One in Three Nursing Home Patients Are Harmed By Medical Errors

A recent government survey found that approximately one-third of patients who were discharged from hospitals to skilled nursing facilities, were harmed by treatments they received in the facilities. Most of the incidents could have been prevented, according to the report, which was conducted by the U.S. Health and Human Services Department, Office of the Inspector General.

The survey was based on a large sampling of Medicare patients discharged from hospitals to skilled nursing facilities during a one-year period from 2011-2012, NPR reports. Problems observed in the nursing homes included errors related to patient monitoring, and medication errors.

Approximately 60 percent of nursing home residents were harmed by their treatment were readmitted to the hospital as a result, and the report estimates that such readmissions cost Medicare about $2.8 billion a year.

The American Health Care Association, which represents the nursing home industry, responded to the report, telling NPR that this study was conducted before the Association’s quality improvement initiative, which has been showing progress in skilled nursing facilities across the country.

An INQRI-funded study led by Linda Flynn and Dong-Churl Suh examined the “Impact of Nursing Structures and Processes on Medication Errors.” The multidisciplinary research team identified changes in nursing care processes needed to prevent medication errors as well as adjustments in nurse staffing and the practice environment that can facilitate interception of such errors.

HHS Plan to Reduce HAIs on Track for Some Categories, Improvements Still Needed

The Health and Human Services’ (HHS) plan to reduce hospital-acquired infections (HAIs) has made progress in numerous areas, but more work is needed to address all of the categories, according to a new RAND Corporation evaluation published in Medical Care.

The HHS National Action Plan to Prevent Healthcare-Associated Infections focuses on six high-priority HAI categories: clostridium difficile infection; surgical site infection; central line-associated bloodstream infection; ventilator-associated events; catheter-associated urinary tract infection; and methicillin-resistant staphylococcus aureus.

RAND researchers interviewed with representatives from nine HHS regions and found that providers are on track to meet reduction targets for some, but not all HAI categories, FierceHealthcare reports. One area for improvement is ensuring adequate financial resources and staff for HAI prevention, which could be done through collaboration at the federal, regional, and state levels, according to the report. Through collaboration, alliances can leverage financial resources and staff capabilities to focus on larger initiatives, such as patient safety.

Reducing central line-associated bloodstream infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Hospitals Try To Control Readmissions, Even When It Hurts Profits

Yesterday, Fred Mogul, of WNYC, in collaboration with NPR and Kaiser Health News, reported how hospitals nationwide have implemented a variety of programs to curb costly readmissions. Starting in the fall of 2012, the Department of Health & Human Services is planning to begin penalizing hospitals for readmissions for patients discharged after experiencing heart attacks, heart failure or pneumonia. With one in five Medicare patients being readmitted to hospitals within 30 days of their initial discharge and research suggesting that 75% of these readmissions are preventable, hospitals have adopted care programs that aim to curb readmissions, improve transitional care from acute care facilities to the patient's home, and help the hospital avoid penalties from the HHS.

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HHS Partnership for Patients Initiative

Today, the Department of Health and Human Services announced their commitment to use $1 billion in new funding from the Affordable Care Act to meet two important patient safety goals:

1. Reduce preventable hospital injuries by 40% by 2013; and
2. Cut preventable hospital readmissions by 20% by 2013.

Patient advocate Sorrel King introduced HHS Secretary Kathleen Sebelius and Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services, who announced the Partnership for Patients Initiative which will unite providers, health systems, insurers, patients and advocates around the goal to reduce medical errors.

As Administrator Berwick said, we have the best trained and best equipped health workforce. The safety issues facing our health care system are indeed system-oriented. As we work to develop new processes and improved systems, we believe that nurses can and should be at the forefront of the discussion.

As recently articulated in the Institute of Medicine report on “The Future of Nursing: Leading Change, Advancing Health,” nurses are integral to promoting health and preventing medical errors in hospitals, clinics and everywhere patients are treated. The recommendations in the report are a testament to the value of nurses in ensuring patient safety. The recommendations encourage interprofessional collaboration and patient-centered teams that incorporate the skills and talents of all health professionals.