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.

  • June/July 2010 Issue
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News Briefs

Checklists Lower Mortality Rate for Urgent Surgery
A new study found that using a simple checklist of safety procedures helped surgical teams avoid medical errors and reduce deaths during urgent surgery. The 19-item checklist, introduced by the World Health Organization in 2008, had been shown to reduce complications during many types of surgery. Still, there were some concerns that taking time to run through the checklist might not be practical and could be harmful when surgery was urgently needed, for example to treat open fractures. In the Annals of Surgery study, involving 1,700 patients who had urgent surgery in eight hospitals around the world, researchers found that the number of deaths dropped by almost two-thirds, from 3.7 percent to 1.4 percent, and the number of surgical complications fell by more than a third with use of the safety checklist.

Europe to Launch Health IT Agenda
Last month, the European Commission proposed a 10-year "Digital Agenda," which calls for use of information technology to help curb rising health care costs and to enable member states of the European Union (EU) to improve care for their aging populations, among other steps. It aims to give all Europeans online access to their medical information by 2015, and to create interoperable medical records that can be accessed anywhere in the E.U., for use in emergencies, by 2012. In addition, the plan calls for widespread deployment of telemedicine services by 2020.

California Targets Retained Foreign Objects
In the last two years, California hospitals reported 350 cases of "retained foreign objects," such as drill bits, screws, sponges, and needles, accidentally left inside patients after surgery; such errors represent 14 percent of all medical errors reported during this time period. Twenty-nine of the cases were serious enough that the state levied fines on the hospitals under a three-year-old law that gives public health officials the authority to issue penalties for violations that put patients at risk of death or injury. California intends to use $800,000 of the $3 million it has collected in fines since 2007 to investigate ways to reduce the incidence of such medical errors. Hospitals are exploring processes such as performing low-dose X-rays to detect anything left behind, empowering all members of a surgical team to examine excisions before closure and to call for instrument counts, and using radio-frequency detection systems on equipment.

AHRQ Launches Software for Reporting Hospital Performance Information
This month, the Agency for Healthcare Research and Quality (AHRQ) released MONAHRQ—My Own Network Powered by AHRQ—free Windows-based software with which states, hospitals, and other organizations can compile data on hospital performance and create custom Web sites for internal or public performance reporting. MONAHRQ is intended to provide a simple platform for data collection and analysis. Users download the software, input their own inpatient administrative data, and then generate a data-driven Web site with information on the quality of care at the hospital level, health care utilization at the hospital level, preventable hospitalizations at the county level, and rates of conditions and procedures at the county level.

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