Editor’s Notebook

Conferences and Silos

By Susan Carr

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.

Perspective

Enforceable Regulations for Patient Safety

By Karen Wolk Feinstein, PhD

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.”

IT Integration in the OR

By Mitch Work, MPA, FHIMSS

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.

Suicide Prevention Outside the Psychiatry Department: A Bundled Approach

By Susan Bumgarner, BSN, MSN and Van Haygood, BSN, MS

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.

Healthcare FMEA in the Veterans Health Administration

By Erik Stalhandske, MPP, MHSA; Joe DeRosier, PE, CSP; Ryan Wilson, MS; and
Joe Murphy, APR, MS Carr

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.

Unit Transformation Improves Safety for Mothers and Newborns

By Stephanie Dougherty, BSN; Jeanne Whaley, RN; Ardath Youngblood, BSN, MN; and Robert M. Pickoff, MD, MMM

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.

Risk Management & Patient Safety

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.

Health IT & Quality

We Need Privacy Now

By Barry P. Chaiken, MD, FHIMSS 

Although a simple definition, it captures our greatest concern about
the digitization of our medical information. Who will access my medical
record? Will the information be used against me? Will it be released on
the Internet?

AHRQ

Patient Safety: One Decade after To Err Is Human

By Carolyn M. Clancy, MD

Nearly 10 years ago, the news that more people
die each year from medical errors in U.S. hospitals than from traffic
accidents, breast cancer, or AIDS (IOM, 2000) shocked the nation. We
have made much progress in building a foundation to address patient
safety since the publication of the Institute of Medicine’s (IOM)
report, To Err Is Human: Building a Safer Health System, but considerable work remains to ensure that patients are safe every day and in every place where they receive healthcare.

Viewpoint

An Injustice Has Been Done: Jail Time for an Error

By Michael R. Cohen, RPh, MS, ScD

Eric Cropp is an Ohio hospital pharmacist who was involved in a tragic
medication error that cost the life of a beautiful little girl named
Emily Jerry. For that, he was punished by a criminal court: 6 months in
jail, 6 months home confinement with an electronic sensor locked to his
ankle, 3 years probation, 400 hours of community service, a fine of
$5,000, and payment of court costs.