From Blame to Fair and Just Culture:
A Hospital in the Middle East Shifts Its Paradigm

By Krishnan Sankaranarayanan MS, MBA, CPHQ; Steven A. Matarelli PhD, RN; Hasrat Parkar, MBBS, MRCGP; and Mamoon Abu Haltem MS, RN

The concept of a “culture of safety” emerged from high reliability organizations (HROs) such as in the aviation and nuclear power industries. The objective of HROs is to consistently minimize adverse events despite carrying out inherently intricate and hazardous work. These organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives. Improving the culture of safety within healthcare is long overdue and is now becoming essential to preventing and reducing errors, thereby improving overall healthcare quality (AHRQ, n.d.).

Editor’s Notebook

Lessons Learned—A Book Review as a Small Test of Change

By Susan Carr

Writing book reviews on a regular basis is a goal I have failed to achieve for years. Wanting to write nothing but comprehensive, stimulating reviews, I too often don’t write them at all—a classic case of letting perfect be the enemy of the good.

Culture of Safety

How to Influence Accountability

By David Maxfield, PhD

This Q&A first appeared on the official blog of the Crucial Skills Newsletter—a weekly online publication from the authors of New York Times bestselling books Crucial Conversations, Crucial Accountability, Influencer, and Change Anything.

Infection Control

Using Change Management Principles to Improve Infection Control

By Alan Reder, MA

Change never ends in healthcare. Institutions must constantly adapt to evolving research, regulations, technology, and economic conditions as well as internal crises.
Because change is inevitable, successful organizations prepare for it. They know they must carefully plan the change process so that staff will broadly accept a new protocol, technology, or organizational strategy.
That’s why leaders in healthcare organizations study change management.

News

ACR Task Force on Teleradiology Publishes New Practice Guidelines

Editor’s Notebook

IOM Plans to Add Diagnostic Error to ‘Quality Chasm’ Series

By Susan Carr

Mark L. Graber launched the 6th annual Diagnostic Error in Medicine (DEM) conference with a major announcement. Graber is founder and president of the Society to Improve Diagnosis in Medicine (SIDM), an organization that was formed just prior to last year’s DEM conference. DEM 2013, “Define, Measure, Improve,” was held in September at Northwestern University’s Feinberg School of Medicine in Chicago.

Special Advertising Section

RFID, Barcoding, RTLS: The Connected Hospital

By Tom Inglesby

Whether your facility is 40 years old or 4 months old, advances in technology can help increase patient and staff safety while improving efficiency. Tracking people and things throughout the building, monitoring care and medication, and assuring accurate patient identification are all enhanced by technology. Innovations are coming that can make the Connected Hospital a reality.

News

New Joint Commission Alert Addresses Medical Device Alarm Safety in Hospitals

The constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and ECG (electrocardiogram) machines is creating “alarm fatigue” that puts hospital patients at serious risk, according to a Sentinel Event Alert issued by The Joint Commission in April.

Seven Years, Zero CLABSIs: How a California Hospital Did It

By Alan Reder, MA

Joint Commission executives Mark Chassin, MD, FACP, and Jerod Loeb, PhD, have an uncomfortable question for hospitals: If airlines and chemical plants can maintain superb safety records despite huge potential hazards, why can’t you?