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Engaging Patients and Families in Root Cause Analysis of Sentinel Healthcare Events: The Story of Justin Micalizzi
By Susan Carr Working with two patient advocates, the Reliability Center has released a webcast that analyzes the sudden, unexpected death in January 2001 of 11-year-old Justin Micalizzi immediately following surgery for an infected ankle. For 10 years, the Micalizzi family—especially his mother, Dale, now a well known patient safety advocate—sought unsuccessfully and without the cooperation of the hospital to discover what caused Justin’s death or at least to elicit a clear and honest pledge that the hospital would commit sincerely to understanding what had happened.
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UC Irvine Medical Center Selects iSirona for Medical Device Integration
iSirona, a provider of simplified solutions for medical device integration, announced on May 8 that UC Irvine Medical Center will be implementing iSirona's device connectivity solution throughout its campus.
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HMS Fellowship in Patient Safety and Quality
Established by the academic teaching institutions and Harvard Medical School (HMS), the HMS Fellowship in Patient Safety and Quality is proud to present its first four recipients representing the Class of 2012.
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NPSF Awards Research Grants for Patient Safety Projects
The National Patient Safety Foundation (NPSF) announced on May 9 that it has awarded a total of $200,000 in grants for two innovative patient safety research projects. The grants are awarded through the NPSF Research Grants Program, which promotes studies leading to the prevention of human errors, system errors, patient injuries, and their consequences.
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I-PASS: Standardizing Patient "Handoffs" to Reduce Medical Errors
A new patient safety and medical education initiative, standardizing and improving how patient care is "handed off" during hospital shift changes, can reduce medical errors by as much as 40 percent, report physicians at the Pediatric Academic Societies annual meeting in Boston.
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Psych Patients Need Patience in the ER, Average Wait 11 Hours
Patients having psychiatric emergencies wait 11.5 hours in the emergency department, and those who are older, uninsured or intoxicated wait even longer, according to a study published online recently in Annals of Emergency Medicine (“Patient and Practice-Related Determinants of Emergency Department Length of Stay for Patients with Psychiatric Illness").
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ANA and AONE Release Joint Principles of Collaboration
Communication and collaboration are critical elements of success for effective work environments, particularly in health care. When these elements break down, the result can be a cascade of negative events. Yet when collaboration is strong, it reaps positive benefits on the workplace culture and patient outcomes.
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The Risk of Workarounds
By Tim Vanderveen, PharmD, MS
In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through ourCenter for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.
Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.
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Ekahau Launches Next Generation Wi-Fi RTLS Staff Badge and Pager
Ekahau Inc. announced the May 8 launch of its newest Wi-Fi staff badge.
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Northeast Georgia Physicians Group Chooses Phytel to Enhance Its Patient-Centered Medical Home Model
Phytel, the leader in automated physician-led population health improvement, recently announced that Northeast Georgia Physicians Group has selected Phytel and its Atmosphere platform to help transform all of its 30-plus ambulatory-care clinics into patient-centered medical homes by the end of the year.
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Another Way to Do Harm
By Susan Carr In PSQH, we usually focus on preventing patient harm that results from errors—mediation overdoses, wrong-site surgery, MRI accidents, failure to rescue, etc.—that trace back to systemic problems in healthcare institutions. Those problems include poor communication, environments full of distraction and stress, inadequate training, power hierarchies, to name a few.
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Enlivening Biophilia: Sky Factory Promotes Healing for Cancer Patients
The Sky Factory, a fine art and technology company, will exhibit at ESTRO 31 in Barcelona, May 9 - 13.
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Healthcare Providers to Increase Efficiency with InSites Connect
Intelligent InSites, Inc., the leading provider of enterprise real-time location systems (RTLS) software helping hospitals improve operation performance and patient satisfaction while supporting multiple RFID and RTLS technologies, has annouced that its InSites Connect RTLS mobility solution is now available in Apple's App Store.
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Sotera Wireless Reports FDA Clearance of ViSi Mobile System
Sotera Wireless, Inc. announced that it has received 510(k) clearance from the United States Food and Drug Administration (FDA) for the ViSi Mobile™ System, a new continuous vital signs monitoring system for use in hospitals.
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ViaValve Safety I.V. Catheter Receives 510(k) Clearance from the U.S. FDA
Smiths Medical, a leading global medical device manufacturer, announced on April 23 that its ViaValve Safety I.V. Catheter has been cleared by the U.S. Food and Drug Administration (FDA) and can be marketed in the United States.
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Failure Reporting, Analysis and Corrective Action System Released
PROACTOnDemand, the new RCA SaaS Web Application for performing and delivering Root Cause Analysis developed by Reliability Center, Inc., of Hopewell, Virginia was awarded the Product of the Year Gold Award by Plant Engineering magazine readers in the Maintenance Software category.
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CareFusion and Cerner Integrate Smart Pump Technologies to Help Improve Medication Safety and Efficiency
CareFusion and Cerner recently announced the live limited commercial release of a new infusion pump connectivity solution at Oklahoma Heart Hospital, one of the nation's first all-digital hospitals exclusively focused on heart care.
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Johns Hopkins Patient Safety Expert Peter Pronovost Earns Dual National Honors
Peter Pronovost, M.D., Ph.D., F.C.C.M., a world-renowned patient safety champion who’s devoted his career to making hospitals and health care safer for patients by reducing medical errors and avoidable harm, is the recipient of two national honors.
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International ACS NSQIP Scholarships 2012
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) offers International ACS NSQIP Scholarships for two surgeons from countries other than the United States or Canada who demonstrate strong interests in surgical quality improvement.
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NQF Endorses All-Cause Unplanned Readmissions Measures
The National Quality Forum (NQF) Board of Directors has endorsed two measures that address all-cause unplanned readmissions in hospitals – an area of healthcare targeted for improvement given national imperatives to make healthcare safer, more affordable, and keep people healthy.
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50,000 Physicians Now on Doximity Medical Network
In the year since its launch, Doximity has grown to over 50,000 active physicians and is now used by 9% of all doctors in the United States. In that time, Doximity has also facilitated more than one million connections between doctors— affecting the care of tens of millions of American patients. In reaching this milestone, Doximity has established itself as the largest and fastest-growing professional network for physicians online.
Doximity uniquely provides a HIPAA-compliant platform where physicians use their real name and verified credentials to establish and share their professional expertise.
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Physicians, Hospitals, Health Groups Announce Initiative to Improve the Medical Liability Environment in Massachusetts
Led by the Massachusetts Medical Society, six health care organizations announced on April 18, 2012, the start of a major initiative to improve the medical liability system in the Commonwealth.
The new alliance has launched its effort with the release of a Roadmap to Reform, an alternative approach to medical liability intended to improve patient safety, increase transparency, reduce litigation, and cut costs to the health care system, and with the announcement that seven hospitals will participate in a pilot program this year to implement the reforms.
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Health Literacy Innovations Offers Scholarships to IHA Conference
As part of its commitment to share health literacy best practices, education, and knowledge, Health Literacy Innovations, creators of the Health Literacy Advisor™ (in Spanish—Asesor de Comunicación en Salud™), announced it will offer seven scholarships to the 11th Annual IHA Health Literacy Conference.
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Joslin Diabetes Center Partners with Phytel on CME Research Project
Phytel, the leader in physician-led population health improvement, and the Joslin Diabetes Center, a Harvard Medical School affiliate in the forefront of the fight against diabetes, recently announced their collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies for continuing medical education (CME) programs. The results will be used to inform ongoing efforts to improve diabetes care.
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Franciscan Alliance Signs Medical Device Integration Agreement with iSirona
iSirona®, a provider of simplified solutions for medical device integration, announced on April 12 that Franciscan Alliance, one of only 32 Pioneer Accountable Care Organizations (ACO) in the country, has chosen to implement iSirona's device connectivity software.
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Wolters Kluwer Health Unveils Integration between UpToDate and Sentri7
Wolters Kluwer Health, a leading global provider of information for healthcare professionals and students, recently announced that UpToDate's clinical knowledge system has been integrated with Sentri7 surveillance software by Pharmacy OneSource.
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Capsule Promotes Value of Medical Device Integration with New Video Series
Capsule Tech, Inc., the leading provider of medical device connectivity, recently announced “Connected Consultants”, a new video series created to educate clinicians and IT staff within hospitals and healthcare organizations on the important role that medical device integration plays in improving healthcare IT.
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iPad Brings New Wave in Surgeon, Patient Communication
A Henry Ford Hospital surgeon checks in on a patient the day after removing a tumor from his kidney, examining the surgical scar and seeing on the patient’s face that he’s still in a bit of pain. But this isn’t your typical post-surgical hospital rounding.
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