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PATIENT SAFETY: What are top 10 concerns in 2017?

Here is the annual list compiled by ECRI Institute of the top 10 patient safety concerns based on a review of event reports and survey data.

Most organizations already know what their high-frequency, high-severity challenges are.  Rather, this list identifies concerns that might be high priorities for other reasons, such as new risks, existing concerns that are changing because of new technology or care delivery models, and persistent issues that need focused attention or pose new opportunities for intervention.” (page 2)

The Top 10 (these topic headings are quoted directly from the white paper):

  1. Information management in EHRs
  2. Unrecognized patient deterioration
  3. Implementation and use of clinical decision support
  4. Test result reporting and follow-up
  5. Antimicrobial stewardship
  6. Patient identification
  7. Opioid administration and monitoring in acute care
  8. Behavioral health issues in non-behavioral-health settings
  9. Management of new oral anticoagulants
  10. Inadequate organization systems or processes to improve safety and quality

A nice feature of this white paper is that it contains links to ECRI Institute resources that provide advice and guidance on each of these topics.

Source: ECRI Institute. (2017, March). Top 10 patient safety concerns for healthcare organizations 2017: Executive brief. Plymouth Meeting, PA: ECRI Institute. Click here for free full text (but you may be asked to fill out a registration form): https://www.ecri.org/EmailResources/PSRQ/Top10/2017_PSTop10_ExecutiveBrief.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

MRSA: 1.2 percent of hospital stays in California (2013)

In 2013, there were over 3.1 million inpatient stays in California hospitals, according to the California State Inpatient Database – which includes information on patients of all ages.  This study examines characteristics of those patients who had a hospital stay associated with Methicillin-resistant Staphylococcus aureas (MRSA).  Here are some of the findings:

  • 1.2 percent of California hospital stays involved MRSA
  • 1 in 100 California hospital stays involved MRSA
  • Over 40 percent of the MRSA was associated with cellulitis or skin ulcers
  • Only 8 percent of hospitalized patients with MRSA acquired their MRSA in a hospital
  • Another 41.9 percent of hospitalized patient with MRSA acquired their MRSA in the community after contact with some type of health care facility

Source: Sutton, J.P., and Steiner, C.A. (2016, Oct.). Hospital-, health care-, and community-acquired MRSA: Estimates from California hospitals, 2013. Healthcare Cost and Utilization Project Statistical Brief, 212.  Click here: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb212-MRSA-Hospital-Stays-California-2013.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

INFECTION CONTROL: CUSP program found to reduce UTIs in non-ICU units

The federal government funded the Comprehensive Unit-based Safety Program (CUSP), a multi-year, nationwide effort to decrease the rate of urinary tract infection associated with the use of catheters in hospitalized patients.  This project was under the leadership of AHA’s Health Research & Educational Trust (HRET).  The project involved disseminating information and tool kits about best practices and collecting data.  Data from over 600 hospitals were studied; these findings represent part of the hospitals that participated.  It was found that hospital units that were not ICUs benefited from the program – as evidenced by a reduced UTI infection rate – but ICUs did not.

Reductions occurred mainly in non-ICUs, where catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days…”

Source: Saint, S., and others. (2016, June 2). A program to prevent catheter-associated urinary tract infection in acute care. The New England Journal of Medicine, 374(22), 2111-2119.  Click here for free full text: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1504906  Posted by AHA Resource Center (312)422-2050, rc@aha.org

PATIENT SAFETY: Handoffs between ICU and OR

There is a lot of literature describing problems with, and best practices for, the transfer of care of post-surgical patients moving into the intensive care unit setting.  However, after conducting a comprehensive literature search, the authors of this brief commentary found no comparable literature about the reverse type of handoff – for patients going from the special care unit into surgery.  They suggest that a checklist be adopted and give an example of one such checklist.  They also recommend that a verbal handoff be required.

What do I like about this article?  The authors are authoritative (Mount Sinai and Johns Hopkins medical schools) and I like the actual example of the handoff checklist.  Also, I like it that they appear to be filling a gap in the medical literature – at least at the time that they wrote this commentary.

Source: Evans, A.S., Yee, M.S., and Hogue, C.W. (2014, Mar.). Often overlooked problems with handoffs: From the intensive care unit to the operating room.  Anesthesia & Analgesia, 118(3), 687-689.  Click here for free full text: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/03000/Often_Overlooked_Problems_with_Handoffs___From_the.31.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICUs: How do high-performing hospitals reduce CLABSI rates?

This is a study out of Johns Hopkins of 17 intensive care units at 7 hospitals – comparing practices related to reducing the central line-associated bloodstream infection (CLABSI) rate.  High performers were defined as those with less than 1 infection per 1000 catheter-days over the period of at least one year.  Low performers were defined as having over 3 infections per 1000 catheter-days.

I particularly like the tables and the appendices to this article.  The tables identify characteristics of high-performers in bullet-point brevity for each of the following levels of hospital employees: senior leadership, ICU managers, infection prevention and quality improvement staff, and frontline staff.  The appendices contain specific questions that make up a CLABSI Conversation – again differentiated between senior management, infection control / quality improvement staff, and ICU staff.

Source: Pham, J.C., and others. (2016, Apr.-June). CLABSI Conversations: Lessons from peer-to-peer assessments to reduce central line-associated bloodstream infections. Quality Management in Health Care, 25(2), 67-78.  Click here for publisher’s website:  http://journals.lww.com/qmhcjournal/pages/articleviewer.aspx?year=2016&issue=04000&article=00001&type=abstract  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

PATIENT FALLS: Humpty Dumpty Falls Prevention Program(TM) for children

After discovering a lack of patient fall prevention programs tailored to the needs of children, the Nicklaus Children’s Hospital (Miami, FL) developed the Humpty Dumpty Falls Prevention Program(TM), which has been adopted for use by over 1100 hospitals worldwide.  Both articles describe the development process and the tool itself.  In comparing data on children who fall, it was discovered that children with these characteristics were most likely to fall:

  • Children under age 3
  • Adolescents who have neurological diagnosis


  1. Gonzalez, J., Hill-Rodriguez, D., Hernandez, L.M., and others. (2016, June). Nurse Leader, 14(3), 212-218.  Click here: http://www.nurseleader.com/article/S1541-4612%2815%2930014-8/pdf
  2. [This earlier article is available in free full text]: Hill-Rodriguez, D., Messmer, P.R., Williams, P.D., and others. (2008, Jan.). The Humpty Dumpty Falls Scale: A case-control study. Journal for Specialists in Pediatric Nursing, 14(2), 22-32.  Click here: https://www.nicklauschildrens.org/NCH/media/docs/pdf/Humpty-Dumpty-Journal-of-Pediatric-Specialists.pdf    Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Most costly adverse drug-related hospitalizations: top 10 by type among Medicare patients

This was a study of national data from 2000 to 2008 of the types of medication that cause older people to be admitted to hospitals due to adverse drug reactions.  The database was the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample, and focuses on Medicare beneficiaries only.  The study looks at the overall cost to the nation as well as the average charge per patient.

Here are the top 10 classes of drugs and the average hospital charge per patient.

Principal drug-related diagnoses (2000-2008)

  1. $20,918  Central nervous system stimulants (for example, opiate antagonists)
  2. $20,279  Analgesics, antipyretics, and antirheumatics
  3. $19,287  Drug-induced hemorrhagic gastritis
  4. $19,026  Neuropathy due to drugs
  5. $18,296  Systemic agents
  6. $17,417  Allergic dermatitis
  7. $16,884  Sedatives and hypnotics
  8. $16,796  Muscle relaxants and related
  9. $16,444  Agents that affect blood constituents
  10. $16,019  Water, mineral, and uric acid metabolism drugs

Source: Shamliyan, T.A., and Kane, R.L. (2016, June). Drug-related harms in hospitalized Medicare beneficiaries: Results from the Healthcare Cost and Utilization Project, 2000-2008. Journal of Patient Safety, 12(2), 89-107.  Click here to go to publisher’s website: http://journals.lww.com/journalpatientsafety/Pages/default.aspx   Posted by AHA Resource Center (312) 422-2050, rc@aha.org