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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.
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.
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.
Purpose of Review
To assess adverse events of antidepressants in the treatment of major depressive disorder in adults 65 years of age or older.
In people 65 years of age or older:
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.
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:
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.
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.
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.
All Cause Harm Prevention in Nursing Homes Applying Strategies from the New CMS Change Package
Thursday, January 24, 2019, 3:00pm ET (1 hour) Recording Available.
One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences.
Change Package to prevent harm related to medication adverse events, other adverse events, infection, and abuse,and neglect for nursing home residents.
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