e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

You've heard the macabre joke that hospitals and doctors "bury their mistakes." Well, here's an interesting twist: At Kaiser Permanente hospitals in Southern California, doctors are doing precisely the opposite. They're rolling back time in the death process – exhuming their unknown mistakes so to speak – to see what, if anything, they can learn in order to save similar patients the next time around.

But they're not doing it the old way through invasive autopsies. Those are expensive, increasingly unpopular with families, forbidden by some religions, and often don't reveal that much about errors in the process of hospital care.

Kaiser has a new concept, the e-Autopsy.

Kaiser's hybrid manual and electronic mortality review uses storytelling and specialists' scrutiny to study medical charts of patients who died in the hospital. The process builds a precise timeline of what happened. The goal is to prevent death and/or improve end-of-life care by looking for places to improve—from ambulatory settings prior to admission to the inpatient bedside.

via healthleadersmedia.com

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HHS Releases National Plan to Improve Health Literacy | HHS.gov

Today, the United States Department of Health and Human Services released The National Action Plan to Improve Health Literacy aimed at making health information and services easier to understand and use. The plan calls for improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites, and recommendations to the public.

According to the report, efforts to improve the health literacy skills of both the public and health professionals are needed to achieve a health literate society—a critical need as health reform generates more demand for consumer and patient information that is easy-to-understand and culturally and linguistically appropriate.

According to research from the U.S. Department of Education, only 12 percent of English-speaking adults in the United States have proficient health literacy skills. The overwhelming majority of adults have difficulty understanding and using everyday health information that comes from many sources, including the media, web sites, nutrition and medicine labels, and health professionals.

“Health literacy is needed to make health reform a reality,” said HHS Secretary Kathleen Sebelius. “Without health information that makes sense to them, people can’t access cost effective, safe, and high quality health services. But, HHS can’t do it alone,” she added. “We need payers and providers of health care services to communicate clearly and make the necessary changes to improve their communication with consumers, patients, and beneficiaries. Today’s plan is only the beginning of a long-term process with our many partners in all sectors that we hope will result in a society that encourages people to live longer, healthier lives.”

via hhs.gov

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Nearly 60% of paid home caregivers make medication errors, study finds - McKnight's Long Term Care News

One-third of paid caregivers who work for clients who live in their own homes had difficulty reading and understanding health-related information and instructions. Furthermore, 60% of them made medication errors involving their clients, according to Northwestern University researchers, who say the study is the first of its kind.

Investigators at the university recruited 100 paid, non-family caregivers in the Chicago area and evaluated their literacy with health-related tasks and knowledge. While researchers emphasized that the majority of caregivers are good people who are trying to support their families, medication-error levels are a serious cause of concern.

They found that most paid caregivers are women with an average age of 50 years old. Many are foreign born with limited schooling. They are usually paid about $9 an hour, though almost one-third earns less than minimum wage.

via mcknights.com

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Medical News: Nursing Home Med Errors Vary by Form of Drug - in Geriatrics, General Geriatrics from MedPage Today

Residents in nursing and old age homes are four times as likely to get an incorrect dose of medication if it's in liquid rather than pill form, researchers reported.

In a study in 55 British homes, errors included such things as incorrect measurements and not shaking a suspension, according to David Phillip Alldred, PhD, of the University of Leeds in Leeds, England, and colleagues.

Errors also were more likely with inhalers and other drug formulations, compared with pills or tablets dispensed using a monitored dosage system, Alldred and colleagues reported online in BMJ Quality and Safety.

Monitored dosage systems -- also known as unit dose systems -- consist of a tray or cassette with compartments for one or more doses for a particular day and time and are intended to simplify the administration of medications for staff, the researchers noted.

But such systems can't be used for all medications -- liquids, among others -- and it's not clear that they are safer than delivering drugs from the manufacturer's own packaging, Alldred and colleagues noted.

via medpagetoday.com

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