In addition to his position at CHPSO, he is a Special Advisor to the Center for Quality Improvement and Patient Safety in the Agency for Healthcare Research & Quality, the Department of Health and Human Services. Dr. Jaffe has extensive experience in both clinical care and health system leadership. Prior to becoming Executive Director of CHPSO, he was Executive Director of Medical Services for the University of California system. In this role, he served as the senior physician in the system, which included oversight of quality of care at the five academic health systems and the ten student health centers. He also has served on a number of federal and state advisory committees on topics as varied as patient privacy, disaster planning, electronic health record safety and EMTALA reform.
This White Paper is a translated and edited version of a guideline document drafted by the German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit/APS). It contains guidelines intended for all parties involved with the complex changeover to ISO 80369 connectors and it aims to contribute to patient safety across the different healthcare applications.
March 11, 2014, the Centers for Medicare & Medicaid Services (CMS) issued the final rule implementing a number of provisions of the Affordable Care Act (ACA), including the provision that hospitals must satisfy certain patient safety and quality improvement requirements to contract with a qualified health plan (QHP) through Covered California, the state’s health insurance exchange.
CHPSO continues to monitor the problem of incorrect storage temperatures for vaccines (for the latest of several articles on this issue, see the March 2012 CHPSO Patient Safety News). Many vaccines include an adjuvant that will separate from the immunogen when frozen, reducing or eliminating its efficacy. This article focuses on a recent Office of Inspector General (OIG) report, Vaccines for Children Program: Vulnerabilities in Vaccine Management (OEI-04-10-00430).
Health Affairs recently published results from a 2011 survey of patients with serious illnesses, serious injuries or chronic diseases in eleven countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. The survey focused on access, care coordination and management, patient engagement, safety and the extent to which having a primary care practice with attributes of a patient-centered medical home influenced the patient’s care experience.
CHPSO is beginning to receive reports of retained surgical items. The goal is to understand better the causes and steps to reduce their incidence. Of the initial 20 reports, only two involved sponges or instruments; the rest were of miscellaneous items, some of which were left intentionally. For example, a micro-needle that fell into the incision may be left behind when the risks involved with attempted retrieval are judged to outweigh the risk of retention.
Building on earlier research showing broad variation in patient safety culture within individual hospitals, Dutch investigators evaluated the rate of preventable adverse events, both between hospitals and between hospital departments. Twenty percent of all Dutch hospitals were included in the study.
California law requires hospitals to report certain events to the Department of Public Health, which may issue administrative penalties in certain cases. The California Hospital Association maintains a database of those reports that elicited a penalty. CHA members can access the database at www.calhospital.org/ij-catalog/reports.
The Institute of Medicine (IOM) released a study of the 510(k) clearance process for medical devices.Their answer to the question: “Does the 510(k) clearance process provide a reasonable assurance of safety and effectiveness?” was: “The 510(k) clearance process is not intended to evaluate the safety and effectiveness of medical devices with some exceptions.The 510(k) process cannot be transformed into a premarket evaluation of safety and effectiveness as long as the standard for clearance is substantial equivalence to any previously cleared device.” As one of the committee members at the IO
Humans cannot perform tasks correctly each time. Unaided, 98 percent correct performance is excellent. Nevertheless, when the consequences of error are severe, multiple system redesign steps may be needed to reduce the rate to an acceptable level. Achieving zero error may be impossible. Transfusion medicine provides a good example of the roadblocks to perfection.
Investigators evaluated checklists designed for an “independent double checking” process in which the second person, without referring to the first person’s work, decides upon a setting or dosage, then checks his/her conclusions with those of the first person. Checklists were evaluated in a simulator to identity components that were most effective in identifying chemotherapy administration errors.
Starting in June, CHPSO members will be able to participate in an evaluation of retained surgical item (RSI) incidents. The purpose of this initiative is to assist hospitals in their root cause analysis process and help CHPSO identify common underlying causes of RSIs, particularly broken devices and fragments.
Information for this case was obtained from newspaper accounts. See references for details.
A 10-fold overdose of calcium chloride contributed to the death of an infant on September 19th of last year. According to the family, a nurse accidentally miscalculated the dose. After an investigation, the hospital changed its policy to allow only pharmacists and anesthesiologists to access calcium chloride in non-emergency situations.
On March 23, 2005, a fire and explosion occurred at BP’s refinery in Texas City, Texas, killing 15 workers and injuring more than 170 others. A multitude of equipment failures and human decisions contributed to the disaster. To date, BP’s fines and victim compensation expenses are over $1.7 billion.
One year after the event, BP’s Senior Group Vice President, Safety & Operations, addressed the Second Global Congress on Process Safety.
Problems at the point of care frequently arise. How the front-line staff addresses those problems affects the capability for organizational learning. The most common staff response to a problem is one that prevents learning.
A new regulation effective January 2011, Patient-Centered Labels for Prescription Drug Containers (Title 16 Section 1707.5), includes among other provisions a standardized set of patient instructions expected to cover about 90 percent of prescriptions. While the regulation affects labels on drug containers dispensed to patients, the standardized text can also provide a method for reducing discrepancies on other documents such as discharge instructions and prescription slips.
This report details an error by an inexperienced pharmacist committed when handling easily confused medications with similar drug names. One patient’s death at this major teaching hospital was ascribed to the inadvertent drug swap. The event shook the self-confidence of those at the institution and was broadly covered in the popular press.