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.

Enhancing Clinical Education and Training, Improving Care

By Manon Maitland Schladen, MSE, PMP, EdS; and Cynthia G. Pineda, MD, FAAPM&RI

More than a decade ago the Institute of Medicine published its landmark study, To Err is Human (2000), documenting an unacceptably high rate of medical errors, many of them resulting from poor clinical decision-making. In fact, surgeons in the United States make medical errors more than 4,000 times a year, which can result in permanent injury or death. These types of preventable errors include wrong-site surgery, retained surgical items, wrong-patient surgery, and wrong-procedure surgery, causing nearly half of the affected patients to suffer temporary injury (Landro, 2012).

A Team Approach to Fall Prevention

By Catherine Edmonds, MSN, RN, CNL

Falls are a growing health concern, especially within the acute care arena. A fall is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (Johnson et al., 2011). More than 30% of adults age 65 and older fall each year (Centers for Disease Control and Prevention, 2011), and up to 50% of adults age 85 and older fall each year (Bohl et al., 2010). With the aging population, the incidence of falls is only expected to increase.

Mentoring Programs: Essential for Sustaining a Culture of Safety

By Mary A. Seisser, MSN, RN, CPHRM, CPHQ, FASHRM; and Rosalie S. Brown, BA, MHA, RN, CPHRM

An effective mentoring program can strengthen a healthcare enterprise’s performance in many areas, including quality improvement, risk management, personnel recruitment and retention, staff education, and leadership. By enhancing staff knowledge and team integration, mentoring programs help support an enterprise-wide culture of safety, which, in turn, helps minimize adverse patient occurrences and related financial losses. This article examines the theory and practice of mentoring, focusing on how adult learning strategies and ongoing managerial support can improve mentor-mentee rapport and produce better outcomes for participating individuals and the organization.