American College of Surgeons

Four Critical Elements of an Effective Quality Improvement Process

By Clifford Ko, MD, MSHS

More than a decade since the Institute of Medicine’s (IOM) landmark To Err Is Human report put a spotlight on quality improvement and patient safety, there has been little reduction in the rate of adverse events, according to The New England Journal of Medicine (2010).

ISMP

Short of Everything Except Errors: Harm Associated with Drug Shortages

By The Institute for Safe Medication Practices

In the November 3, 2011, ISMP newsletter, we asked hospital pharmacy staff to let us know if the drug shortage problem in the United States has continued to result in harmful outcomes for hospitalized patients. At that time, an Associated Press article had just reported 15 deaths in the prior 15 months that were linked directly to drug shortages (Johnson, 2011). (Thirteen of these deaths had also been reported to ISMP.) In response to our request for information, nearly 100 practitioners took our short survey and strengthened our belief that the ongoing drug shortage crisis is extracting a significant toll on patient safety.

Health IT & Quality

Print Me a Pill

By Barry P. Chaiken, MD, FHIMSS

During the first Star Trek series released in the mid 1960s, the creators introduced viewers to several magical devices—the Communicator, the Padd, the Replicator, and the Transporter. Although building the latter device requires the repeal of several laws of physics, the other three commonly exist today for the public to use. Smart phones are the Communicator of today allowing us to speak, text, or email to anyone around the world who might have a similar device.

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.