The business case for patient safety

Clinical Orthopaedics and Related Research

Volumn 457, Issue , 2007, Pages 21-34

  Hwang, Raymond W ^a   Herndon, James H ^a,b  

^a PARTNERS HEALTHCARE   (United States)

^b MASSACHUSETTS GENERAL HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CEFOTAXIME; CEFTRIAXONE; CYCLOPHOSPHAMIDE; DRUG;

ACUTE HEART INFARCTION; CONFERENCE PAPER; CONGESTIVE HEART FAILURE; COST BENEFIT ANALYSIS; DEEP VEIN THROMBOSIS; DIAGNOSTIC ERROR; ECONOMIC ASPECT; FALLING; HEALTH CARE; HEALTH CARE DELIVERY; HEALTH CARE PERSONNEL; HEALTH CARE QUALITY; HOSPITAL INFECTION; HUMAN; LENGTH OF STAY; LUNG EMBOLISM; MALPRACTICE; MEDICAL ERROR; NUCLEAR MAGNETIC RESONANCE IMAGING; OUTCOME ASSESSMENT; PATIENT SAFETY; PNEUMONIA; POSTOPERATIVE COMPLICATION; POSTOPERATIVE HEMORRHAGE; PRIORITY JOURNAL; QUALITY OF LIFE; REIMBURSEMENT; STROKE; WOUND INFECTION; CROSS INFECTION; CULTURAL FACTOR; DRUG SURVEILLANCE PROGRAM; ECONOMICS; PEROPERATIVE COMPLICATION; REVIEW; SAFETY;

ADVERSE DRUG REACTION REPORTING SYSTEMS; CROSS INFECTION; CULTURAL CHARACTERISTICS; HUMANS; INTRAOPERATIVE COMPLICATIONS; PHARMACEUTICAL PREPARATIONS; POSTOPERATIVE COMPLICATIONS; QUALITY ASSURANCE, HEALTH CARE; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT;

EID: 34147126953     PISSN: 0009921X     EISSN: 15281132     Source Type: Journal    
DOI: 10.1097/BLO.0b013e3180342816     Document Type: Conference Paper

References (119)

1. Agency for Healthcare Research and Quality. Role of partnerships: second annual meeting of child health services researchers, June 27, 2000, Rockville, MD. Available at: http://www.ahrq.gov/research/chsr2.htm. Accessed January 24, 2006.
2. Ahnfelt L, Herberts P, Malchau H, Andersson GB. Prognosis of total hip replacement. A Swedish multicenter study of 4,664 revisions. Acta Orthop Scand Suppl. 1990;238:1-26.
3. American Academy of Orthopaedic Surgeons. Wrong Site Surgery. Available at: http://www.aaos.org/wrong/viewscrp.cfm. Accessed December 30, 2006.
4. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M. An alternate strategy for studying adverse events in medical care. Lancet. 1997;349:309-313.
5. Arnst C. The best medical care in the U.S. Bus Week. 2006;50-56.
6. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;318:771-775.
7. Baker SP, O'Neill B, Ginsburg M, Guohua L. The Injury Fact Book, 2nd ed. New York: Oxford University Press; 1992.
8. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759-763.
9. Barrack RL, Sawhney J, Hsu J, Cofield RH. Cost analysis of revision total hip arthroplasty: a 5-year followup study. Clin Orthop Relat Res. 1999;369:175-178.
10. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348:2526-2534.
11. Bates DW, Leape LL, Cullen DJ. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316.
12. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape LL. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-311.
13. Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:313-321.
14. Baxt WG. Application of artificial neural networks to clinical medicine. Lancet. 1995;346:1135-1138.
15. Birkmeyer JD, Dimick JB. The Leapfrog Group's patient safety practices 2003: The potential benefits of universal adoption, February 2004, Washington, DC. Available at: http://www.leapfroggroup.org/media/file/Leapfrog-Birkmeyer. pdf. Accessed January 23, 2006.
16. Bennett JV, Brachman PS, eds. Hospital Infections. Boston: Little, Brown and Company; 1992:577-596.
17. Bozic KJ, Durbhakula S, Berry DJ, Naessens JM, Rappaport K, Cisternas M, Saleh KJ, Rubash HE. Hospital resource utilization for primary and revision total knee arthroplasty. J Bone Joint Surg Am. 2005;87:570-576.
18. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87:1746-1751.
19. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Harvard Medical Practice Study I. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
20. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996;335:1963-1967.
21. Bruce J, Russell EM, Mollison J, Krukowski ZH. The measurement and monitoring of surgical adverse events. Health Technol Assess. 2001;5:1-194.
22. Burt CW, Hing E. Use of computerized clinical support systems in medical settings: United States, 2001-03. Adv Data. 2005;353:1-8.
23. Center for Drug Evaluation and Research. US Food and Drug Administration Web site. Report to the nation, 2004: improving public health through human drugs. Available at: http://www.fda.gov/cder/reports/rtn/2004/rtn2004.htm. Accessed January 11, 2006.
24. Centers for Medicare and Medicaid Services, National Health Expenditure Data. Available at: http://www.cms.hhs.gov/NationalHealthExpendData/ 02_NationalHealthAccountsHistorical.asp# TopOfPage. Accessed January 6, 2007.
25. Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005;24:240-249.
26. Chassin MR. Is health care ready for six-sigma quality? Milbank Q. 1998;76:565-591.
27. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301-306.
28. Conrad DA, Gardner M. Updated Economic Implications of the Leapfrog Group. Washington, DC: The Leapfrog Group; 2005.
29. Council on Graduate Medical Education and National Advisory Council on Nurse Education and Practice. Joint Meeting, Collaborative Education to Ensure Patient Safety: September 13-14, 2000, Washington, DC. Available at: http://www.cogme.gov/jointmtg.htm. Accessed December 30, 2006.
30. Coye MJ. The eICU and new business models in health care [VISICU press release]. May 5, 2005. Available at: http://www.visicu.com/press/news/archive. asp. Accessed December 30, 2006.
31. Dimick JB, Weeks WB, Karia RJ, Das S, Campbell DA Jr. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-937.
32. Donchin Y, Gopher D, Olin M. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;32:294-300.
33. Eisenberg JM. Testimony on reauthorization of the Agency for Health Care Policy and Research before the Senate Subcommittee on Public Health and Safety, February 11, 1998. Available at: http://www.ahrq.gov/news/test298a.htm. Accessed January 15, 2006.
34. Findlay S, ed. Reducing Medical Errors and Improving Patient Safety: Success Stories From the Front Lines of Medicine: National Coalition on Health Care, The Institute for Healthcare Improvement, February, 2000, Washington, DC. Available at: http://www.nchc.org/materials/studies/index.shtml. Accessed January 24, 2006.
35. Gawande AA, Studdert DM, Orav EJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229-235.
36. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66-75.
37. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614-621.
38. Guth KA, Kleiner B. Quality assurance in the health care industry. J Health Care Finance. 2005;31:33-40.
39. Haley RW. Managing Hospital Infection Control for Cost-Effectiveness. Chicago: American Hospital Association; 1986.
40. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, Hooton TM. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol. 1985;121:182-205.
41. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511-520.
42. Hamblen DL. Diagnosis of infection and the role of permanent excision arthroplasty. Orthop Clin North Am. 1993;24:743-749.
43. Hanson CW, Deutschman CS, Anderson HL 3rd, Reilly PM, Behringer EC, Schwab CW, Price J. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274.
44. Hanssen AD, Rand JA. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect. 1999;48:111-122.
45. Harper ML, Helmreich RL. Identifying barriers to the success of a reporting system. Agency for Healthcare Research and Quality, Advances in Patient Safety Vol 3:167-178. Available at: http://www.ahrq.gov/QUAL/advances/. Accessed January 20, 2006.
46. Harvey MA. Invisible excellence: presidential address from the 31st Congress of the Society of Critical Care Medicine. Crit Care Med. 2002;30:729-732.
47. Health Grades Quality Study. Patient safety in American hospitals 2004. Available at: http://www.healthgrades.com/media/english/pdf/ HG_Patient_Safety_Study_Final.pdf. Accessed November 30, 2005.
48. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996;331:140-145.
49. Herndon JH. Patient safety. Clin Orthop Relat Res. 2005;440:242-250.
50. Herndon JH. One more turn of the wrench. J Bone Joint Surg Am. 2003;85:2036-2048.
51. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, cost and prevention. Infect Control Hosp Epidemiol. 1996;17:552-557.
52. Johnson JA, Bootman LJ. Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med. 1995;155:1949-1956.
53. Kaushal R, Jha AK, Franz C, Glaser J, Shetty KD, Jaggi T, Middleton B, Kuperman GJ, Khorasani R, Tanasijevic M, Bates DW, Brigham and Women's Hospital CPOE Working Group. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006;13:261-266.
54. Kaushal R, Jha AK, Franz C, Tonushree J, Bates DW. The costs and benefits of computerized physician order entry. J Gen Intern Med. 2004;19-S1:216.
55. Kilpatrick KE, Lohr KN, Leatherman S, Pink G, Buckel JM, Legarde C, Whitener L. The insufficiency of evidence to establish the business case for quality. Int J Qual Health Care. 2005;17:347-355.
56. Kocher MS, Henley MB. It is the money that matters: decision analysis and cost-effectiveness analysis. Clin Orthop Relat Res. 2003;413:106-116.
57. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington DC: National Academies Press; 1999.
58. Krizek T. Surgical error: ethical issues of adverse events. Arch Surg. 2000;135:1359-1360.
59. Kuperman GJ, Teich JM, Tanasijevic MJ, Ma'Luf N, Rittenberg E, Jha A, Fiskio J, Winkelman J, Bates DW. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J Am Med Inform Assoc. 1999;6:512-522.
60. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353-357.
61. Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251-269.
62. Lavernia CJ. Quantifying cost effective healthcare. Orthop Tech Rev. 1999;1.
63. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200-1205.
64. Leape LL. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383.
65. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study, II. N Engl J Med. 1991;324:377-384.
66. The Leapfrog Group. Available at: www.leapfroggroup.org. Accessed January 15, 2006, 2005.
67. The Leapfrog Group. Leapfrog Group incentives & rewards lily pad, basic toolkit for frogs. Available at: http://www.leapfroggroup.org/media/file/ Leapfrog-Incentives_and_Rewards_Toolkit.pdf. Accessed December 17, 2005.
68. Lee TH, Zapert K. Do high-deductible health plans threaten quality of care? N Engl J Med. 2005;353:1202-1204.
69. Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis. 2003;36:1157-1161.
70. Lockley SW, Landrigan CP, Barger LK, Czeisler CA. When policy meets physiology: the challenge of reducing resident work hours. Clin Orthop Relat Res. 2006;449:116-127.
71. Mason J, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond M. When is it cost effective to change the behavior of health professionals. JAMA. 2001;286:2988-2992.
72. McCarthy D, Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Q. 2006;84:165-200.
73. Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85:193-197.
74. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348:2281-2284.
75. Morbidity and Mortality Weekly Report. Public health focus: surveillance, prevention, and control of nosocomial infections. Centers for Disease Control and Prevention. 1992;41:783-787.
76. Morimoto T, Gandhi TK, Seger AC, Hsieh TC, Bates DW. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care. 2004;13:306-314.
77. Morris AH. Decision support and safety of clinical environments. Qual Saf Health Care. 2002;11:69-75.
78. Mullaney TJ. The doctor is (plugged) in. BusinessWeek June 26, 2006. Available at: http://www.businessweek.com/magazine/content/06_26/b3990076.htm? chan=search. Accessed July 5, 2006.
79. Mullaney TJ. Doctors wielding data. Business Week, Nov 21, 2005. Available at: http://www.businessweek.com/magazine/content/05_47/b3960415.htm? chan=search. Accessed January 17, 2006.
80. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/ncipc/wisqars. Accessed January 15, 2006.
81. National Coalition on Health Care, The Institute for Healthcare Improvement. Reducing medical errors and improving patient safety: success stories from the front lines of medicine. February, 2000. Available at: http://www.nchc.org/releases/medical_errors.pdf. Accessed January 24, 2006.
82. National Quality Forum. Serious reportable events in healthcare: a consensus report. Washington, DC: National Quality Forum; 2002.
83. National Quality Forum 2002. Safe practices for better healthcare: a consensus report. Washington, DC: National Quality Forum; May 2003.
84. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-1722.
85. Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006;25:204-211.
86. Nordenberg T. Make no mistake! Medical errors can be deadly serious. FDA Consum. 2000;34:13-18.
87. Office of Disability. Aging and Long-Term Care Policy. Confronting the new health care crisis: improving health care quality and lowering costs by fixing our medical liability system. Washington, DC: US Dept of Health and Human Services; 2002.
88. Pennsylvania Health Care Cost Containment Council. Research Brief 2005. Available at: http://www.phc4.org/reports/researchbriefs/082506/. Accessed January 11, 2006.
89. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77-87.
90. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-130.
91. Premier, Inc. Promising trends in medical error disclosure. Available at: http://www.premierinc.com/safety/safety-share/06-04_full_txt.htm#Premier. Accessed January 23, 2006.
92. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288:2151-2162.
93. Pronovost PJ, Young T, Dorman T, Robinson K, Angus D. Association between physician staffing and outcomes: a systematic review. Crit Care Med. 1999;27.
94. Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, Anderson RJ. Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med. 2002;162:2186-2190.
95. Rosenfeld BA, Dorman T, Breslow MJ, Pronovost PJ, Jenckes M, Zhang N, Anderson G, Rubin H. Intensive care unit telemedicine: alternative paradigm for providing continuous intensivist care. Crit Care Med. 2000;28:3925-3931.
96. Rosenstein AH. Measuring the benefit of performance improvement and decision support. Am J Med Qual. 1999;14:262-269.
97. Rothschild J, Federico FA, Gandhi TK. Analysis of medication related malpractice claims: causes, preventability, and costs. Arch Intern Med. 2002;16:2414-2420.
98. Safety-Centered Solutions. The Impact of Medical Errors on Hospital Costs and Productivity. Available at: www.scCARE.com. Accessed November 2, 2005.
99. Sahni H, Jayakumar PN, Lalla RK, Vasudev MK, Kovoor JME. Anaphylactoid reaction following intravenous gadolinium dimeglumine - a case report. Ind J Radiol Imag. 2002;12:81-82.
100. Schenkel SM, Khare RK, Rosenthal MM, Sutcliffe KM, Lewton EL. Resident perceptions of medical errors in the emergency department. Acad Emerg Med. 2003;10:1318-1324.
101. Schyve PM. What you can do: the trustee, the patient and JCAHO. Trustee. 2003;56:19-21, 1.
102. Sculco TP. The economic impact of infected total joint arthroplasty. Instr Course Lect. 1993;42:349-351.
103. Small SD, Barach P. Patient safety and health policy: a history and review. Hematol Oncol Clin North Am. 2002;16:1463-1482.
104. Smarr LE. Statement of the Physician Insurers Association of America before a joint hearing of the United States Senate Judiciary Committee and Health, Education, Labor and Pensions Committee, February 11, 2003. Available at: http://www.thepiaa.org/pdf_files/February_11_Testimony.pdf. Accessed January 14, 2006.
105. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med. 2000;160:2741-2747.
106. Thomas EJ, Studdert DM, Newhouse JP, Zbar BI, Howard KM, Williams EJ, Brennan TA. Costs of medical injuries in Utah and Colorado. Inq. 1999;36:255-264.
107. US Congressional House Subcommittee Oversight Investigation. Cost and Quality of Health Care: Unnecessary Surgery. Washington, DC: Government Printing Office; 1976.
108. Voluntary Hospitals of America. Consumer Demand for Clinical Quality: The Giant Awakens. Irving, TX: VHA; 2001.
109. Wachter RM. The end of the beginning: patient safety five years after "to err is human". Health Aff (Millwood). 2004;W4:534-545.
110. Wachter RM, Shojania KG. Internal Bleeding. New York: Rugged Land LLC; 2004.
111. Weeks W, Wallace A. Broadening the business case for patient safety. Arch Intern Med. 2003;163:1112.
112. Weiler PC, Newhouse JP, Hiatt HH. Propsal for medical liability reform. JAMA. 1992;267:2355-2358.
113. Weinberger S, Weeks W. The evolution of new business in health care. J Health Care Finance. 2004;31:53-61.
114. Weiss GG. Are frivolous suits really a problem. Med Econ. 2006;83:31-35.
115. Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, Gatsonis C, Feibelmann S, Ridley N. Error reporting and disclosure systems: view from hospital leaders. JAMA. 2005;293:1359-1366.
116. Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984;3:6-32.
117. Wenzel RP, Edmond MB. The impact of hospital acquired bloodstream infections. Emerg Infect Dis. 2001;7:174-177.
118. Youngberg BJ, Hatlie MJ, eds. The Economics of Patient Safety. London: Jones and Bartlett Publishers International; 2004.
119. Zhan C, Miller M. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874.