Issue link: https://beckershealthcare.uberflip.com/i/1475102
20 PATIENT SAFETY & OUTCOMES 25% of Medicare recipients harmed during hospital stays, HHS says By Andrew Cass T wenty-five percent of Medicare enrollees experienced harm during hospital stays in October 2018, according to a May 12 report from the HHS Office of the Inspector General. For its study, the office reviewed medical records for a random sam- ple of 770 Medicare patients who were discharged from acute care hospitals during October 2018. Six things to know: 1. Twelve percent of patients experienced adverse effects that led to longer hospital stays, permanent harm, lifesaving intervention or death, according to the report. 2. irteen percent of patients experienced temporary harm, which required intervention but did not cause lasting harm, prolong hospi- tal stays, or require life-sustaining measures. 3. e most common type of harm was related to medication, such as patients experiencing delirium or other changes in mental status, according to the report. 4. Forty-three percent of harm events were preventable, according to the report. Preventable events were commonly linked to substandard or inadequate care provided to the patient. 5. Twenty-three percent of patients who experience harm events required treatment that led to additional Medicare costs, according to the report. 6. A previous report found that 27 percent of hospitalized Medicare patients experienced harm in October 2008. n Joint Commission warns of 'diagnostic overshadowing' in sentinel event alert By Erica Carbajal T he Joint Commission on June 22 issued a sentinel event alert to turn more attention to the effects of diagnostic overshadowing — the attribution of symptoms to an existing diagnosis instead of a possible comorbid condition — and actions to address it. "Diagnostic overshadowing is a serious safety and quality concern as an initial misdiagnosis can have a significant impact on quality of life, including the physical and psychological wellness of patients," said Ana Pujols McKee, MD, executive vice president, chief medical officer, and chief diversity, equity and inclusion officer at The Joint Commission. "I urge my physician colleagues to recognize that diagnostic overshadowing stems from cognitive bias and work to reduce this through training and education programs." The quality improvement and patient safety group said diagnostic overshadowing exists among interactions between clinicians and patients with physical disabilities or previous diagnoses, and others experiencing health disparities. The sentinel alert outlines action items to address the issue, such as listening and interview techniques designed to enhance patient engagement and shared decision- making. n CDC, CMS and others call for urgent action on patient safety By Mackenzie Bean A group of federal and industry safety leaders have issued an urgent call for healthcare organizations to rebuild the foundations for safe care that deteriorated during the pandemic. The National Steering Committee for Patient Safety — a group of leaders from 27 organizations, including the CDC, CMS and Agency for Healthcare Research and Quality — issued the call to action. The expert committee, created by the Institute for Healthcare Improvement, shared its Declaration to Advance Patient Safety in May during the institute's Patient Safety Congress in Dallas. The committee is urging healthcare leaders to: 1. Review the 17 recommendations and strategies to improve patient safety detailed in its national action plan. 2. Appoint a leader and team to evaluate their organization's current state of safety using a self-assessment tool. 3. Implement strategies to strengthen their organization's safety performance and develop methods to track progress by using an implementation resource guide. "There is a critical need for healthcare leaders to take urgent action to create, rebuild and sustain the foundations for safe care to address long-standing challenges and troubling setbacks in patient and workforce safety during the pandemic," Patricia McGaffigan, RN, vice president of the institute, said in a May 17 news release. "The national action plan provides leaders with the tools to assess the current state of their organization's foundational safety practices and offers actionable solutions for a clear path forward." n