Quality Matters Archive

Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.

  • December 2010/January 2011 Issue
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News Briefs

Medical Errors Common and Persistent, Study Finds
A study of 10 North Carolina hospitals found that medical errors occurred frequently and their number did not decrease over time. According to the New York Times the study, conducted from 2002 to 2007 and published in the New England Journal of Medicine in November, is one of the most rigorous large-scale studies to analyze and track patient harm over time since the publication of To Err Is Human, the landmark 1999 report from the Institute of Medicine. The most common problems found were complications from procedures or drugs and hospital-acquired infections. The study focused on North Carolina hospitals because these institutions have been more engaged in efforts to improve patient safety than those in most other states. The study found that approximately 18 percent of patients were harmed by medical care, with 63 percent of the injuries deemed avoidable. Most of the problems were minor, though 2.4 percent caused or contributed to a patient’s death. Researchers pointed to hospital providers’ failure to implement known safety procedures to avoid mistakes and infections as the leading reason for the lack of progress.

IoM Panel Focuses on Safety of Health IT
A new Institute of Medicine panel met for the first time in December to discuss the safety of electronic health records and other health information technology (IT) systems. The Committee on Patient Safety and Health Information Technology will focus on the potential unintended consequences of integrating computerized systems into health care—including computer errors, design flaws, and communication breakdowns. As of February 2010, the U.S. Food and Drug Administration said it had received 260 reports of health IT malfunctions that had the potential to cause patient harm. At the meeting, panelists discussed the potential benefits and risks of health IT, ways to ensure safe software and system design, reporting of patient safety events, and the oversight of health IT safety. The panelists will conduct a yearlong study and issue recommendations.

Hospitals to Report ICU Infections in 2011
As of January 1, 2011, all acute-care hospitals will be required to report the number of patients who develop bloodstream infections in their intensive care and neonatal intensive care units to the Centers for Disease Control and Prevention. Each hospital’s data will appear later in 2011 on Hospital Compare, the Centers for Medicare and Medicaid Services Web site. While reporting this information is voluntary, hospitals stand to lose 2 percent of their Medicare funding beginning in fiscal year 2013 if they fail to share it.

Fewer Hospital CIOs Feel Ready to Comply with Meaningful Use
According to a new survey, hospital chief information officers (CIOs) are feeling less prepared than they did earlier this year to qualify for "meaningful use" incentives by April 2011. The survey, fielded in November 2010 among members of the College of Healthcare Information Management Executives, found that only 15 percent of CIOs expect their organization to qualify for the incentive payments from Medicaid and Medicare in 2011, which require providers to demonstrate they are making meaningful use of electronic health records. This represents a drop from the initial survey of this group in August 2010, which found 28 percent of CIOs said they expected to qualify for the incentives. The CIOs expressed concern about implementing computerized provider order entry systems and capturing and submitting quality measures. In both surveys, about 10 percent of respondents said their organizations were not likely to qualify for the meaningful use incentives until fiscal years 2013 or 2014.

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