Patient safety requires vigilance

Infections in surgery centers show need for ongoing focus on patient safety and quality

You’ve heard the reports of misdiagnoses, botched surgeries, and now, a report from the Centers for Disease Control and Prevention that shows a serious problem with infection control in same-day surgery centers across the country.

The report, which was conducted by the Centers for Disease Control and Prevention and published first in the Journal of the American Medical Association and last week in the Washington Post, reflected unsafe practices that were observed in same-day surgery centers in Maryland, North Carolina and Oklahoma. The safety lapses were very basic, from failure to wash hands or wear gloves, to reusing devices meant for one patient on multiple patients. At the end of the day, 67 percent of the centers in the study had at least one lapse in infection control and 57 percent were cited for deficiencies.

While it is not known whether the safety lapses identified in this study led to infections in patients, we do know that infections in the surgical and hospital settings are a very real, very serious matter. In March 2010, the Leapfrog Group (of which BHCAG is a founding member) released a report on central-line associated blood stream infections, or CLABSIs, which cause at least 30 percent of the estimated 99,000 hospital-infection related deaths in the United States and account for billions of dollars in avoidable health care costs every year.

The Leapfrog report, which targeted 926 hospitals in Minnesota and across the country, was significant not only because of what it revealed about the CLABSI rates in hospitals. It was significant because it demonstrated the real-life value that comes from public reporting of performance data by health care providers. In this case, the public learned of the serious health problems a central-line infection can present and whether their hospital was up to par in preventing them.

However, many hospitals, including six in Minnesota chose not to respond to requests for data regarding their CLABSI rates. This failure to publicly report performance data robs individual health care consumers and health care purchasers of their ability to make informed decisions about where they receive care. It also stunts efforts to transform the health care reimbursement system from one that rewards for quantity of services performed to one that rewards for quality outcomes achieved.

And that’s where the commonality lies between the CDC study and the Leapfrog report. Both examples shine a light on the need for greater patient safety measures in health care facilities. BHCAG and its member organizations believe that patient safety is not a topic that should be pulled off the shelf and paraded around once a year. Patient safety should always be front and center in the health care reform debate.

It is equally important to remember that the key to improving patient safety is public reporting of data, such as shown in these studies. Whether data is voluntarily submitted through programs like BHCAG’s Minnesota Bridges to Excellence initiative, Minnesota Community Measurement, or through reports such as those mentioned here; business leaders, the health care community, and political leaders need to work together to generate greater momentum and compliance for public reporting among health care providers. And, since we’re talking about public reporting, let’s not forget to recognize those health care providers that have been leaders in this area and that have, as a result, realized notable improvements in care delivery and patient outcomes.

Look for more on the topic of rewards for improving care delivery and patient outcomes later this month as we celebrate the fifth anniversary of the Bridges to Excellence program.

In the spirit of collaboration,

Caroyln Pare
President and CEO
The Buyers Health Care Action Group