Fall Prevention: Stand Up to Falls
“Why do we fall? So we can learn to pick ourselves back up.” That inspirational quote is designed to focus on lessons that can be learned in order to move forward effectively and ultimately succeed.
When a fall is approached as an opportunity to learn, new knowledge is gained, informing changes that can lead to improvement. Learning is at the heart of improvement, innovation, and growth. But when a patient fall is treated as a failure, the learning stops.
ISMP: Key Medication Errors in the Surgical Environment
Medication errors in the perioperative area received widespread media attention with the publication of an article in the journal Anesthesiology (Nanji, Patel, Shaikh, Seger, and Bates, 2016). The perioperative area is one of the most medication-intensive locations in a hospital, often with more medications, particularly high-alert medications, administered per patient than other patient care units. Yet, this area of the hospital often operates with fewer medication safety strategies in place than most other patient care units. For example, the anesthesia provider often selects, prepares, labels, and administers medications without the benefit of electronic clinical decision support, pharmacy review of medication orders prior to administration, barcode scanning of products prior to administration, and other secondary checks by other healthcare providers (Nanji et al., 2016; Brown, 2014). This lack of normal checks and balances, along with the use of multiple medications, time-sensitive tasks, complex and stressful working conditions, distractions, and fatigue all contribute to making the perioperative area particularly error-prone when medications are administered.
‘Citizen Jury’ Recommends Ways to Improve Diagnosis
The Society to Improve Diagnosis in Medicine (SIDM), the Jefferson Center, and the Maxwell School of Citizenship and Public Affairs at Syracuse University are working with healthcare consumers to develop a list of the ways patients can reduce diagnostic error. The project is using a process developed by the Jefferson Center’s founder, Ned Crosby, PhD, … Continued
Opioids: What Do Healthcare Professionals Want and Need to Know?
The availability of, and access to effective and safe treatments for pain remain serious problems in the United States (Institute of Medicine, 2011). Opioid medications are important for addressing short-term and chronic pain management. Given the benefits that they provide, usage of opioids has become widespread over the past decade. However, opioid medications also carry substantial risk, and their increased usage has introduced a host of unintended consequences across the care continuum. Given this, opioids have significant implications for patient safety. The National Patient Safety Foundation (NPSF) conducted a convenience flash poll survey to obtain a snapshot of opioid-related patient safety concerns, learning needs, and familiarity with existing seminal publications among healthcare professionals.
Winners of the Eisenberg Patient Safety and Quality Award Announced
The National Quality Forum (NQF) and The Joint Commission announced the 2015 winners of the John M. Eisenberg Patient Safety and Quality Award, last Friday. The award, named after the former head of the Agency for Healthcare Research and Quality, recognizes those who have made great achievements in the arena of patient safety and quality. … Continued
Mercy Selects Datix Patient Safety and Risk Managment Solution
Mercy, the seventh largest Catholic health care system, has selected patient safety and risk management software from Datix to give a comprehensive view of incidents, complaints and claims across the organization. After a thorough evaluation, Datix was selected as a result of its ability to aggregate patient safety data in real time. Datix’s powerful dashboards … Continued
Safety Issues Dominate Joint Commission List of Most-Cited Standards of 2015
The Joint Commission’s latest list of most-cited standards was dominated by safety issues. Following a multi-year trend, eight of the top 10 cited standards came from the Environment of Care, Life Safety or Infection Control chapters, with most of them merely swapping places within the top 10. The standards are those most frequently found not … Continued
Readmissions Dip 47% When Some Patients Self-Administer IV Antibiotics
By: Alexandra Wilson Pecci, HealthLeaders Media Uninsured patients requiring prolonged courses of treatment with intravenous antibiotics can be trained to treat themselves at home and achieve outcomes comparable to patients who receive treatment in traditional settings, data shows. Teaching uninsured patients how to self-administer IV antibiotics for outpatient parenteral antimicrobial therapy (OPAT) has … Continued
Exploring the Intersection of Concurrent Surgeries and False Claims Enforcement
Renewed focus on concurrent surgeries underscores patient safety concerns. Newspaper investigation has thrust issue into national spotlight, prompting American College of Surgeon Updates
The practice of concurrent surgeries has become a top concern for hospitals across the country following a Boston Globe investigation into the practices of a reputable Massachusetts hospital.
In October, the Globe published a lengthy exposé into the practice of “concurrent” or “double-booking” surgeries at Massachusetts General Hospital (MGH), ranked as the top hospital in the nation by U.S. News and World Report in 2015-2016. The Globe’s investigation revealed an ongoing battle within the health system that pitted one long-time surgeon against the hospital’s top brass in his quest to eliminate concurrent surgeries. The investigation also described specific incidents in which patients were harmed or even paralyzed during double-booked procedures.
The Globe investigation has pushed the issues of concurrent surgeries – a common practice among many academic medical systems across the country – to the surface, drawing criticisms from patient safety advocates and prompting organizations like the American College of Surgeons (ACS) to review current policies on concurrent or overlapping surgeries.
EHR Copy and Paste Best Practices Toolkit Released
Copying and pasting information in EHRs is a common practice that can save busy physicians and other staff valuable time, but it can also introduce significant errors into the record. In an effort to help physicians make the most of the copy and paste function while protecting the integrity of the record, the Partnership for … Continued