Becker's Clinical Quality & Infection Control

23 PATIENT SAFETY & OUTCOMES Healthgrades recognizes 448 hospitals for patient safety By Mackenzie Bean H ealthgrades has identified 448 hospitals as the recipients of its 2022 Patient Safety Excel- lence Award, the organization said March 15. To determine the recipients, Healthgrades analyzed 2018-20 Medicare data on 14 patient safety indica- tors defined by the Agency for Healthcare Research and Quality. Through its analysis, Healthgrades identified 170,231 potentially preventable safety events among Medicare patients in U.S. hospitals. In addition, four safety indicators accounted for 74 percent of all safety events: • In-hospital fall resulting in hip fracture — 22.2 percent • Collapsed lung resulting from a procedure or surgery — 21.1 percent • Pressure sores or bed sores — 15.3 percent • Catheter-related bloodstream infections — 15 percent If all U.S. hospitals performed similarly to award winners, an average of 100,189 safety events could have been avoided, Healthgrades found. n Nurse's conviction should be wake-up call for health system leaders, IHI says By Mackenzie Bean R aDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improve- ment said March 30. Ms. Vaught was convicted March 25 of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. She was sentenced to three years of supervised probation May 13. "We know from decades of work in hospitals and other care set- tings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors." The organization said criminal prosecution of errors over-fo- cuses on the individual and diverts attention from necessary system-level issues and improvements. "Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them." n Let us be clear: Our commitment to provid- ing a safe and high-quality healthcare envi- ronment for our patients and team members remains paramount. We continuously work to produce the best outcomes by creating more standardized practices and process- es, rigorous reporting and monitoring of patient outcomes and building a culture that emphasizes quality and safety over blame and fault-finding. A culture of safety reduces harm and saves lives. Advancing safety begins with policies that protect team members for reporting mis- haps and depends on our collective ability to learn from mistakes — whether human, technical or system-induced errors. is protection is reflected in the safeguards we have put in place to prevent falls, and reduce hospital-acquired infections, medi- cation errors and other preventable events. We remind and encourage our teams to report safety issues through an online link so we can enact strategies and processes to prevent mistakes from happening again. Each safety event requires a systemic re- view — without an automatic disciplinary action or punitive response. is commitment to safety is saving patients' lives. Hospitals have made major strides in reducing hospital-acquired infec- tions, post-operative sepsis, falls and drug errors and other preventable events. In fact, New Jersey hospitals performed better than or equal to national averages for most patient safety indicators, the New Jersey Department of Health has reported. ere's no question that we have more to do, but let's not forget how we got here: by creating a deep sense of individual and institutional responsibility in our hospitals and care locations, emphasizing fairness and transparency in our reporting and support for our care teams. At a time when nurses and other front- line heroes are exhausted by two years of a pandemic and are often struggling with a challenging public, let's remember we must have their backs. We do this by providing safe environments for trans- parency, reporting and improving care processes. We are partners — hospitals and care teams — working collectively to provide the best outcomes for the patients we are privileged to serve. n

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