ASQ Healthcare Division Newsletter
PSQH Turns Five
With this issue, Patient Safety & Quality Healthcare (PSQH)
reaches its fifth anniversary, which prompts me to take a moment and
think about how much the world has changed and stayed the same in the
past five years. When we published the first issue, in July 2004, the
patient safety community was discussing how much progress—if any—had
been made since the IOM published To Err Is Human five years earlier, and now we are assessing progress made over the past 10 years.
Is Heparin Therapy Outmoded?
Dager et al. offer expert, useful, and pertinent advice regarding safe use of heparin (“Heaparin: Improving Treatment and Reducing Risk of Harm,”
Jan/Feb 2009). They miss the salient opportunity to make an even
stronger case: heparin is outmoded therapy, and should be replaced by
use of low- and ultra-low molecular heparins (LMWHs), except perhaps in
certain circumstances. LMWHs have been used for more than 20 years in
Europe and have been approved for use in the United States since the
Patient Safety Councils:
A New Tool for Patient Safety
Nearly 10 years after the Institute of Medicine’s To Err Is Human
report (2000) galvanized the national patient safety movement,
healthcare providers and organizations have re-tooled many of their
inpatient processes, systems, and training programs as they aim to
deliver safer medical care.
Q & A
State of the Art in Diagnostic Clinical Decision Support
With the recent passage of the American
Reinvestment and Recovery Act of 2009 (ARRA) and the release of the
Obama administration’s 10-year budget plan, health information
technology (IT) will play a key role in any efforts to reform
healthcare. The ARRA is investing more than $19 billion over 5 years on
health IT, specifically electronic medical records, through economic
incentives presented to physicians, clinics, and hospitals.
High-Alert Medications: Error Prevalence and Severity
Use of medications is the most common patient
treatment intervention in healthcare. It is also the most common source
of adverse events in the inpatient setting (Leape et al., 1991).
Adverse events from medication usage increase morbidity and mortality
as well as the overall cost of care.
Medication Safety Technologies:
What Is and Is Not Working
Almost ten years ago, the Institute of Medicine report, To Err Is Human
(2000), galvanized healthcare, patients, Congress, and the media to pay
attention to the problems of patient and medication safety. In the
years that followed, hospitals made enormous investments to improve
practice and implement safety technologies. How far have we come? Where
are we now? Is there any way to anticipate what happens next?
Biomedical Device Integration:
The Impact on Clinicians at the Point of Care
Hospitals are constantly evaluating new
technologies that promise to improve the quality of care, create a
safer care environment, and improve both clinical and operational
efficiency. If, however, technologies are evaluated solely on their
individual merits, they may introduce problems to the clinician’s
complex work environment. When new technologies are deployed, there is
often some impact to the clinical workflow.
Tests of Change:
Simulated Design of Experiments in Healthcare Delivery
Hospital administrators and quality department personnel seeking to improve hospital processes often find it difficult to implement change. This is true especially when
recommended changes potentially are highly disruptive, directly affect
patient quality of care, or must be tested in a trial-and-error
approach. The risk aversion that arises from past failed attempts and
lack of confidence in the success of proposed changes exacts a
significant toll on continuous improvement efforts.