I look forward each spring to attending the National Patient Safety Foundation’s (NPSF) Patient Safety Congress for great education and networking opportunities. I especially look forward to the pre-conference programs NPSF offers, which this year (May 17–19) added a half-day on medical simulation to the customary full-day sessions on leadership and community engagement.
Building a Culture of Safety
In the 10-plus years since the inaugural publication of the Institute of Medicine (IOM) study on medical error, To Err Is Human, there has been surprisingly little progress in reducing the rate of medical error, despite the adoption of technologies specifically intended to combat medical errors. A growing number of people attribute this lack of progress to fundamental flaws in the American healthcare culture that prevent success.
Common Cause Analysis
To improve medication safety, many healthcare systems implement a technology (such as barcode at point of care) or a best practice (such as double-check of high-risk medications). This approach turns performance improvement into experimentation with other people’s solutions for other people’s system problems — the assumption being all providers share the same system problems.
Post-Discharge Call Programs
Improving Satisfaction and Safety
For patients coming home from the hospital after surgery, an emergency department (ED) visit or any other inpatient stay, the change in location has both positive and negative possibilities. On one hand, because the patient is returning to familiar surroundings and routines, recovery may be easier. On the other hand, it may be harder.
Safety Huddles for a Culture of Safety
When the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System in 2000, the executives and quality and patient safety staff at Gundersen Lutheran immediately started discussions around issues emphasized in the report.