Patient Safety Monitor

Patient Safety Monitor Journal

Patient Safety Monitor is a searchable, web-based crosswalk that organizes state, CMS, and Joint Commission requirements by topic. It also provides access to news and analysis on dozens of the most challenging patient safety issues via the monthly journal, the tools and templates library, and the weekly e-newsletter.

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Issue 12, December 1, 2015 - VIEW THE FULL ISSUE

• Eight goals to improve diagnoses

  Building on a 1999 report that focused on treatment, the IOM turns its attention toward diagnostic...

• A broader focus on falls inside and outside the hospital

  The Joint Commission urges providers to focus on injury prevention through risk assessment, data...

• Comprehensive training and robust data crucial to robotic surgical safety

  Recent data highlights device malfunctions that led to injury and death, but experts say better...

• Show me the money: HHS invests in patient safety

  The federal government is shelling out nearly $800 million to transform clinical practices and...

• GAO: Value-based payments have no impact on quality trends, for now

  A report released by the Government Accountability Office concluded that CMS' Hospital Value-Based...

Issue 11, November 1, 2015 - VIEW THE FULL ISSUE

• Joint Commission NPSG updates reflect existing CAUTI best practices

  When The Joint Commission announced its proposed changes to NPSG.07.06.01 in September, it's...

• OpenNotes allow patients to catch errors, engage in care

  When the OpenNotes initiative first began in 2010, it consisted of just over 100 primary care...

• Yelp bolsters reviews with ProPublica data in new partnership

  As more consumer websites get into the business of rating physicians, hospitals are jumping on...

• What's in a name? When it comes to newborns, there could be a medical error

  A new, simple, distinct naming convention for pediatric patients could have a huge impact on...

• Safety advocates: Certain patient safety practices should be mandatory

  Hand hygiene compliance and influenza vaccination are two patient safety practices that should be...

Issue 10, October 1, 2015 - VIEW THE FULL ISSUE

• Data analytics and systems engineering offer the keys to improved patient care

  At any given moment, the intensity level within the ICU at Beth Israel Deaconess Medical Center...

• Miscommunication during ED handoffs paves the way for patient harm opportunities

  Over the last decade, patient handoff procedures have become an integral part of the patient care...

• Surgeon Scorecard offers transparency, creates a path for improved care

  The nonprofit news organization ProPublica has never been one to shy away from controversy...

• Antibiotic initiative includes stewardship oversight

  Antibiotic resistance has reached a "tipping point," according to a Vital Signs report...

• FDA issues additional guidelines for ­reprocessing medical scopes

  Following a string of infectious outbreaks tied to duodenoscopes earlier this year, the FDA has...

Issue 9, September 1, 2015 - VIEW THE FULL ISSUE

• New RCA approach leans on prioritization and action to fix gaps in care

  For years, hospitals have used root cause analysis (RCA) to identify gaps in their healthcare...

• The role of patients and families in dietary safety

  Hospitalized patients have a long list of potential safety concerns, ranging from medication...

• New software aims to improve communication, patient handoffs

  With one click of his mouse, Auron Priestly, MD, CEO and founder of Kolkin Corp. in Newport Beach...

• Patient satisfaction and quality care: Evaluating a contentious partnership

  Some hospitals wonder if patient satisfaction efforts distract from quality concerns

• Study: SSI bundle lowers the risk of infections for joint and cardiac surgeries

  Surgical bundles have become commonplace in the healthcare industry, particularly to help stave...

• Surgeon scorecard weighs complication rates of individual practitioners

  Those advocating for more transparency in healthcare will be pleased with the Surgeon Scorecard...

Issue 8, August 1, 2015 - VIEW THE FULL ISSUE

• Four classes of RSIs

  Although sponges continue to be the most detrimental, small miscellaneous items are an emerging...

• Leapfrog grades reveal disparities in quality care across state lines

  Quality improvement requires strength in numbers. At least that's what hospitals in Maryland and...

• Researchers find multiple human factors pervasive in never events

  A new study finds that approximately four to nine human factors contribute to each never event.

• Food and health stakeholders discuss antibiotic resistance at the White House

  In early June, representatives from farming and healthcare convened at the White House to discuss...

Issue 7, July 1, 2015 - VIEW THE FULL ISSUE

• California legislation makes antimicrobial stewardship a priority

  As the rest of the nation shifts its focus toward antibiotic stewardship, California leads the...

• Alarm safety tops patient safety list, but medication errors are still a focal point

  ECRI's 2015 list of top patient safety concerns offers some familiar foes along with some timely...

• Real-time feedback and monetary rewards pull physicians into quality care

  A study published in the April edition of the Journal of Hospital Medicine combines the principles...

• Proposed IPPS 2016 rule hones in on reimbursement for quality care

  Rule furthers CMS's plan to transition from fee-for-service payments to value-based purchasing by...

• Olympus feels the heat on duodenoscope reprocessing

  In the months following the carbapenem-resistant enterobacteriaceae outbreak linked to...

Issue 6, June 1, 2015 - VIEW THE FULL ISSUE

• What do the TUG robots do?

  Two San Francisco hospitals share their experiences with a fleet of robots that ­collect trash...

• How do nurses interact with medical devices?

  Hospital rooms contain an increasing number of medical devices that don't talk to one another...

• Reducing patient falls: Two healthcare systems, two different approaches

  As patient falls continue to plague healthcare facilities of all shapes and sizes, health systems...

• Social media plays a role in quality care, even if you don't know it

  Mass General researchers reveal the importance of social media presence and its impact on quality...

• AHRQ: Quality care made progress in 2014, but disparities still exist

  The 2014 National Healthcare Quality and Disparities report, released by the Agency for Healthcare...

Issue 5, May 1, 2015 - VIEW THE FULL ISSUE

• Southern California CRE outbreaks raise ­questions about scope reprocessing

  Recent carbapenem-resistant enterobacteriaceae (CRE) outbreaks at two Los Angeles hospitals have...

• What The Joint ­Commission says about opioids and ­respiratory compromise

  In February, representatives from pulmonary medicine and patient safety organizations gathered...

• In Minnesota, adverse event improvement goes beyond statistics

  Although patient safety data has played a larger role in dictating hospital and state initiatives...

• Preventing adverse drug events requires pharmacist involvement

  Adverse drug events (ADE) make up an overwhelming number of healthcare-acquired conditions (HAC...

• Ohio Children's Hospital initiative expands ­quality improvement outside state lines

  Initiative saved $60 million and avoided 2,500 serious events in the last three years

• NPSF roundtable reevaluates patient safety ­priorities

  Fifteen years after the Institute of Medicine's landmark report, To Err Is Human: Building a Safer...

Issue 4, April 1, 2015 - VIEW THE FULL ISSUE

• Are readmissions penalties fair? How community factors influence the equation

  Studies show that income, the number of primary care physicians, and the quality of nursing homes...

• Measles outbreak raises patient safety challenge for pediatricians

  As measles cases increase across the country, some physicians are adopting a hardline stance...

• NPSF report homes in on the importance of transparency in healthcare

  Although transparency is often met with fears of litigation, experts identify four domains where...

• Care transitions are complex, but crucial to patient safety and quality care

  Journal for Healthcare Quality issue focuses on importance of involving patients and families

• Medicaid reform paves the way to improved care in Oregon

  Three years after cutting a deal for $1.9 billion in federal funding, Oregon is seeing improvements

• Studies show tracking surgical outcomes doesn't necessarily lead to improvement

  Two studies published in the Journal of the American Medical Association (JAMA) indicate that...

Issue 3, March 1, 2015 - VIEW THE FULL ISSUE

• HAC penalties shine spotlight on safety while prompting questions about fairness

  Hospitals respond to Medicare reimbursement cuts for more than 700 hospitals

• Process improvements in the ED increase sepsis bundle compliance, reduce mortality

  By improving compliance with the sepsis three-hour bundle, Dartmouth-Hitchcock Medical Center...

• ACGME duty hour reforms

  Recent studies offer middle ground to long-standing debate, and experts say future reforms may be...

• Survey: A little respect goes a long way

  Patients who feel disrespected were 2.5 times more likely to experience medical error

• Top patient safety stories from the previous month

  A study published in PLOS Biology in January indicates that the Ebola crisis in Liberia could be...

Issue 2, February 1, 2015 - VIEW THE FULL ISSUE

• UV robots take center stage in the fight against pathogens

  Infection control concerns arise after hospitals struggle to dispose of Category A waste in the...

• Study: Advanced EHRs reduce patient safety events

  Once again, alarm safety and data integrity tops the list, while IV mix-up and ventilator...

• Improper use of restraints leads to patient safety concerns

  Experts call for alternatives to physical restraints, particularly when managing ICU patients and...

• Michigan quality collaborative focuses on anesthesiology practices

  A partnership between Blue Cross Blue Shield and the University of Michigan Health System aims to...

• HHS: HACs declined 17% in three years

  A report released on December 2, by the Department of Health and Human Services' (HHS) Agency for...

Issue 1, January 1, 2015 - VIEW THE FULL ISSUE

• Joint Commission highlights standards that apply to Ebola preparedness

  Few health emergencies have the ability to ignite such widespread panic as a potential epidemic...

• Improving engagement scores

  Safety champions at Henry Ford Health System have helped transform the way staff members prevent...

• The Joint Commission officially releases new patient safety chapter

  After much anticipation from patient safety experts, on October 20, The Joint Commission released...

• Could Google Glass improve surgical outcomes?

  Responding to knowledge gap with emerging surgical tools, FUSE training program aims to improve...