Never Events: Rhode Island Hospital Uses Integrated Approach to Prevent Falls

Never Events

Rhode Island Hospital Uses Integrated Approach to Prevent Falls

Falls have been a patient safety concern for years. Yet there has been
an increased focus on this issue in recent times, as its scope and
resulting costs have come into clearer focus. Pressure has come from
many directions. In July 2000, the Joint Commission issued Sentinel Event Alert 14,
“Fatal Falls: Lessons for the Future,“ and in 2005 made reducing the
risk of patient harm from falls one of its National Patient Safety
Goals.

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How a Captive Insurer Uses Data and Incentives to Advance Patient Safety

How a Captive Insurer Uses Data and Incentives to
Advance Patient Safety

The Institute of Medicine report (2000), To Err Is Human,
unveiled a truth about the U.S. healthcare system that was previously
either obscure or unrecognized: we have a “non-system” of care with a
relatively high frequency of errors. The high defect rate leads to the
death of thousands of people each year from preventable errors — more
individuals than die from motor vehicle accidents, breast cancer, or
AIDS (Kohn, 2000).

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Health IT & Quality: Making Meaningful Use “Meaningful”

Health IT & Quality

Making Meaningful Use “Meaningful”

A short three years ago, the Office of the
National Coordinator for Health Information Technology was funded
at a level of less than $150 million. Today, thanks to the Health
Information Technology for Economic and Clinical Health Act of 2009 — part of the American Recovery and Reinvestment Act —
the ONC received a budget of over $2 billion. In addition, no less than
an additional $19 billion is set aside to facilitate the adoption of
electronic medical records over the next decade.

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AHRQ: Comparative Effectiveness Research

AHRQ

Comparative Effectiveness Research: Keeping the Patient at the Center

With this issue, Patient Safety & Quality Healthcare (PSQH)
reaches its fifth anniversary, which prompts me to take a moment and
think about how much the world has changed and stayed the same in the
past five years. When we published the first issue, in July 2004, the
patient safety community was discussing how much progress—if any—had
been made since the IOM published To Err Is Human five years earlier, and now we are assessing progress made over the past 10 years.

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Editor’s Notebook: Conferences and Silos

Editor’s Notebook

Conferences and Silos

While attending a number of conferences in October, I was struck by the
siloed nature of most of the educational sessions I attend. As a member
of the media, I go to a lot of conferences. Though I often work on
articles that identify “silos” — the provincial cultures of specialized
communities in healthcare — as counter-productive for safety, I had not
previously recognized the silos in conference-based education.

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Perspective: Enforceable Regulations for Patient Safety

Perspective

Enforceable Regulations for Patient Safety

The Institute of Medicine (IOM) report, To Err Is Human (2000),
recommended a national goal of reducing medical errors by 50% within 5
years. To say that we haven’t met this goal would be an understatement.
In its latest National Healthcare Quality Report, the Agency for
Healthcare Research and Quality (AHRQ) asserts that, “measures of
patient safety … indicate not only a lack of improvement but also, in
fact, a decline of almost 1 percent in this area.”

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IT Integration in the OR

IT Integration in the OR

Faced with increasing demands from the public and private purchasers
and payers of healthcare, clinician and administrative leaders in
hospital organizations are moving forward to address issues of
operational efficiency, clinician workflow, patient safety, and care
quality.

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Suicide Prevention Outside the Psychiatry Department

Suicide Prevention Outside the Psychiatry Department: A Bundled Approach

With the advent of The Joint Commission’s National Patient Safety Goals (NPSG) and the Institute of Medicine’s report To Err Is Human
(IOM, 2000), patient safety has returned to the forefront in
healthcare. Meanwhile, across the nation, the network of inpatient
psychiatric facilities is shrinking. The number of persons struggling
with mental health conditions, however, is not, and their demands on
the acute healthcare system are growing.

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Healthcare FMEA in the Veterans Health Administration

Healthcare FMEA in the Veterans Health Administration

Failure modes and effects analysis (FMEA) is a procedure that analyzes
potential failure modes within a given system. Each failure mode is
classified by severity to determine the effect of failures on the
system. FMEA is widely used in manufacturing, such as during various
phases of a product life cycle. It has become increasingly common to
find FMEA used in the service industries.

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Unit Transformation Improves Safety for Mothers and Newborns

Unit Transformation Improves Safety for Mothers and Newborns

In “Delivering System Transformation: Respect, Communication, and Best
Practices” (Dougherty et al., 2007), we described what we found when we
looked closely into patient safety at the Maternity and Newborn Care
Center (MNCC) at our organization, Hunterdon Medical Center. We found
problems that included some identified as common root causes of
perinatal death and injury by The Joint Commission in its Sentinel
Event Alert Issue #30, “Preventing Infant Death and Injury During
Delivery”: poor communication, unavailable physician staff, hierarchy
and intimidation, and inadequate staff competence and fetal monitoring
training.

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