• AHRQ Report Reviews 47 Practices To Improve Patient Safety (3/20)

    Tuesday, March 10, 2020 | AHRQ

    A new report from the Agency for Healthcare Research and Quality (AHRQ) reviews 47 practices that target patient safety improvement in hospitals, primary care practices, long-term care facilities and other healthcare settings. The report, Making Healthcare Safer III, was published as AHRQ joins others in observing Patient Safety Awareness Week.

    “As we implement 21st century healthcare, we need to make sure that all patients are getting the highest quality and safest care possible,” said AHRQ Director Gopal Khanna, M.B.A. “With this report, AHRQ is seeking to support a culture of safety across the entire healthcare ecosystem. We expect this report to shape the national, regional, and local patient safety agendas for years to come.”

    The 47 patient safety practices (PSPs) are categorized in major topic areas, such as:

    • Medication management.
    • Healthcare-associated infections (HAIs).
    • Nursing-sensitive practices.
    • Procedural events.
    • Diagnostic errors.
    • Crosscutting factors.

    These areas include PSPs such as clinical decision support technologies, use of rapid-response teams, special hygiene and disinfection interventions to prevent HAIs, and several practices designed to prevent medication errors and reduce opioid misuse and overdose.

    Despite sustained national attention and notable successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, HAIs, falls and obstetric adverse events are blamed for thousands of deaths and hundreds of thousands of injuries each year. AHRQ statistics (PDF) estimate that in 2017, there were 86 hospital-acquired conditions per 1,000 hospital discharges—a figure that has fallen steadily in recent years but remains alarmingly high.

    Making Healthcare Safer III addresses this by supporting the implementation of PSPs where appropriate, advancing a framework for patient safety transformation and considering the contextual factors that can lead to successful use of patient safety interventions.

     “Before clinicians commit to implementing a patient safety practice, they want to know that they won’t be wasting their precious time and resources,” said Jeffrey Brady, M.D., director of AHRQ’s Center for Quality Improvement and Patient Safety. “This report provides information the field needs to evaluate how to prioritize efforts to keep patients safe.”

    The report calls for more research specifically into what makes for successful implementation of a patient safety intervention, a call that Dr. Brady echoed. “With patient safety, we increasingly know what to do—but often the challenge is how to make improvements work in the context of a specific facility or setting and have them succeed in the real world,” he said.

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  • Do You Know Who Your New QIN-QIO Is? (2/20)

    Wednesday, February 5, 2020 | Staff

    In November 2019, the Centers for Medicare & Medicaid Services quietly implemented the 12th Statement of Work for the Quality Improvement Network Quality Improvement Organizations (QIN-QIOs).

    This five-year contract includes a shift in how/where the QIN-QIOs operate. There are now 14 Medicare-funded QIN-QIOs nationwide. For example, IPRO is a lead contractor partnering with two other QIOs to cover 11 states and the District of Columbia. IPRO will direct activities in New York, New Jersey, and Ohio; Healthcentric Advisors will cover all six New England states (Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island); and Qlarant will handle Maryland, Delaware, and the District of Columbia.

    "QIN-QIOs serving under the 12th Statement of Work will provide customized quality improvement to nursing homes and providers, serving rural communities and the most vulnerable populations. Through this body of work, CMS is focusing on results, protecting taxpayer dollars, and most importantly, ensuring the safety and quality of care delivered to every Medicare beneficiary," says HealthCentric Advisors.

     The QIN-QIOs will address nursing home and community coalition quality improvement in the following areas:

    • Improving Behavioral Health Outcomes – Including Opioid Misuse
    • Increasing Patient Safety
    • Increasing Chronic Disease Self-Management
    • Increasing the Quality of Care Transitions
    • Improving Nursing Home Quality
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  • AHRQ 2019 Chartbook on Patient Safety (10/19)

    Monday, October 28, 2019 | AHRQ

    This Chartbook on Patient Safety includes a section with results from the National Nursing Home Survey on Patient Safety:

    National Healthcare Quality and Disparities Report

    This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety. A PowerPoint version is also available that users can download for presentations.

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  • Consensus Recommendations to Prevent Secondary Fractures in Adults 65+ with Osteoporosis (10/19)

    Monday, October 14, 2019 | Hinda and Arthur Marcus Institute for Aging Research

    Coalition Reaches Consensus on Recommendations to Prevent Secondary Fractures in Adults 65+ with Osteoporosis

    Recommendations target all health care professionals who participate in the care of older adults at risk for osteoporotic fractures

    BOSTON (October 2, 2019) - A multistakeholder coalition assembled by the American Society for Bone and Mineral Research (ASBMR) has issued clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture - the most serious complication associated with osteoporosis. Douglas P. Kiel, M.D., M.P.H., Director of the Musculoskeletal Research Center in the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife and Professor of Medicine at Harvard Medical School, is senior author on the report and served as co-leader of the project. The recommendations were published last month in the Journal of Bone and Mineral Research to coincide with the annual meeting of the ASBMR where Dr. Kiel was honored with the 2019 Esteemed Frederic C. Bartter Award. This prestigious award is bestowed upon an ASBMR member in recognition of outstanding clinical investigation in disorders of bone and mineral metabolism. 

    The coalition developed 13 recommendations strongly supported by the empirical literature and recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction.
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  • AHRQ Study: Adverse Events in LTC Residents Transitioning From Hospital Back to NF (8/19)

    Monday, August 12, 2019 | AHRQ

    Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.


    Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
    Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

    Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.


    Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.


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  • AHRQ: Adverse Effects of Pharmacological Treatments of Major Depression in Older Adults (3/19)

    Tuesday, April 2, 2019 | AHRQ

    Purpose of Review

    To assess adverse events of antidepressants in the treatment of major depressive disorder in adults 65 years of age or older.

    Key Messages

    In people 65 years of age or older:

    • Serotonin norepinephrine reuptake inhibitors (SNRIs) (duloxetine and venlafaxine) cause adverse events more often than placebo and most likely lead to discontinuation of therapy during treatment of up to 12 weeks.
    • Selective serotonin reuptake inhibitors (SSRIs) (escitalopram and fluoxetine) most likely cause adverse events at a similar frequency to placebo therapy but still may lead to discontinuation of therapy during treatment of up to 12 weeks.
    • Duloxetine most likely increases the risk of falls over longer treatment (<24 weeks)
    • Adverse events contributing to discontinuation of therapy were rarely reported in a way that allowed clear characterization of what adverse events to expect.
    • Few studies compared other antidepressants to placebo or to each other, or reported other outcomes. Trial data were sparse, and trials were short in duration, underpowered, and studied low doses of antidepressants. Observational studies had limitations related to their design. Long-term, rigorous comparative studies are needed.
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  • Nurse Involvement Can Boost Antibiotic Stewardship Efforts (3/19)

    Monday, March 11, 2019 | AHRQ

    From AHRQ News Now:

    Including bedside nurses in antibiotic stewardship activities has been identified by professional nursing groups and the CDC as an important—but missing—element in the success of these programs. To help fill this void, a new AHRQ-funded study published in the journal Infection Control and Hospital Epidemiology identifies several areas where bedside nurses could play an enhanced role in improving antibiotic prescribing practices.

    Nurses’ expertise can be used to: ensure appropriate testing for Clostridiodes difficile (C. diff) infection through accurate documentation and medication reviews; assess relevant indications before obtaining urine culture specimens to prevent the use of unnecessary antibiotics; ensure optimal antibiotic administration by helping patients transition from intravenous to oral therapies; obtain and document accurate patient histories of penicillin allergies; and use a team-based review to ensure that antibiotic therapies are not unnecessarily prolonged.

    The authors also identified ways to integrate nurses into an organization’s stewardship program, including on-the-job learning about antibiotics, potential drug interactions and adverse drug events.


    From AHRQ News Now:

    Including bedside nurses in antibiotic stewardship activities has been identified by professional nursing groups and the CDC as an important—but missing—element in the success of these programs. To help fill this void, a new AHRQ-funded study published in the journal Infection Control and Hospital Epidemiology identifies several areas where bedside nurses could play an enhanced role in improving antibiotic prescribing practices.

    Nurses’ expertise can be used to: ensure appropriate testing for Clostridiodes difficile (C. diff) infection through accurate documentation and medication reviews; assess relevant indications before obtaining urine culture specimens to prevent the use of unnecessary antibiotics; ensure optimal antibiotic administration by helping patients transition from intravenous to oral therapies; obtain and document accurate patient histories of penicillin allergies; and use a team-based review to ensure that antibiotic therapies are not unnecessarily prolonged.

    The authors also identified ways to integrate nurses into an organization’s stewardship program, including on-the-job learning about antibiotics, potential drug interactions and adverse drug events.

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  • CMS Online Immediate Jeopardy Update Training (3/19)

    Friday, March 8, 2019 | CMS

    The Immediate Jeopardy Update Training introduces surveyors and non-surveyors to the revised Appendix Q–Core Guidelines to Determining Immediate Jeopardy. The Core Appendix Q focuses on the key components necessary to establish immediate jeopardy (IJ) under the regulations. 

    These key components are:

    • Noncompliance.
    • Serious harm, injury, impairment, or death that has occurred or is likely to occur. 
    • Immediate need for action by the provider/supplier to address the noncompliance.

    The Core Appendix Q also contains information about how surveyors should determine whether IJ exists, and it includes a template that surveyors must use to ensure that sufficient evidence exists for each key component of IJ.

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  • CMS Revises Appendix Q, Guidance on Immediate Jeopardy / State Operations Manual (3/19)

    Thursday, March 7, 2019 | CMS

    Memorandum Summary

    Core Appendix Q and Subparts - Appendix Q to the State Operations Manual (SOM), which provides guidance for identifying immediate jeopardy, has been revised. The revision creates a Core Appendix Q that will be used by surveyors of all provider and supplier types in determining when to cite immediate jeopardy. CMS has drafted subparts to Appendix Q that focus on immediate jeopardy concerns occurring in nursing homes and clinical laboratories since those provider types have specific policies related to immediate jeopardy. 

    Key Components of Immediate Jeopardy – To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.

    Immediate Jeopardy Template – A template has been developed to assist surveyors in documenting the information necessary to establish each of the key components of immediate jeopardy. Survey teams must use the immediate jeopardy template attached to Appendix Q to document evidence of each component of immediate jeopardy and use the template to convey information to the surveyed entity.

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  • AHRQ Surveys on Patient Safety Culture Nursing Home Survey: 2019 Database Report (2/19)

    Thursday, February 14, 2019 | AHRQ

    The most recent AHRQ Nursing Home Survey on Patient Safety Culture Database Report presents data from 191 nursing homes and 10,499 nursing home respondents who completed the survey between January 2016 and July 2018 and submitted data to the Nursing Home SOPS database. The report presents statistics (averages, standard deviations, minimum and maximum scores, and percentiles) on the patient safety culture composite measures and items from the survey. Appendixes A and B present overall results by nursing home characteristics (bed size, ownership, census region, and urban/rural status) and respondent characteristics (job title, nursing home work area, interaction with residents, shift worked most often, and tenure in nursing home). The report contains data voluntarily submitted by participating nursing homes and is not representative of all U.S. nursing homes.


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