Also see Statement of deficiencies. During a complaint investigation or a regular periodic survey of a health facility such as a hospital, the Centers for Medicare & Medicaid Services or a state agency acting on its behalf may find deficiencies. These are documented as a failure to meet Conditions of Participation (for hospitals), a failure to comply with Requirements (for skilled nursing facilities or nursing facilities) or a failure to meet Conditions for Coverage (for ambulatory surgical centers). This will result in a government issuing a statement of deficiencies called a “2567” that identifies issues that must be corrected. If the facility does not fix the problems, it may lose federal reimbursement although Medicare has rarely taken this draconian level of action. These 2567 reports hurt the organization in other ways, by affecting its ability to contract with health plans, receive physician referrals and overall, maintain its good reputation.
Abuse, neglect, exploitation
A huge issue in health care settings, especially nursing homes, is the increasing finding of abuse, neglect and exploitation caused by health providers. The issue has drawn the attention of the Office of the Inspector General at regular intervals, most recently in this report from June of 2019.
Most health facilities require periodic (usually every 39 months) inspections by any of a number of Medicare-certified accreditation or deeming agencies such as The Joint Commission, a requirement to enable eligibility for payment from commercial payers, state Medicaid programs, the military health care system or Medicare.
Any injury to a patient caused by medical care, including administration of a drug or vaccine, surgery, or any procedure or other medical intervention. Examples include a pneumothorax from central venous catheter placement, anaphylaxis or allergic reaction to penicillin, postoperative wound infection or hospital-acquired delirium provoked by stays in an intensive care unit. An adverse event does not necessarily mean negligence or poor quality, but merely that an undesirable outcome resulted from medical care or diagnosis.
Electronic devices that alert providers to potentially dangerous declines in a patient’s condition but have low thresholds for their prompts, sounding many false alarms. The result is that the provider ignores them all, including the one that they should not. Alarm fatigue has been named as one of the top 10 health technology hazards by the ECRI, and for three of the last eight years was the number 1 hazard on that list. Ventilator alarms are especially troublesome.
Ambulatory surgery center
With more than 5,800 free-standing ambulatory surgery centers now operating in the U.S., ASCs represent an increasingly popular setting for increasingly complex procedures. Like hospital outpatient departments, patients are almost always discharged home before midnight and do not stay more than 24 hours. Usually, they are independently owned and not next door to a hospital or hospital outpatient department, so there are concerns about making sure sufficient transfer agreements exist in case of an emergency. They treat healthier patients, and are not usually subject to serious infection outbreaks as acute care hospitals are. Increasingly, however, some hospital leaders who worry about competition from ASCs are collaborating with physician groups to share ownership and to quality safeguards, and not lose profit to competitors. They also may collaborate to guide patient selection, routing less healthy patients to inpatient surgery. However, there are increasing concerns that ASCs may not be getting the scrutiny they require, as this September Office of Inspector General report detailed. Medicare defines an ASC here.
A list of medications that should be avoided in ambulatory elderly patients. The criteria lists doses or frequencies of administration that should not be exceeded and lists medications that older people with certain common conditions should avoid. The criteria references most medications, including sedative-hypnotics, antidepressants, anti-psychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine-2 blockers, antibiotics and other drugs. Source: the Agency for Healthcare Research and Quality Patient Safety Net glossary.
Black Box warning
Issued by the U.S. Food and Drug Administration, the alert on certain prescription drug containers calls attention to any known or suspected serious or life-threatening risks.
Clostridioides difficile is a bacterium that causes half a million illnesses in the U.S. a year, is transmitted in health care settings and is persistent in that 20% of patients who become symptomatic with diarrhea and colitis will get another occurrence. It is a serious infection in that nearly 10% of those over the age of 65 who develop symptoms will not survive.
Catheter-associated urinary tract infections, or CAUTI, are the most common type of health care-associated infection reported to the National Healthcare Safety Network (NHSN), a division of the Centers for Disease Control and Prevention. In a hospital, 75% of these infections are associated with a urinary catheter, which between 15% and 25% of hospitalized patients receive during their stay. Efforts to reduce infections by refining catheter insertion and maintenance techniques are ongoing in all healthcare facilities and have been somewhat successful. In hospitals, CAUTI infections that are transmitted in a hospital are considered hospital-acquired conditions. Those hospitals that are among the 25 percent with the highest rates of CAUTIs endure cuts in their Medicare reimbursement, as part of the Hospital-Acquired Condition Reduction Program established by the Patient Protection and Affordable Care Act.
Central line-associated bloodstream infections (CLABSI)
Central line-associated bloodstream infections, are another type of infection in Medicare’s Hospital-Acquired Condition Reduction Program. Though preventable, they are the cause of thousands of deaths, and add billions of dollars in extra costs to the U.S. health care system, according to the Centers for Disease Control and Prevention. While they are often mentioned with CAUTIs, they are different in that the infectious agent enters the bloodstream through a central line rather than through a catheter. Prevention efforts include rigorous hand hygiene, central line maintenance that follows guidelines and removal of the central line as soon as it’s no longer needed. The CDC advises patients to know a hospital’s CLABSI rate before agreeing to go there. Medicare’s Hospital Compare allows one to look that up.
CDI – clinical documentation integrity or clinical documentation improvement
For accuracy, honesty and data gathering, it’s important that medical records speak the same language to reflect patient history and clinical information that can be coded, classified, reimbursed and used for quality benchmarking. Clinical documentation personnel also have expanded layers of responsibility and require increased training in the use of current disease and condition classification terminology such as ICD 10 or diagnostic related groups. Also see ICD 10.
Circling the drain
A phrase used in many acute care settings by providers when a patient, despite despairing providers’ best efforts, rapidly and surprisingly loses organ function and is near death. The phrase may sound inhumane, but its use represents providers’ genuine despair and helplessness that they were powerless to stop the decline.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
The Consumer Assessment of Healthcare Providers and Systems is a type of patient survey used by many providers to reveal how a patient perceived his or her experience of care. It also is used by Medicare as a quality measure that determines some fraction of payment. Patient experience surveys reflect the patient’s sense of care, and do not reflect whether the patient was given the right care.
Also near miss. The Agency for Healthcare Research and Quality describes the close call as “An event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). Such events have also been termed near miss incidents.”
The Agency for Healthcare Research and Quality has put together a system for PSOs, which are federally designated organizations that work with hospitals to identify and prevent errors. That Common Formats system aggregates electronic information about lapses in patient safety in a consistent format to give health providers and AHRQ the ability to collect sensitive information about errors and near misses. It de-identifies that information so that other organizations can learn from that experience, and no one is embarrassed or humiliated. The PSO program affords contributing organizations legal protection so that they feel free to report sensitive issues. A recent Office of Inspector General report that surveyed general acute care hospitals found that just over half work with a PSO. Among those that do not, one reason given was uncertainty about the program’s legal protections. See also Network of Patient Safety Databases.
Hospital-acquired conditions (HACs)
Conditions, such as infections or pressure ulcers, that a patient gets while in a care setting such as a nursing home or hospital. Medicare now has financial penalties for hospitals that are among the 25% of those with the highest rates, a provision established by the Patient Protection and Affordable Care Act.
Similar to iatrogenic, but an event that takes place in a hospital. Usually refers to an infection transmitted in a health care setting. For example, nosocomial pneumonia would be a pneumonia that is transmitted to a patient in the hospital for another reason.
Unnecessary care, which includes surgeries, lab tests, imaging and physician office visits and hospitalizations, is estimated by a survey of physicians to be about 15% to 30%, but results from a variety of causes such as physician uncertainty, poor training, fear of medical malpractice lawsuits, patient demands and inability to see whether the procedure has already been done.
Patient Safety Organization
Approved as PSOs by the federal Agency for Health Care Research and Quality, these organizations, such as ECRI (one of the largest), work with health care organizations to define problems, hazards and errors in a way that offers legal protection so that personnel are encouraged to share learning experiences. There are currently 87 such PSOs listed by AHRQ.
Polyexploitation or polyvictimization
When a senior or disabled person is being exploited in more ways than one, for example financially exploited by a scammer as well as physically abused by a caregiver.
A term adopted by The Joint Commission to mean any event that affects a patient by causing death, permanent harm or severe temporary harm with intervention to sustain life. Sentinel events occur in any health facility, from medical offices where surgery is performed, labs, behavioral health facilities, nursing homes, ambulatory care settings such as emergency departments or surgery centers, and hospitals.
Sentinel events include suicide of any patient being treated in an around-the-clock care setting or within 72 hours of discharge; unanticapted death of a full-term infant; discharge of an infant to the wrong family; abduction of any patient receiving care, treatment and services; any unauthorized departure of a patient from an around-the-clock care setting that leads to death, permanent or severe temporary harm to the patient; reaction to an administration of blood or blood products due to major blood group incompatibility; rape, assault eading to death, permanent harm or severe temporary harm or homicide of any patient receiving care while on the care setting site; any invasive procedure on the wrong patient at the wrong time or that is unintended; unintended retention of a foreign object in a patient after an invasive procedure; severe neonatal hyperbilirubinemia or prolonged fluoroscopy with a cumulative dose greater than 1,500 rads to a single filed or delivery of radiotherapy to the wrong body regon or greater than 25% above the planned radiotherapy dose.
Sentinel events also include a fire, flame or unanticipated smoke, heat, or flashes during patient care, any maternal death related to the birth process or severe maternal morbidity or illness not related to a patient’s underlying condition or illness that results in permanent or severe temporary harm.
SOPS hospital survey
SOPS is the Agency for Healthcare Research and Quality’s new and improved 2.0 Survey of Patient Safety Culture.
Treatment Emergent Adverse Event (TEAE)
A category of adverse events that can particularly occur with cancer or autoimmune condition treatments during a clinical trial is the treatment emergent adverse event. This is an often unexpected adverse (negative) outcome or event that arises during the course of treatment that did not appear to exist beforehand or appears to be worsening a pre-existing condition or problem. Whereas adverse events may or may not be related to a treatment, a TEAE is distinguished by its appearing specifically while treatment is ongoing or very soon thereafter, often with an infusion therapy or a treatment that requires multiple visits over time.