Corporate Compliance

OIG Report Critical of CMS Handling of Serious Adverse Events

By Renee H. Martin, JD, RN, MSN

In late 2011, the Office of Inspector General (OIG) released a report that examined CMS’s response to serious adverse events in hospitals. The report, Adverse Events in Hospitals: Medicare’s Responses to Alleged Serious Events (Levinson, 2011), concludes that “Medicare’s system of hospital oversight missed opportunities to address patient safety in its response to alleged serious adverse events.”

News

Editor’s Notebook

Culture’s Reciprocal Rewards

By Susan Carr

Spring is a busy season for conferences. In May, I attended a few and missed a few because there weren’t enough hours and days in the month. At the ones I did attend, the effect of an institution’s culture on patient safety was a common theme.

  May/June 2014 Quality Conundrums Lynn Helmer, MD, MBA, CHCQM • ABQAURP Diplomate since 1998 • http://www.drdnj.com Accountability vs. Just Culture – A Quality Conundrum? Does a culture of accountability demand that physicians and nurses who make mistakes be punished under all circumstances? Does a punitive environment increase or decrease the likelihood of errors? Conversely, … Continued

ISMP

Building Patient Safety Skills: Common Pitfalls in Root Cause Analysis

By The Institute for Safe Medication Practices

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous RCAs in the past 15 years since The Joint Commission first required its use to investigate sentinel events. RCA is the most basic type of event investigation; an analytical approach to problem solving that seeks to identify why adverse events happen and how to prevent them.

We Can All Define Patient Safety… or Can We?

By Della M. Lin, MD, and Sanjaya Kumar, MD

Patient safety is a term used frequently in healthcare… perhaps too frequently, and sometimes without appropriate context. An exploratory survey was conducted at the Estes Park Institute conferences in the 2009–2010 season to probe the definition of patient safety among hospital executives, board members, and physician leaders. Participants were given 3 to 4 minutes to define patient safety with up to 10 single words.

Noah’s Story: Please Listen

By Tanya Lord, MPH, PhD

Communication in healthcare—provider to patient, patient to provider, and provider to provider—is at the heart of improving quality and patient safety. This is the story of my son Noah, whose experience with the healthcare system 13 years ago inspired me to work toward making positive changes in hospital care. His story is interspersed below with my present-day commentary about what I now understand about how poor communication contributed to his death. I hope Noah’s story inspires patients, families, and providers to communicate as effectively as possible and helps other patients and families avoid harm.

Q & A with Diane Pinakiewicz
‘Patient Safety Is Everyone’s Work’

By Susan Carr

Diane Pinakiewicz has been president of the National Patient Safety Foundation (NPSF) since 2005, having been a founding member of its board in 1997. With prior experience in executive positions across a variety of healthcare sectors, Diane’s commitment to patient care has been the common thread that has taken her from her first job in hospital administration to now running the country’s premier patient safety organization.