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.

Editor’s Notebook

Summer Reading

By Susan Carr

Staying current on developments in patient
safety and quality improvement allows me to indulge my eclectic taste
in reading. Looking back at what I’ve read this summer, I see a wide
range of topics and a couple of books in particular that I’d like to
recommend.

A 260-pound psychiatric patient charges his nurse and strikes her in the face as she prepares to take his blood pressure in the emergency department (ED).

I recently conducted a medication history for a patient who was seen in our clinic for rectal bleeding, weakness, and blurred vision. Mrs. J. is a pleasant woman in her mid-80s who was visiting to our cardiology practice for the first time.

We highlighted the importance of medical device interoperability for patient safety in an article in PSQH in January/February 2007.

These are truly troubled times. Perhaps we are seeing the most difficult challenges across our country and our world that any of us will ever see. These challenges are both professional and personal. They impact our good work, our personal aspirations, and what we hope for our families.

New entities created to help health providers reduce the incidence of patient safety events and maintain confidentiality about those events will gear up for action in 2009.

When asked, I say that PSQH is not peer reviewed, but that’s not entirely accurate. I’ve always looked to members of our Editorial Advisory Board for direction and, increasingly, for peer reviews of manuscripts submitted for publication.

How would you react if you learned that local pediatricians were steering patients away from your hospital’s emergency department and sending them to a competitor because they lacked confidence in the quality of care in your emergency department?