Infection Control

Some of the country’s healthcare facilities are in a war with killer robots, and the robots are winning. Luckily, the robots are on their side. While so-called “germ-zapping robots,” which use ultraviolet (UV) light technology to kill multidrugresistant organisms (MDRO), are being increasingly deployed by hospitals as part of infection control programs and Ebola response … Continued

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To Do No Harm, Rethink How to Measure Hand Hygiene

By Paul Alper, BA Primum non nocere is a Latin phrase that means, “First, do no harm.” It is a precept taught to healthcare students around the world and paraphrased in the Hippocratic Oath. Unfortunately, a vast amount of avoidable harm still takes place in healthcare settings worldwide. The good news is that a new … Continued

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Blood Clot Prevention Relies on Standardizing Best Practices Through Technology

Hospitals large and small share approaches to HA-VTE prevention through use of clinical decision-making tools, data analytics

In 2004, Greg Maynard, MD, MSc, SFHM, chief quality officer at the University of California, Davis in Sacramento, began working on deep vein thrombosis (DVT) prevention at the University of California, San Diego (UCSD). More than 12 years and one nationally recognized implementation guideline later, his hospital system is one of the leaders in preventing healthcare-associated venous thromboembolism (HA-VTE).

The University of California’s Center for Health Quality and Innovation is one of eight healthcare facilities recognized by the CDC for its work in preventing HA-VTE, more commonly known as blood clots. According to the CDC, VTE impacts as many as 900,000 patients each year, leading to 100,000 premature deaths and adding as much as $10 billion in healthcare costs.

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Award Recognizes Excellence in Patient and Family Engagement

IORA Health and the Children’s Hospital of Philadelphia (CHOP) Patient and Family Experience Team and Outpatient Clinical Service Leadership were the winners of the third annual John Q. Sherman Award for Excellence in Patient Engagement at the National Patient Safety Foundation’s (NPSF) 18th Annual Patient Safety Congress last month in Scottsdale, Arizona. Iora Health was … Continued

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Massachusetts Alliance Previews Study Results, Shares Resources at Annual CARe Forum

“Meaningful improvement only occurs when you normalize honesty.” 

                                                                                          —Rick Boothman  

 

As the executive director of clinical safety and chief risk officer at the University of Michigan Health System, Rick Boothman, JD, works with patients, families, clinicians, and staff members following cases of medical injury. Boothman started a program at Michigan in July 2001 that established honesty and respect as ground rules for communication, apology, and resolution of cases that traditionally have been ignored, shunned, or—when the subject of malpractice complaints—denied and defended.

Boothman was the closing speaker at the fourth annual forum of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI), held at the offices of the Massachusetts Medical Society (MMS) in April. The founders of MACRMI were inspired by Boothman’s “Michigan model” and a handful of other programs across the country dedicated to offering open communication, apology, and fair compensation to patients and families harmed by medical care (Beaulieu, 2012). These programs also treat clinicians and staff members with compassion and often offer them emotional support, recognizing that healthcare workers may be traumatized by adverse events involving patients.

“Meaningful improvement only occurs when you normalize honesty.” 

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Trigger Tool Adds Consistency to Adverse Tracking

Clinicians using a trigger tool can track overall harms and specific harms over time, and learn from past incidents and assess patient safety efforts, researchers say.

This article first appeared on HealthLeaders Media, June 8, 2016.

By: Alexandra Wilson Pesci

A new tool to retrospectively identify adverse events has the potential to make pediatric hospital care safer, research suggests.

Researchers at the AHRQ-funded Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital have developed and tested the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which flags triggers, or clues, in the medical record that tip off medical professionals that an adverse event might have occurred.

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New ISMP Best Practices Underscore Facility-Wide Consistency

Institute for Safe Medication Practices revises two of its six existing best practices, adds five more The Institute for Safe Medication Practices’ (ISMP) recently released “2016-2017 Targeted Medication Safety Best Practices for Hospitals,” which includes revisions to two existing best practices and five additional recommendations to reduce common medication errors. All told, the ISMP recommendations … Continued

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U.S. Woman Contracts Infection Resistant to Last-Resort Antibiotic


In April, a Pennsylvania patient was being treated for a urinary tract infection when her physicians discovered she had a strain of colistin-resistant E. coli. Colistin is the industry’s “fallback” antibiotic, only used when bacteria are resistant to all other forms of antibiotics. The discovery means an antibacterial-resistance exists for every type of antibiotic, creating the risk of an infection invulnerable to all antibiotic treatments.

Antimicrobial Agents and Chemotherapy reported that the E. coli’s colistin resistance came from a gene called mcr-1. The mcr-1 gene and its corresponding drug resistance can be shared between bacteria, potentially creating entire strains of colistin-resistant infections. Researchers say that when combined with other forms of sharable antibiotic-resistance, mcr-1 could result in the first infection that’s completely invulnerable to all forms of antibiotics.

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NQF: Antibiotics ‘Playbook’ to Synch with Accreditation Standards

Source: HealthLeaders Media News In addition to aligning with coming standards from The Joint Commission, the document also promises to help hospitals follow existing guidelines from CMS and the CDC. A new “playbook” on the appropriate use of antibiotics aims to help hospitals reduce rates of drug-resistant infections and prepare for new standards to be … Continued

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Joint Commission Deletes More Than 130 Requirements, Including Medical Record Requirements

In a bold move, the Joint Commission deleted 131 requirements for the hospital program in late April. The deleted requirements include a number of documentation, privacy, and information continuity requirements. Some of the deleted requirements were removed because they were duplicative of other requirements or implicit in other standards, the Joint Commission said. Others, however, … Continued

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