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MEDICAL ERRORS may cause 400,000 deaths annually in US

Fifteen years ago, the famous To Err Is Human report issued by the Institute of Medicine estimated that the number of patients who die from medical errors is about 98,000 each year.  A more recent estimate puts that number at over 400,000 annually.  This is not meant to suggest that the problem has grown worse, rather that the earlier estimate was too low.  This brief report in JAMA is a recap of a Senate subcommittee hearing held in July (there is a link below to the video of the hearing if you’d like to watch the whole thing).

Dr. Peter Pronovost, who has been a champion in decreasing the rate of central line-associated bloodstream infections (CLABSI), testified that it would be beneficial to have a national system for collection of patient safety-related data.  Such a system might logically build on the existing database that tracks health care-associated infections that is maintained by the Centers for Disease Control.

It is also suggested that a national patient safety monitoring board should be created.

Sources: Kuehn, B.M.  Patient safety still lagging: advocates call for national patient safety monitoring board.  JAMA.  Aug. 20, 2014.  Click here for full text: http://jama.jamanetwork.com/data/Journals/JAMA/0/jmn140070.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

This article refers to a Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging hearing.  Click here for access: http://www.help.senate.gov/hearings/hearing/?id=478e8a35-5056-a032-52f8-a65f8bd0e5ef

The article refers to the report To Err Is Human, which can be accessed here: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

The article refers to the Centers for Disease Control and Prevention’s HAI Prevalence Survey, which can be explored here: http://www.cdc.gov/HAI/surveillance/index.html 


Checklists to Improve Patient Safety

AHA’s Health Research and Educational Trust has just released a series of 10 evidence-based checklists for improving patient safety in these areas:

  1. Adverse drug effects
  2. Catheter-associated urinary tract infections
  3. Central line-associated blood stream infections
  4. Early elective deliveries [Cesarean]
  5. Injuries from falls and immobility
  6. Hospital-acquired pressure ulcers
  7. Preventable readmissions
  8. Surgical site infections
  9. Ventilator-associated pneumonias and events
  10. Venous thromboembolisms

For additional information, ‘change packages’ for each checklist topic are available on the AHA/HRET Hospital Engagement Network [HEN] web site at www.hret-hen.org.

Source: Checklists to improve patient safety; signature leadership series. Health Research and Educational Trust in partnership with American Hospital Association, June 2013. http://www.hpoe.org/Reports-HPOE/CkLists_PatientSafety.pdf

Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Sustained zero CLABSI is achievable

A study published in the Archives of Internal Medicine examined central line-associated bloodstream infection (CLABSI) data for intensive care units of hospitals located predominantly in Michigan. The hospitals all participated in a targeted quality improvement iniative known as the Comprehensive Unit-based Safety Program, or CUSP, that was implemented through the Michigan Keystone ICU Project. The researchers found that 60 percent of the 80 ICUs evaluated were infection-free for a year or more, and 26 percent achieved two years or more. In the study, smaller hospitals sustained zero infections longer than larger hospitals.

Source: Lipitz-Snyderman, A., and others. The ability of intensive care units to maintain zero central line-associated bloodstream infections. Archives of Internal Medicine. 171(9):856-858, May 9, 2011. http://archinte.ama-assn.org/cgi/content/extract/171/9/856

Posted by the AHA Resource Center, (312) 422-2050 rc@aha.org