Leadership Practices to Advance Patient Safety

By Jane Durney Crowley, BSN, MHA and Jana B. Deen, BSN, JD

Historically, the medical community has accepted that a certain amount of unintended injury and error will occur because of the complex nature of medicine and variation in patients. The executive team of a large multi-state health system knew it had to change that mindset among leaders and healthcare providers in its 32 hospitals.

Patient Safety Organizations:
Building a Safer Healthcare System

By William Minogue, MD; Inga Adams-Pizarro, MHS;
and Patty Montone Charvat

The surge of voluntary regional and national initiatives to improve patient safety demonstrates the momentum building to unite the healthcare community. Recently, the Institute for Healthcare Improvement's 100,000 and 5 Million Lives Campaigns enrolled thousands of hospitals in a concerted effort targeting patient safety. Regionally, states such as Maryland have established networks to encourage peer-to-peer collaboration and learning. Now, the federal government has set the groundwork for a national network of organizations working to reduce harm to patients.

Pilot Study: The Role of the Hospitalized Patient in Medication Administration Safety

By Marilyn Macdonald, RN, PhD

Continuous Pulse Oximetry Monitoring
in the Inpatient Population

By Josh Pyke, BE; Klaus Christoffersen, PhD; Jean Avery, MBA, BSN;
George T. Blike, MD; Susan P. McGrath, PhD;
and Nancy Karon, RN, BSN, ONC

John Smith is admitted late Monday afternoon to the post-surgical ward after a total knee replacement. John is overweight, though not morbidly obese, and has an undeclared history of snoring. He wakes up at 5:30 Tuesday morning with considerable pain; over the next hour he exhausts the opiate supply in his PCA pump, and his nurse inserts a new syringe before her shift ends at 7 a.m. It will be more than 45 minutes before John is next checked by the nurse starting his day shift — plenty of time for John's high dosage of opiate analgesics, exacerbated by his undiagnosed sleep apnea, to send him dangerously deep into respiratory depression.