Maine Medicine Weekly Update - 04/23/2018  (Plain Text Version)

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In this issue:
•  Opioid Prescribing for Pain Continues to Decline in Maine
•  MMA is 165 Years Old on Saturday, April 28, 2018
•  MMA Listening Session in Presque Isle on Tuesday, May 15 6-8pm
•  MMA Board Meets on Wednesday, April 25, 2018
•  Hanley Center Health Leadership Development Class XI Graduates Twenty-nine Healthcare Leaders
•  MICIS: Next Steps in Addressing Maine's Opioid Crisis
•  AMA, Specialty Societies Ask CMS to Reduce 2018 MIPS Reporting Period
•  Consumers for Affordable Health Care to Honor MMA EVP Gordon Smith at 30th Anniversary Celebration on June 7th
•  Maine Education Department Announces School Immunization Changes
•  24 Maine Hospitals Report Sentinel Events
•  Doctors Without Borders Coming to Maine May 1st
•  Looking for Help in Paying for Medical School?
•  Take Control of Debt - April 24 Webinar Presented by Baystate Financial
•  Final Legislative Call of the Session This Tuesday, April 24th
•  Legislative Report: Adjournment?
•  FREE 8-Hr. MAT Waiver Training Being Offered in Dover, NH - Friday, April 27th
•  Maine Society of Eye Physicians and Surgeons Spring Educational & Business Meeting - Friday, May 4th
•  Introduction to Lean in Healthcare Full-Day Workshop on Tuesday, May 8
•  Maine Chapter, American College of Surgeons Annual Meeting in Kennebunkport, ME - May 18-20
•  One River, One Ocean: June 2-14, 2018
•  New Free CME on Alzheimer's Risk, Detection, and Management
•  Peer Navigation Program from Facing Our Risk of Cancer Empowered (FORCE)
•  Online Learning Opportunities Offering CME Credits - from the Northern New England Practice Transformation Network
•  Outpatient Internal Medicine Physician Bangor, Maine
•  Family Practice Physician - Bucksport Regional Health Center
•  Relocate to Beautiful Southwestern Maine - Medical Director/Family Practice Physician
•  Psychiatry Faculty, Division of Child & Adolescent Psychiatry
•  Psychiatric Medical Director
•  Maine's Largest FQHC in need of Physician for Geriatric Program
•  Multiple Family Med Opportunities in Beloved Community Health Centers
•  Outpatient Only - Internal Medicine with Loan Repayment & Sign-on Bonus
•  Internal Medicine Outpatient Physician
•  Clinical Cardiology Opportunity
•  Opportunities at the VA for Volunteer Physicians


24 Maine Hospitals Report Sentinel Events

 The 2017 "Sentinel Events Annual Report" states that 34 of Maine's 38 hospitals reported a total of 256 sentinel events in calendar 2017, according to an article from the Maine Hospital Association.


[from the Maine Hospital Association's Hospital Update]

Hospitals reported the majority of sentinel events, although another nine events were reported by other facilities covered under the sentinel event law.

The number of events reported represents a 13.2 percent increase in reported events from 2016 to 2017, a fact that the Sentinel Event Team (SET) took as due to increased surveillance rather than an increase in events.

The report said that 20 percent of the events occurred on a weekend or a holiday. 

Of the 27 different categories of sentinel events, eight categories made up 83 percent of the total events:

  • Stage 3 or 4 and unstageable pressure ulcers at 83 (31 percent);
  • Fall with serious injury at 43 (16 percent);
  • Unanticipated death within 48 hours of treatment at 32 (12 percent);
  • Unanticipated death at 21 (8 percent);
  • Wrong-site surgery at 15 (6 percent);
  • Unanticipated transfer to another facility at 9 (3 percent);
  • Death or serious injury from a medication error at 9 (3 percent); and
  • Unintended retention of a foreign object at 8 (3 percent).

Pressure ulcers have been in the top three most frequently reported sentinel events over the past seven years, the report said.  Falls with patient death or serious injury continue to remain the second most reported sentinel event.  Reported events show that falls frequently occur when the patient is getting up to use the toilet.

The SET continues to see issues, such as the failure to use the surgical timeout process, contribute to continued wrong-site surgeries.  The SET questioned if timeouts are being performed accurately and with the required attention. 

The most common action items from the root cause analysis stemming from these sentinel events are policies and procedures, education and training, and evaluation.

The SET plans to focus on the following goals for 2018:

  • Continue to provide technical assistance and consultations, as requested, to facilities;
  • Continue to assess facilities’ compliance with the sentinel event law by conducting on-site reviews.  On-site reviews at all hospitals that have not yet been reviewed will be completed in 2018;
  • Continue to enhance the sentinel event database with relevant information and analyze complaint data to identify trends in events, track individual facility events and use data effectively;
  • Continue to publish the quarterly sentinel event newsletter;
  • Review and revise the sentinel event rules to clarify reporting criteria and other modifications;
  • Continue to develop collaborative workgroups to discuss challenges and best practices related to patient safety;
  • Collaborate with facilities to ensure compliance with notifying the SET of an event within one business day of the event being discovered, and submission of a root cause analysis and associated requirements with 45 days of reporting; and
  • Look at methods to review outpatient provider-based practices listed on facilities’ licenses for compliance with the program and reportable events.