MITSS: Supporting Patients and Families for More than a Decade

By Winifred N. Tobin

Over the past decade, the patient safety movement has focused much of its attention on prevention, and rightly so. Still, even in the safest of systems, things can, and often do, go wrong. Of late, much has been published regarding the “second victim,” a term used to describe healthcare providers finding themselves on the sharp end of an error or adverse event. Yet, little has been documented about the emotional impact on patients and their families and the need for support following these events.

Addressing Alarm Problems in the Emergency Department

By Kathryn M. Pelczarski

Stand for a few moments in the middle of your emergency department (ED) to just listen and observe. How many alarms do you hear? Can you distinguish where each alarm is coming from and whether it’s a physiologic monitor or ventilator or infusion pump alarm? Does each alarm connote the level of urgency needed for the nurse to respond promptly and appropriately? Do you observe nurses scurrying to respond? Or do the alarms perpetuate while no one responds?

Health IT & Quality

American Autos Circa 1970 and Healthcare

By Barry P. Chaiken, MD, FHIMSS

The Ford Pinto was a really terrible car. The gas tank was positioned such that, in a collision, protruding differential bolts would puncture the tank, leading to frequent car fires. This defect led to the death of more than 27 people and many others maimed. Other cars representative of this defect-filled era of U.S. auto manufacture include the Ford Fairmont, AMC Gremlin, and Chevy Vega. Cars made in the United States in the 1970s and 1980s were poorly designed, cheaply assembled, and reliably unreliable.

Change of Scenery: Just What the Doctor Ordered

By Diane Garry, RN, BSN, MEd, and Tina Mason, ARNP, MSN, AOCN®, AOCNS®

Being hospitalized should not necessarily preclude a patient from going outdoors independently, that is, without the assistance or supervision of a healthcare staff member. Nonetheless, reconciling the need to ensure patient safety with the patient’s desire to enjoy the therapeutic benefit of being off the unit and outdoors can create conflict for patients and healthcare providers.

AHRQ

CUSP: Scaling Up a Safety Framework

By Carolyn M. Clancy, MD

In the 13 years since the Institute of Medicine (IOM) issued its clarion call exposing major deficiencies in U.S. healthcare (2000), improving patient safety has been a foremost goal within our system. Providers, purchasers, consumers, payers, regulators, and other stakeholders have worked tirelessly together to formulate strategies to reduce needless harms (including needless deaths) resulting from care.

Diagnostic errors (i.e., diagnoses that are delayed, wrong, or missed) are increasingly recognized as a patient safety concern in ambulatory care (Singh & Graber, 2010). A recent report from the American Medical Association (AMA) Center for Patient Safety (Lorincz et al., 2011) highlighted the importance of diagnostic error and the critical need for future research on this topic.

ISMP

Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

By The Institute for Safe Medication Practices

Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in their facilities.

Editor’s Notebook

Personal Accountability

By Susan Carr

I’m struck by the number and variety of patient safety initiatives that individuals, organizations, and government entities have underway. We’re engaged in so many different activities in the name of safety and quality, it’s hard to tell if we’re headed collectively toward a coherent goal. Despite success stories and pockets of excellence, many still wonder if we’re better off than we were a decade ago. In patient safety, how can we be sure that we’re cultivating a forest and not just a vast collection of specimen trees?

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Fall Prevention: No, Falls Are Not Inevitable

By Tom Inglesby

Patients fall. It’s a fact of hospital life. Weakened by illness or surgery, confused by medication or aging, patients try to do more than they can and the result is often a fall. It might be a fall from bed, a fall while trying to walk unsupported, a fall when trying to get up from a chair. These things happen all too regularly. As caregivers, your job is to prevent those falls from happening.