I, like many of you, read in July about another heparin-IV versus heparin-flush incident. As reported by CNN.com, as many as 17 infants in Corpus Christi, Texas, received the all-too-common 1000x overdose believed in this case to have been caused by a mixing error. As of this writing, two of the children have died, though causes of death were still uncertain. Several industry leaders said that barcoding is an obvious solution, but if the error occurred when the drug was being prepared or mixed in the pharmacy department, many found it difficult to understand how a few black lines in a barcode would have made a difference.

Patient Safety. It’s one of the highest priorities in healthcare today. The Institute of Medicine reported in 1999 that approximately 1 in 10 patients in the United States is injured and nearly 100,000 die every year from preventable medical errors. While most of the news seems discouraging, many hospitals are making progress in bringing about improvements in their patient safety practices. To help recognize these healthcare organizations, Precision Dynamics Corporation (PDC) and Patient Safety & Quality Healthcare (PSQH) cosponsored a nationwide Partner in Patient Safety Success Story contest.

Making drugs is messy. Take heparin. You raise pigs and then slaughter them. You isolate the pig intestines and cook them. Then you scrape the intestinal insides, dry them, and get them to a factory to undergo more processing (Harris, 2008).

One early morning in September 1982, a 12-year-old girl awoke in her home in the outskirts of Chicago with moderate cold symptoms. Her loving parents prepared a tall glass of water and one Extra Strength Tylenol® capsule for her to take before sending her back to bed. A few hours later, Mr. and Mrs. Kellerman awoke to find their daughter Mary critically ill on the bathroom floor. Her parents rushed her to the hospital, and she died a short time later.

While not spread evenly, our national investment into improving the quality of care has begun to pay dividends. So far, the payback has been modest: Quality inched upward by 2.3% between 1994 and 2005, according to a 2007 national report from the Agency for Healthcare Research and Quality (AHRQ).

In late October, I attended three conferences: Health 2.0, the Center for Connected Health symposium, and the annual congress of the Center for the Integration of Medicine and Innovative Technologies. Although these organizations have somewhat different audiences (Health 2.0 is more a community than organization), their conferences share a focus on technology, especially applications and devices that give patients new ways to manage their health and medical care.

In the United States, vaccine-preventable diseases cost in excess of $10 billion annually. Pneumococcal disease and influenza combined were the 8th leading cause of death in 2004 (Kung, et al., 2008).

Unknown to most Americans, the United States provides universal health coverage to its more than 305 million citizens and legal residents.

For as long as healthcare professionals have worked to improve patient safety, they have debated which criteria are appropriate for evaluating improvement initiatives and what evidence is required before programs are widely implemented.

Increasingly, healthcare consumers engage with clinicians and administrators in discussions about improving the safety and quality of healthcare.