VHIG Digest: Volume 1, No. 1
By Matt Kynes, VMS IV
In the News…
1. Joint Commission Targets Patient Hand-Offs – 10/21/10
The Joint Commission released a progress report on their initiative to improve patient hand-offs. In collaboration with 10 hospital systems, they reported that hand-offs were deficient 37% of the time. Common reasons cited for defective hand-offs included “an institutional culture that doesn’t emphasize teamwork and respect, ineffective communication methods, inadequate time carved out for the transfer, inaccurate or incomplete information from the sender and an inability on the receiver’s end to focus on the patient due to other priorities.” Organizations that implemented solutions to address the issues were able to reduce their hand-off errors by 52%.
Source: Joint Commission-Hospital Collaboration Targets Handoffs
2. Breast Cancer Screening in Chicago Deficient – 10/20/10
A report analyzing screening and treatment data for Chicago-area hospitals found that many were performing below national standards. Only 1/3 of facilities could demonstrate that they were meeting stands for early detection, and only 1/3 could show that they met timeliness standards of getting newly diagnosed patients into treatment within 30 days. “It’s pretty clear we have a long way to go in terms of guaranteeing high-quality screening and treatment in all of the facilities,” said Anne Marie Murphy, executive director of the Metropolitan Chicago Breast Cancer Task Force. However, this level of cooperation between 55 hospitals is an important step in the right direction.
Source: Study: Quality of breast cancer care in Chicago isn’t uniform
3. Editorial Highlights Delicate Balance Between Protecting and Losing Touch with Patients – 10/21/10
In a New York Times editorial, Dr. Pauline Chen discusses the fear of contagion that many doctors possess and how it may prevent them from providing care that is as high quality and empathetic as it might otherwise be.
Source: Losing Touch With the Patient
In the Literature
1. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era
In a review of 27,370 incidents from 6000 physicians over 6.5 years reported to a Colorado insurance database, the study found 25 wrong-patient and 107 wrong-site surgeries. Up to 35.5% of those errors inflicted ‘significant harm’ on patients, including one death. In their assessment of root causes, the authors found that no pre-procedure time-out was performed in 72% of wrong-site procedures. Sub-group analysis by specialty revealed that internal medicine specialists had the highest error rate, with 24% of all errors, followed by orthopedists at 22.4%, general surgeons at 16.8% and anesthesiologists at 12.1%. Pathologists, urologists, ob-gyns, pediatricians and others tied at around 8% each.
2. Pneumococcal Vaccination Process Improvement in an Acute Care Setting
Although pneumococcal vaccination has been available since 1977 it is often underutilized in clinical settings. In this study, a group in St. Louis reports that by making systematic changes to their vaccination process in the areas of assessment, ordering, obtaining and administering vaccines they were able increased their vaccination rate from 34.7% to over 90% in a two-year period. This achievement was accomplished by the plan-do-study-act (PDSA) model for improvement.