By the Institute for Safe Medication Practices

Now that 2016 is underway, the Institute for Safe Medication Practices (ISMP) would like to extend its sincere thanks to the many healthcare providers, consumers, advocacy groups, organizations, agencies, and companies that have allowed us to be part of their journey to reduce patient harm from medication errors. It has been both a distinct privilege and a profound responsibility to touch the lives of so many during the past year. Since becoming a charitable organization more than two decades ago, ISMP has pursued a singular mission to advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors.

New technology identifies, measures, and documents manual intravenous bolus injections in real time

By James H. Philip, ME(E), MD, CCE; Mark Mitchell, MD, MSEE; and Celine Peters, RN, MN

Anesthesiologists have long played a role in advancing medication safety. More than 30 years ago, the Anesthesia Patient Safety Foundation (APSF) was launched as an independent organization with the vision that “no patient shall be harmed by anesthesia” (Stoelting, n.d.). Recognizing the importance of multidisciplinary collaboration, the APSF includes anesthesiologists, nurse anesthetists, nurses, manufacturers of equipment and drugs, regulators, risk managers, attorneys, insurers, and engineers.

In December 1999, the Institute of Medicine released To Err Is Human: Building a Safer Health System, which launched the patient safety movement and galvanized the public’s attention with its estimate that between 44,000 and 98,000 individuals die each year in the United States from medical errors.

By Charles Locke, MD, CHCQM

ABQAURP Diplomate, ACPA Board Member

On August 6, 2015, President Obama signed into law the Notice of Observation Treatment and Implication for Care Eligibility Act or NOTICE Act (Public Law 114–42). This law creates, one year from signing, a “Medicare requirement for hospital notification of observation status.”

MITSS presented Jeanine Thomas, president of the MRSA Survivors Network, with this year’s HOPE Award. MITSS, or Medically Induced Trauma Support Services, Inc., is a nonprofit organization founded in 2002 whose mission is to support healing and restore hope to patients, families, and clinicians impacted by adverse medical events. The MITSS HOPE Award, first given out in 2008, recognizes the people and organizations that support the people affected by those events.

Measurement is central to current discussions about the state of patient safety, as well as federal healthcare reform and efforts to move toward value-based purchasing. Using data to understand, drive, and evaluate improvement efforts has a long history. In fact, the patient safety movement was launched by a memorable data point: medical errors cause between 44,000 and 98,000 deaths each year in the United States (Kohn, Corrigan, & Donaldson, 2000). And the axiom “you can’t improve what you can’t measure” is a touchstone for quality improvement.

By Anne Press

The traditional medical school curriculum has a heavy scientific focus, especially in the first two years. In an already jam-packed curriculum, it can be difficult to replace any of the materials with improvement science. To combat this, Hofstra-North Shore-LIJ School of Medicine launched—with the school’s inaugural class in 2011—a four-year curriculum in patient safety, quality, and effectiveness.

By Mel Bradley, MD, MSPH

Haddon’s matrix is an incident analysis and prevention tool composed of two dimensions: rows equating to incident phases and columns representing the epidemiological triad of host, agent, and environment (Figure 1) (Haddon, 1980). The pre-incident and incident cells are filled with factors that have contributed to an incident or potential contributors to an anticipated incident. Mitigation controls to help prevent similar incidents from occurring are delineated in the post-incident cells.

New technology identifies, measures, and documents manual intravenous bolus injections in real time

By James H. Philip, ME(E), MD, CCE; Mark Mitchell, MD, MSEE; and Celine Peters, RN, MN

Anesthesiologists have long played a role in advancing medication safety. More than 30 years ago, the Anesthesia Patient Safety Foundation (APSF) was launched as an independent organization with the vision that “no patient shall be harmed by anesthesia” (Stoelting, n.d.). Recognizing the importance of multidisciplinary collaboration, the APSF includes anesthesiologists, nurse anesthetists, nurses, manufacturers of equipment and drugs, regulators, risk managers, attorneys, insurers, and engineers.

By Charlie Berg, BA, BSEE

In recent years, hospitals have made great strides in the adoption of electronic health records (EHR). As of 2014, 76% of hospitals in the United States were employing an EHR system to manage clinical information (American Hospital Association, 2015). The perioperative staff is now looking for improvements to their workflow and work environment from these electronic systems, seeking patient-safety focused integration of information carefully selected from the growing flood of electronic data.