Medication Reconciliation in Daily Rounds in the NICU

By Sanghee Suh, BA; Melody Linton; John Chuo MD, MS

There is a major thrust for patient safety nationwide. With an estimated 1.5 million preventable adverse drug events (ADEs) occurring annually in the United States, there is still a need for better error prevention systems (Institute of Medicine, 2007).

State-wide Leadership Creates a Culture of Patient Safety in Rhode Island

By Mary Cooper, MD, JD; Joan Flynn; Patricia Daughenbaugh RN, MSN, MBA; and Kathy Martin, MBA

To provide a safer environment for patients in Rhode Island, 13 hospitals in the state have initiated a program to improve the way data on adverse medical events is reported, analyzed, shared, and utilized.

Daily Check-In for Safety: From Best Practice to Common Practice

By Carole Stockmeier, MHA, CMQ-OE; and Craig Clapper, PE, CMQ-OE

In the nuclear power industry, knowing the status of plant operations and early identification of potential problems is safety critical. At nuclear generating stations across the country, like the Black Fox plant (a pseudonym), each day begins with a plan-of-the-day meeting of plant leaders.

Automated Pre-op Instructions in a Culture of Continuous Improvement

By James Gottesman, MD

The benefits of providing patients with pre-operative instructions tailored specifically to their unique procedures, health status, and medications are well established. Patient safety perhaps tops this list. Healthcare providers have long recognized that offering clear, easily understandable instructions that cover requirements including fasting, discontinuing anticoagulants or blood pressure regulators, avoiding tobacco and alcohol, and more can enhance patient safety by reducing the chances of potentially life-threatening perioperative complications (Tea, 2010).

The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough

By David Maxfield; Joseph Grenny; Ramón Lavandero, RN, MA, MSN, FAAN; and Linda Groah, RN, MSN, CNOR, CNAA, FAAN

Poor communication is deadly, especially in critical care settings (Wachter, 2010; The Joint Commission, 2010). When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm (Alvarez, 2006; Gandhi, 2005) and even death (Consumers Union, 2009; Institute of Medicine, 2000).

Patient Safety Summit in Emergency Care

By Stephen D. Armstrong

Emergency care and patient safety thought-leaders from across North America convened in Las Vegas in May 2011 to spend two days together to address the patient safety challenges and opportunities throughout the continuum of emergency care. The event was hosted by the Emergency Medicine Patient Safety Foundation (EMPSF), a national not-for-profit organization based in California whose mission is to improve patient safety in the practice of emergency medicine through education, research, collaboration, and training.