3 Stories You Need: Never Events and the Weekend Effect, Yelp for Hospitals, Beware of Computerized Infusion Pumps

mednews-logo.300We know you’re busy, but we don’t want you to miss important healthcare quality and patient safety news. Here’s a roundup of stories you may have missed but need to take a look at before calling it a week. (Sign up on the right if you’d like these news alerts delivered to you.)

  1. Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: national analysis
    A new study published in the BMJ in April suggests that the chance of experiencing a hospital-acquired condition, such as a fall, pressure ulcer or infection, is 20% greater for weekend admissions as compared to patients admitted on weekdays. Access the study here and learn more about researchers’ thoughts on how to combat the “weekend effect.”
  2. This Website Is Basically Yelp for Hospitals
    A California-based startup has launched a new website that allows individuals to research the efficiency of almost any given hospital . The site, analyticsMD, assigns a letter grade to each hospital based on CMS data related primarily to the organizations’ emergency rooms, patient satisfaction and in-patient cost efficiency.
  3. FDA Issues Recs for Reducing Risk Associated with Computerized Infusion Pumps
    The Food and Drug Administration has issued a Safety Communication alerting users of Hospira LifeCare PCA3 and PCA5 Infusion Pump Systems to security vulnerabilities with these devices which are designed for continuous delivery of anesthetic or therapeutic drugs.


FDA Issues Recs for Reducing Risk Associated with Computerized Infusion Pumps

IV.300The Food and Drug Administration has issued a Safety Communication alerting users of Hospira LifeCare PCA3 and PCA5 Infusion Pump Systems to security vulnerabilities with these devices which are designed for continuous delivery of anesthetic or therapeutic drugs.

An independent researcher has identified certain security vulnerabilities that could interfere with the workings of the pumps that can be programmed remotely through a health care facility’s Ethernet or wireless network. Although the FDA is not aware of any adverse events or unauthorized device access related to such vulnerabilities at this time, the agency has established a set of recommendations for reducing the risk associated with the use of these particular computerized devices.


2 Stories You Need: No Value Care, Expanded HAI Reporting

mednews-logo.300Here are a couple of important healthcare quality and patient safety stories you may have missed but need to take a look at before calling it a week. (Sign up on the right if you’d like these news alerts delivered to you.)

  1. Overkill
    “It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care,” Atul Gawande explains in this piece written for The New Yorker. Consider the impact of overtesting, overdiagnosis and overtreatment which Gawande terms as “no value care” and says is terribly widespread in today’s healthcare industry.
  2. Hospital Infection Reporting to Widen, Definitions to Get More Precise
    Central line-associated bloodstream infections and catheter-associated urinary tract infections occur regularly beyond the ICU, but until now, hospitals haven’t been expected to collect data on the infections occurring in other units. The CDC and CMS say that a broadened reporting requirement and a clearer understanding of what constitutes a reportable infection will give more hospitals access to the tools and resources they need to drive quality improvement.


[Webinar] NPSF Offers CPPS Review Course

NPSF.logo.300The National Patient Safety Foundation will host a live webinar aimed at preparing patient safety professionals for the Certified Professional in Patient Safety exam on Thursday, June 11, 2015 from 10 a.m. to 5 p.m. (ET).

Course content will include:

• In-depth review of the six patient safety domains
• Discussion of patient safety scenarios similar to actual exam      questions
• Assessment of your level of preparedness for the exam and  direction regarding areas for self-study

The course will be moderated by Karen Garvey, RN, BSN, MPA/HCA, CPHRM, CPPS, Vice President, Quality, Safety & Performance Improvement, Parkland Hospital & Health System. Cost of the CPPS Review Course is $355 for members of the American Society of Professionals in Patient Safety or $395 for non-members.

To learn more and to register for NPSF’s online CPPS review course, click here.

 

Nursing Retrospective, Pros of Star Ratings, And 2 More Stories You Need

mednews-logo.300We ‘re right in the middle of National Nurses Week 2015 — a time to officially commend the hard work of the women and men who put the “care” in healthcare. Here’s a roundup of important healthcare quality and patient safety stories you may have missed but need to take a look at before calling it a week. (Sign up on the right if you’d like these news alerts delivered to you.)

  1. Celebrate National Nurses Week With a LIFE Cover Story on Nursing in the 1930s
    The days of “almost any girl” being able to become a nurse are far behind us. With a list of qualifications that only begins with an extensive science-based education, nurses truly are the superheroes of today’s healthcare industry. This photo essay, shot by Alfred Eisenstaedtas, offers a look back at what nursing looked like in 1938 and how student nurses were prepared “to secure the health of future generations.”
  2. Finding the Stars of Hospital Care in the U.S.
    Read why Ashish Jha, MD, internist and health policy researcher at Harvard School of Public Health, believes the new hospital star rating system recently introduced by CMS is actually a good idea.
  3. Shift the focus from patient satisfaction to employee satisfaction
    Imagine a healthcare industry in which all staff felt “safe, supported, comfortable, and respected.” A focus on bettering the work environment may be more beneficial than taking the “customer is always right” approach to quality improvement that seems to be sweeping the country.
  4. How the VA, HCA dramatically reduced MRSA infections
    Learn about the four-part MRSA reduction program implemented in VA hospitals nationwide that included surveillance measures, contact precautions, hand hygiene standards and a system wide culture transformation focused on accountability. Then, read about a landmark study launched by HCA that examined the effectiveness of universal screening and isolation of patients with MRSA.

Voluntary Recall Issued for Adrucil

MedWatch

AUDIENCE: Pharmacy, Oncology, Nursing, Risk Manager

ISSUE: Teva Parenteral Medicines issued a voluntary recall of eight lots of Adrucil (fluorouracil injection, USP) 5 g/100 mL (50 mg/mL) due to the potential presence of particulate matter identified as aggregate of silicone rubber pieces from a filler diaphragm and fluorouracil crystals. See the press release for a listing of affected lot numbers.

Administration of an intravenous product with particulate matter has the potential to result in inflammation, allergic reactions, or blockage of blood vessels, leading to tissue death, which may be life-threatening if vital organs are affected.

BACKGROUND: Adrucil Injection is used in the palliative management of carcinoma of the colon, rectum, breast, stomach and pancreas and is packaged in pharmacy bulk packages. The pharmacy bulk package has five 5 g/100ml vials per shelf pack. Individual Adrucil 5 g/100 ml vials have the NDC code 0703-3019-11 and the pharmacy shelf pack has the NDC code 0703-3019-12. The Adrucil 5 g/100 ml vial can be further identified by the statement on the label in red that states “PHARMACY BULK PACKAGE NOT FOR DIRECT INFUSION”. Adrucil 5 g/100 ml vials were distributed in the United States. Teva has distributed this product through the normal distribution chain of wholesalers, retailers, and pharmacies.

RECOMMENDATION: Anyone with an existing inventory of the recalled lots should stop use and distribution, and quarantine the product immediately. Customers should notify all users in their facility. Customers who have further distributed the recalled product should notify any accounts or additional locations which may have received the recalled product and instruct them if they have redistributed the product to notify their accounts, locations or facilities to the user level.

Consumers should contact their physician or healthcare provider if they have experienced any problems that may be related to taking this drug product.

Teva has notified its direct customers by mail and has issued an Urgent Drug Recall Letter to direct customers. Teva is arranging for impacted product to be returned to Inmar.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program:

  • Complete and submit the report online: www.fda.gov/MedWatch/report
  • Download form or call 1-800-332-1088 to request a reporting form. then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

 

Bullying Docs, A Plan for Interoperability and 3 More Stories You Need

mednews-logo.300The complexity of our nation’s healthcare system is intensified by factors including the way professionals communicate with each other to the extent to which technology is utilized and leveraged to achieve desired outcomes. Here’s a roundup of important healthcare quality and patient safety stories you may have missed but need to take a look at before calling it a week. (Sign up on the right if you’d like these news alerts delivered to you.)

  1.  Doctors Throwing Fits
    A new book pulls back the curtain and examines what the author describes as a bullying epidemic that’s putting nurses and patients at risk. Read some of the stories and research that inspired Alexandra Robbins to write, The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital.
  2. Leapfrog Shows Hospitals’ Progress on Safety Grades
    Trend lines are visible now that The Leapfrog Group has rolled out its seventh cycle of Hospital Safety Scores since 2012. Learn more about the scoring process and view your facility’s score here.
  3. Health Information Technology: Where We Stand And Where We Need To Go
    Karen DeSalvo, MD, national coordinator for health IT, outlines her three-fold plan to achieve interoperability which includes universal standards, strategies for holding people accountable and incentivization.
  4. No Return Trips: Hospitals Under Pressure to Lower Readmissions
    Two years after the Robert Woods Johnson Foundation’s release of The Revolving Door: A Report on U.S. Hospital Readmissions, where do we stand in the race to reduce repeat visits to the hospital?  Access that report as well as updated data here.
  5. Is it time to surrender control of the medical record?
    Consider one physician’s commentary inspired by a recent New York Times article that laid out a pretty strong argument for open records.