New! Resident Safety Review Council
On March 1, 2012, the Oregon Legislature passed House Bill 4084, which calls on the Oregon Patient Safety Commission to chair a short-term work group called the Resident Safety Review Council. The Commission is partnering with the Department of Human Services and several other entities to explore already closed and investigated abuse situations to determine how many were actually system-caused adverse events.
Commission Receives Funding for Antimicrobial Stewardship Program
Landmark drug settlement to fund consumer protection activities in Oregon
The tiny bacteria that transmit disease inevitably develop resistance to the antibiotics we use to treat those diseases. In preparation for a time when bacteria become resistant to current antibiotics, infectious disease specialists recommend not using new antibiotics until the old antibiotics have become ineffective. This concept is known as “antimicrobial stewardship.”
On March 20, 2012, Oregon Attorney General John Kroger announced a $3.4 million consumer drug settlement with the pharmaceutical company, Pfizer, Inc. Pfizer allegedly used deceptive marketing claims for its prescription antibiotic Zyvox, a relatively new drug used to treat certain types of pneumonia and bacterial skin infections. Approximately 19 percent of the settlement funds will be used to promote antimicrobial stewardship in Oregon and to teach consumers about proper use of antibiotics.
The Oregon Patient Safety Commission will play a leading role in the effort by supporting hospitals across the state as they strengthen their antibiotic stewardship programs. More information about the Commission’s work in this area is coming soon.
Commission Honors Oregon’s Patient Safety Leaders
At a Patient Safety Awareness Week breakfast event on Friday, March 2, the Commission honored nine health care organizations that are leaders in Oregon’s Patient Safety Reporting Program. The award recipients included two ambulatory surgery centers, five hospitals, one nursing home, and one pharmacy that were recognized for their participation in the Patient Safety Reporting Program as well as their dedication to improving healthcare in Oregon.
The Commission’s website now lists all of the hospitals, nursing homes, and ambulatory surgery centers that met or exceeded the reporting program’s 2011 reporting standards.
ASCs Must Use Surgical Checklist in 2012
The Centers for Medicare and Medicaid Services (CMS) is calling on all ambulatory surgery centers (ASC) to use a safe surgical checklist. CMS’s new Medicare quality reporting program will require all Medicare-certified ASCs to report whether or not they used a “safe surgery checklist” in 2012. No financial penalties will be given if an ASC does not comply with the requirement; however, CMS plans to make reports available to the public that indicate whether an ASC complied with the requirement. ASCs will be subject to financial penalties associated with this requirement in future years.
In CMS’s original communication about this requirement, ASCs were instructed that they must use a checklist as of January 1, 2012 in order to answer “yes” to checklist use in their annual report to CMS. However, in May 2012, CMS published the ASC Quality Reporting Measures Specifications Manual, which indicates, “ASCs that used a safe surgery checklist based on accepted standards of practice at any time during 2012 can answer “yes” when they report whether they used a safe surgery checklist during the year.”
Drug Mix-up Alert from Oregon Board of Pharmacy
According to an OregonLive.com article, the Oregon Board of Pharmacy is warning of an “alarming number of dispensing errors” involving the drugs tramadol and trazondone. The drugs treat different clinical conditions; however, the similar names and look of the drugs increase the possibility that a pharmacist may give a patient an incorrect prescription. In the Oregon Board of Pharmacy’s November newsletter, the Board indicates that they are reviewing several mix-ups involving these two drugs. The Board encourages pharmacists to review how they handle these drugs and to consider establishing “effective preparation and verification procedures” that can prevent such confusion in the future.
One resource to help pharmacists determine when special precautions are needed to avoid medication mix-ups is the Institute for Safe Medication Practices’ List of Confused Drug Names.
Hospitals Work to Eliminate Blood Stream Infections
November 2011
Members of the Oregon Association of Hospitals and Health Systems (OAHHS) join experts from Johns Hopkins University to continue ongoing conversation about how to eliminate Central Line Associated Bloodstream Infections (CLABSI). The STOP BSI program is an integral component of the HAI (healthcare-associated infection) Collaborative managed by the Oregon Patient Safety Commission (OPSC).
Commission Endorses “Partnership for Patients” Initiative
The Commission’s Board of Directors has endorsed Partnership for Patients, the U.S. Department of Health and Human Services’ launch of a new public-private partnership, bringing together healthcare leaders to make hospital care safer, more reliable, and less costly.
