collection process, both states are very comparable in terms of the number of incidents
reported per population size. Working with a volunteer users group, building trust for safe
reporting, streamlining the reporting process, and expanding the categories of reportable
events are all factors contributing to the increase in events reported in 2009. Population
growth, an increase in the number of available beds as well as the increase in ambulatory
surgical centers operating in Utah may also play a role in increased reporting.
4. 2009 sentinel event data for Utah
The following section provides information on the types and frequency of sentinel events (SE)
reported by hospitals and ambulatory surgical centers for the period January-December 2009.
In 2009, there were 101 sentinel events reported overall for the state of Utah. Fifty-four of
these events were surgical or procedural events. For perspective, more than 152,000 hospital
based outpatient surgeries were performed in Utah in 2008.1 There were more than 262,000
hospital discharges in 2008, with surgeries comprising approximately one-quarter of all
discharges.
The following table identifies the growth in sentinel event reporting as the process has become
more streamlined and additional reporting categories were added with the 2007 rule change.
120
100
2001-2009 101
# SE Reported
80 80 80
60
52
44 42
40 37
36
20
4
0
2001 2002 2003 2004 2005 2006 2007 2008 2009
Utah’s growth in reported sentinel events mirrors what is happening on a national basis as
hospitals continue to work toward improved accountability. According to The Joint Commission,
sentinel events rose in six of the 10 areas reported nationally in 2009.
1
AHA Hospital Statistics, 2008 edition.
5. Types of Occurrences
Utah again mirrors the national data reported to The Joint Commission regarding the type of
occurrences and the number of reported events, with “surgical/procedure” events being the
top concern. Events included in this category include “incorrect surgery or patient, wrong body
part, retained foreign object, and interoperative deaths.” Twenty-five of the 58 reported events
in the Surgical/Procedure category were related to retained foreign objects, with many of these
events occurring with obstetrical/gynecological patients.
70
60 58
2009 Sentinel Events by Occurrence
50 Type
40
30
20 18
12
9
10
3
1
0
6. Patient Age Distribution
The following table reflects the age distribution of those patients involved in sentinel events in
2009. As previously stated, 25 of the 58 reported events in the Surgical/Procedure category
were related to retained foreign objects, with many of these events occurring with
obstetrical/gynecological patients. The patient age distribution reflects those individuals of
child-bearing age who may have experienced a retained foreign object sentinel event. The
largest age group experiencing “surgical/procedure” sentinel events continues to be the 66-85
year old cohort. In 2008, seniors comprised more than 17% of all discharges for Utah residents.
The Patient Safety Work Group has identified Retained Foreign Objects as an area of primary
concern, and will be offering best practices protocol to Utah hospitals to improve care in this
area. More information is available in the Utah Patient Safety Initiatives portion of this report.
25
2009 SE - by Age
20
15
10
5
0
7. Utah Patient Safety Initiatives
Opportunities for improvement are abundant as a result of Utah’s voluntary sentinel event
reporting initiative. Efforts are underway to review the 2009 report, to drill down in a
confidential manner to determine failure patterns and improvement opportunities, and to
design statewide improvement efforts. The following is an overview of the work being done to
address the results of the sentinel event data as well as other patient safety concerns.
Retained Foreign Objects--The top concern identified in the 2009 data is the issue of “retained
foreign objects.” Efforts are currently underway by the Patient Safety Work Group to publish a
position paper based on current standards related to the unintended retention of a foreign
body. Upon completion, this paper will be shared with all hospitals for systems improvement
purposes. The group will also execute a “drill down” exercise to identify specific actions and
best practices for reducing the number of these events among facilities.
C3 Initiative—The Utah C3 initiative is committed to assuring that the correct procedure is
performed at the correct site on the correct patient. In 2005, the Utah Patient Safety Steering
Committee adopted statewide guidelines for all hospitals and surgical centers to voluntary
follow to reduce surgical errors. The guidelines include procedural recommendations for site
marking, “time out” procedures and patient verification. To review these guidelines, go to
http://www.uha-utah.org/patientsafety/patientsafety.htm.
Utah CheckPoint—Found at http://utcheckpoint.org/, this website provides reliable data on 14
interventions that medical experts agree should be taken to treat heart attacks, heart failure
and pneumonia. CheckPoint is designed to help Utah citizens learn more about health care and
makes evidence-based health information publicly available and understandable. Additionally,
CheckPoint assists hospitals in continuously improving their performance, and, thereby,
improving the overall quality of care provided to Utah citizens. Utah CheckPoint is a joint effort
between UHA, Utah Hospitals & Health Systems Association and HealthInsight, the quality
improvement organization (QIO) for Utah.
Healthcare Associated Infections—Nosocomial infections, also known as Healthcare-Associated
Infections (HAIs) pose a significant burden on patients and their care within the healthcare
system. Many patients enter a hospital with decreased immunity and are undergoing complex
and invasive procedures introducing different routes of possible infection. The Healthcare-
Associated Infection Work Group (HAIWG) was established to provide recommendations for the
surveillance and prevention of these HAIs in Utah hospitals. This workgroup has utilized the
FMEA process to ascertain process improvements used to reduce infections related to central
line associated bloodstream infections. For more information on this project, go to
http://www.uha-utah.org/patientsafety/patientsafety.htm
“Never Events” Policy Guidelines—In 2008, UHA’s board of trustees adopted guidelines related
to the non-payment for certain conditions caused by medical error. Utah hospitals agreed not
to seek payment for costs associated with the occurrence of a serious event if an investigation
by the hospital determines that the event was reasonably preventable and was within the
8. control of the hospital. The list included in these guidelines details the serious events for which
a hospital will not seek payment if the hospital determines them to be preventable and within
the hospital’s control. The guidelines were distributed to all hospital members for inclusion in
their individual hospital’s policy.
Standardized Patient Wristband Initiative—In 2008, UHA members worked together to reach
consensus on standard colors for patient wristbands in our state. This standardization will
alleviate confusion for staff working at multiple facilities. The color “red” has been standardized
to serve as an “allergy” alert; “yellow” indicates a fall risk, and “purple” indicates “Do Not
Resuscitate.”
Failure Mode Effects Analysis (FMEA)—Three different workgroups have utilized the “Failure
Mode Effects Analysis” technique to determine approaches to reduce the risk of error in
inpatient settings. Two of the analyses took place under the guidance of the Medication Safety
Workgroup. The third analysis was undertaken by members of the Healthcare Associated
Infection work group. More information on this project can be found at http://www.uha-
utah.org/patientsafety/patientsafety.htm
Utah PricePoint—Found at http://utpricepoint.org/ , this Web site allows health care
consumers to receive basic information about inpatient services and charges at Utah’s
hospitals. Utah PricePoint is a joint effort between UHA, Utah Hospitals & Health Systems
Association and the Utah Dept. of Health.
MedCard Initiative—The MedCard initiative is designed to help patients and their families
create and maintain a list of medications currently being used. This is an important first step in
the event of an admission to a hospital, helping in the medication reconciliation process and
thereby reducing the possibility of adverse drug interactions. This initiative, developed and
supported by the Medication Safety Workgroup, offers the MedCard in various forms and is
available for download at http://www.uha-utah.org/patientsafety/medication/MedRec.htm
Safe Patient Lifting Practices—In 2006 UHA convened a workgroup to review and develop state
standards for the transport and lifting of patients. The workgroup explored various options and
after several months of work developed voluntary guidelines for safe patient lifting practices for
the protection of healthcare workers and patients alike.
Healthcare Information Technology—UHA, UMA and other members of the healthcare
community are heavily involved in several projects with the Utah Health Information Network
(UHIN). One of the biggest projects is the cHIE, or Clinical Health Information Exchange
initiative. When completed, this project will allow the transfer of clinical data between
providers, improving the quality of care and alleviating duplication of clinical tests. Another
major effort, ARCHES, will attempt to improve the statewide infrastructure for the transfer of
clinical information between facilities.
9. This report was prepared in cooperation with the Utah Department of Health, HealthInsight and
UHA, Utah Hospitals & Health Systems Association.
For more information on Utah’s Patient Safety Initiatives, go to http://health.utah.gov/psi/.